Banningthehandshakefromtheh
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Opinion VIEWPOINT BanningtheHandshakeFromtheHealthCareSetting Mark Sklansky, MD The handshake represents a deeply established social and compassion. Handshakes between health care Division of Pediatric custom. In recent years, however, there has been in- practitioners and their patients have the potential to Cardiology, creasing recognition of the importance of hands as vec- comfort and to calm. Department of tors for infection, leading to formal recommendations Pediatrics, Mattel Transmission of Communicable Disease Children’s Hospital and policies regarding hand hygiene in hospitals and 1 UCLA, David Geffen other health care facilities. Such programs have been Scope of the Problem School of Medicine at limited by variable compliance and efficacy.1,2 In an at- Nevertheless, the hands of health care workers often UCLA, Los Angeles, California. tempt to avoid contracting or spreading infection, many serve as vectors for transmission of organisms and individuals have made their own efforts to avoid shak- disease.1,3-6 Health care workers’ hands become con- Nikhil Nadkarni, BS ing hands in various settings but, in doing so, may face taminated with pathogens from their patients, and, David Geffen School of social, political, and even financial risks. despite efforts to limit the spread of disease, cross- Medicine at UCLA, Los Particularly in the current era of health care re- contamination of health care workers’ hands com- Angeles, California. form, innovative, practical, and fiscally prudent ap- monly occurs through routine patient and environmen- 1 Lynn Ramirez-Avila, proaches toward the prevention of disease will assume tal contact. The duration of survival of bacteria and MD, MSC increasingly important roles. Regulations to restrict the viruses on the hands of health care workers varies by Division of Infectious handshake from the health care setting, in conjunction pathogen and environmental factors. Moreover, hand- Diseases, Department with more robust hand hygiene programs, may help limit of Pediatrics, Mattel related transmission of organisms in the health care Children’s Hospital the spread of disease and thus could potentially de- setting can contribute to the burden of antimicrobial UCLA, David Geffen crease the clinical and economic burden associated with resistance. School of Medicine at hospital-acquired infections and antimicrobial resis- UCLA, Los Angeles, tance. Effective development and implementation of Importance and Limitations of Hand Hygiene California, and Clinical Epidemiology and such a handshake ban will likely require further study to Hand hygiene has long been recognized as fundamen- Infection Control, confirm and describe the link between handshakes and talforthepreventionofhospital-acquiredinfections.1 Im- Ronald Reagan UCLA provements in hand hygiene have been Medical Center, Los Angeles, California. associated with decreases in bacterial colonization and hospital-acquired in- “Handshake-free zone: to protect your fection rates.1 However, compliance of health and the health of those around health care personnel with hand hy- gieneprogramsaverages40%,1,2 andpa- you, please refrain from shaking hands tients and visitors to the health care set- while on these premises.” ting generally also have low compliance with hand hygiene policies. Moreover, al- cohol-based hand rubs, which have the transmission of pathogens and disease; the promo- taken the place of handwashing in many health care set- tion of an alternative, health-conscious gesture to sub- tings, have limited activity against some pathogens, in- stitute for the handshake; and widespread media and cluding Clostridium difficile.3 At the same time, the effi- educational programs. cacy of handwashing varies with details of technique, such as duration.1 Cultural Context The handshake has evolved over centuries into its cur- Handshake Transmission of Pathogens and Disease rently profound cultural role. Artifacts from ancient The infectious risk of the handshake has been de- Greece suggest that the handshake began as a general scribed in the medical literature since the early 20th gesture of peace, revealing one’s open palm as a sym- century.6 Multiple studies have demonstrated that the bol of honesty and trust. The custom and technique of handshake can and does transmit pathogens,3-6 and this open-palm gesture subsequently evolved into the widespread hand hygiene policies have been predi- modern form of the handshake, now representing an cated on the well-established link between hand trans- international symbol of greeting/departure, reconcili- mission of pathogens and disease.1 Bacterial cross- Corresponding ation, respect, friendship, peace, congratulations, contamination of volunteers through handshaking has Author: Mark Sklansky, good sportsmanship, or formal agreement. Beyond its been found to be more likely than with “fist bumping” MD, Department of 4 Pediatrics, David interpersonal significance, the handshake commonly on a surgical ward. Clostridium difficile spores Geffen School of assumes commercial or political importance. In the (a common cause of diarrhea in the health care setting) Medicine at UCLA, 200 health care setting, where patient encounters com- have been demonstrated to be transmitted via the Medical Plaza, Ste 330, monly begin and end with a handshake, the hand- 3 Los Angeles, CA 90095 handshake. Moreover, the survival of bacteria trans- (msklansky@mednet shake has been shown to have the capability of mitted via the handshake has been found to be pro- .ucla.edu). improving the perception of the physician’s empathy longed in the presence of sputum.5 jama.com JAMA Published online May 15, 2014 E1 Copyright 2014 American Medical Association. All rights reserved. Downloaded From: http://jama.jamanetwork.com/ by a Elmhurst Hospital Center User on 05/15/2014 Opinion Viewpoint Lessons Learned From the Banning of Smoking Infection-conscious alternatives to the handshake may be Although the mortality associated with smoking has been found to found in a variety of secular and religiously based gestures from be substantially greater than that associated with hospital- around the world. Some well-established gestures include the acquired infections, some parallels may be drawn between the pro- familiar hand wave (using an open palm, and practiced widely as posal to remove the handshake from the health care setting and pre- an informal greeting/departure gesture) and placement of the vious efforts to ban smoking from public places. Throughout the right palm over the heart (as practiced in the United States while 1950s and 1960s, smoking represented a well-established social facing the American flag). Practiced predominantly in the Far East, practice. In 1954, more than 50% of physicians in Massachusetts the bow symbolizes reverence and respect but can also have a smoked cigarettes daily and, in 1962, 42% of adults in the United variety of secular/religious meanings and may signify greeting/ States smoked. During this same period, links between smoking, lung departure, humility, obedience, submission, apology, or congratu- cancer,andcoronaryarterydiseasewerebecomingincreasinglyclear. lations. The Namaste gesture, practiced for centuries throughout In 1964, with the release of the first surgeon general report, Smok- South Asia, has become increasingly prevalent in yoga practice ing and Health, came the suggestion to ban smoking, although with throughout the world. By placing the hands, palms together, recognition that “such a proposal is not easily implemented.”7 against the face or chest, and tilting the head forward, the gesture Giventhedeeplyentrenchedculturalroleofsmokingatthetime, symbolizes respect and may carry religious significance among accepting the evidence of the harm associated with smoking, fol- Hindus and Buddhists. In Thailand, the wai gesture functions simi- lowed by banning smoking from public places, would take many larly. The salaam (peace) gesture—wherein the right palm is placed years. Cigarette use has since been banned in public places through- over the heart, sometimes with subtle bowing—has been prac- out much of North America, including in commercial aircraft; many ticed among some Muslims and generally represents a symbol of bars, restaurants, and theaters; and even college campuses of the greeting/departure and respect. University of California. In 2014, only approximately 18% of adults in the United States smoke, and smoking bans protect approxi- Conclusions mately half of Americans from secondhand smoke in the work- Banning the handshake from the health care environment may place. Removing such a deeply embedded cultural custom from so- require further study to confirm and better describe the link cial situations has involved, beyond formal bans/regulations, between handshake-related transmission of pathogens and dis- widespread media and educational efforts, as well as the develop- ease. Moreover, given the profound social role of the handshake, a ment and promotion of effective alternatives, such as nicotine gum, suitable replacement gesture may need to be adopted and then in part because of the addictive nature of nicotine. promoted with widespread media and educational programs. Nevertheless, removing the handshake from the health care set- Alternative Greetings ting may ultimately become recognized as an important way to Given the profound and pervasive social/cultural role of the hand- protect the health of patients and caregivers, rather than as a per- shake, any effort to restrict the handshake