Bringing the Art of Hand Shaking Back to Medical Education
- By Kelly Gardner
At UVM College of Medicine, it is unclear in our clinical skills education whether or not we should shake a patient’s hand at the beginning of the interview. This evidence-based perspective highlights why reintroducing hand shaking, with proper hand hygiene, into medical education would be in our best interest.
As first and second year medical students, we study tirelessly for hours on end, trying to cram endless amounts of medical knowledge into our brains. Transitioning from studying to delivering patient care is imperative, yet sometimes challenging. In medical school, residency, and beyond, we will be accountable for the 6 general competencies set forth by the ACGME: patient care, medical knowledge, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement. All of our education is intended to lead us to one of the most valuable elements of medicine--the establishment of a trusting patient-physician relationship.
At the University of Vermont College of Medicine, we are exposed to considerable simulated clinical experiences from day one through work with standardized patients. This gives us a decided leg up in clerkship rotations. Attendings and residents both here at Fletcher Allen and at affiliate teaching sites are often impressed with our clinical skills and demeanor.
However, one important aspect of our clinical education seems lacking. We need to be taught the importance of starting an encounter with a handshake. This action sets a tone of confidence and assuredness, while offering a human touch to put patient and physician at an equal level. As always, we must be attuned to cultural awareness, knowing when a handshake is appropriate. We must practice good hand hygiene. But most importantly, we must be able to establish trusting relationships with our patients.
Beyond the physical act of shaking hands, nonverbal analyses have focused on the meaning associated with types, forms, and occasions for performing this ritual. Though the exact origin is unknown, shaking hands is an important part of many cultures and has come to signify equality and mutual respect. In ancient Greece, it was sign of friendliness, hospitality, and trust.4 In medieval Europe, it was a sign of trust between kings and knights.4 Nigeria’s handshake differs from ours, as the typical Nigerian handshake begins when persons grasp thumbs, then hands separate with the snapping of the fingers of the other person’s hand.4
The handshake establishes a possible relationship. It expresses both an extension of self and request for reciprocation. There is widespread belief that an individual’s handshake reveals much about that person’s personality.1 Regardless of any empirical support for a relationship between handshaking and personality, it is generally believed that the handshake is an important component of a first impression. A “good” handshake communicates sociability, friendliness, and dominance, whereas a “poor” handshake communicates social introversion, shyness, and neuroticism.1 Notwithstanding of the accuracy of the impressions formed about individuals on the basis of their handshake, the literature on handshaking etiquette and business protocol strongly suggest that a handshake has a substantial impact on how people evaluate others. Given what we know about the potency of first impressions, it might be a good idea to heed the recommendations of experts on handshaking etiquette and make the first handshake a firm one.
It is important to greet patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting.5 The first few moments of a medical encounter are critical to establishing rapport, making the patient feel comfortable, and setting the tone of the interview. While greetings may seem like a mundane aspect of physician-patient communication, attention to this task can set a positive tone for the encounter and increase the chances of developing a therapeutic clinical relationship5. Every patient is different. We must be culturally sensitive and be aware of our patient’s comfort. The handshake relates to the interpersonal effectiveness of the doctor in terms of verbal communication, empathy, trust and compassion. Research shows that most patients want their physician to shake their hand during the greeting.5 That being said, research also shows that older patients are somewhat less likely to express a preference for shaking hands5. As student doctors, we should be encouraged to shake hands with patients while remaining sensitive to nonverbal cues, such as not offering their hand, that might indicate whether patients are open to this behavior.
When engaging in any physical contact with a physician, most patients assume that the physician washed their hands. In one study, roughly half of patients wanted to see the physician wash their hands, and nearly half did not feel witnessing the act was important as long as it was done2. Patients believed that the doctor washed their hands prior to their exam, even when not witnessed by the patient2. Although most patients assume that a physician washes his or her hands prior to the examination, I believe this should be done in the exam room to leave little room for doubt.
For generations, hand washing with soap and water has been considered a measure of personal hygiene. In 1846, Ignaz Semmelweis presented the first evidence indicating that cleansing contaminated hands with antiseptic between obstetric patient contacts may reduce transmission of contagious diseases. Although Semmelweis's practice only earned widespread acceptance years after his death, as research expanded on these seminal studies soap and water hand washing gradually became accepted as one of the most important measures for preventing transmission of pathogens in healthcare.
Total bacterial counts on the hands of medical personnel can be incredibly high.6 Transient flora, which colonize the superficial layers of the skin and are the organisms most frequently associated with healthcare–associated infections, are more amenable to removal by routine hand washing. They are often acquired by health care workers during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient.
Hand antisepsis is paramount in decreasing healthcare–associated infections. A systematic review of publications between 1992 and 2002 on the effectiveness of alcohol-based solutions for hand hygiene showed that alcohol-based hand rubs remove organisms more effectively, require less time, and irritate skin less often than hand washing with soap or other antiseptic agents and water.6 The availability of bedside alcohol-based solutions has increased compliance with hand hygiene.6 When compared with no hand washing, washing hands with an antiseptic agent between patient contacts reduces transmission of healthcare–associated pathogens.
At the University of Vermont College of Medicine, we are taught the importance of hand hygiene, professionalism, and communication in our clinical skills education. What should also be stressed is the importance of starting off every patient encounter with a handshake, when appropriate, with proper hand hygiene. It is the first opportunity to convey our interpersonal effectiveness in terms of communication, empathy, trust and compassion. These human qualities are known to be an important part of patient care. The evolution and growth of the patient-physician relationship starts with a single step, the outward expression of the art of medicine – a handshake.
1. Chaplin, W.F., Phillips, J. B., Brown, J.D., Clanton, N.R., Stein, J.L. (Jul 2000). Handshaking, gender, personality, and first impressions. Journal of Personality and Social Psychology, 79(1), 110-117.
2. Davis, R. L., Wiggins, M. N., Mercado, C. C. and O’Sullivan, P. S. (2007), Defining the core competency of professionalism based on the patient’s perception. Clinical & Experimental Ophthalmology, 35: 51–54.
3. Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices. CDC Morbidity and Mortality Weekly Report. October 26, 2002.
4. Hall, P.M., Spencer Hall, D.A. (November 2009). The Handshake as Interaction. Semiotica, 45(3-4): 249-264.
5. Makoul, G., Zick, A., Green M. (2007). An Evidence-Based Perspective on Greetings in Medical Encounters. Arch Intern Med., 167(11):1172-1176.
6. WHO Guidelines on Hand Hygiene in Health Care 2009