Why most doctors don't wash their hands | Hacker News Reader

Why most doctors don't wash their hands

3quarksdaily.com

42 pointsbookofjoe53 comments

The only thing the article does to address the topic of the headline is include this link [0]. The rest is a combination of anecdote about a doctor failing to wash his hands and history about hand washing.

[0] https://www.ncbi.nlm.nih.gov/books/NBK144026/table/parti_ch1...

Seriously. Reading that title, I expected an article about some counterintuitive reason that it’s better for doctors not to wash their hands.

I have to believe most doctors, by far, do wash their hands.

My wife's an occupational therapist (so, should be lumped in with the PTs who are "less likely to wash their hands") and she's pretty religious about hand washing, keeping work clothes separate, changing shoes when she leave the hospital, etc. I have to imagine it's cultural from the various facilities she's worked in, because she's not otherwise (outside of post-work) a germophobe or anything.

I enjoyed this article. It also included links to other studies indicating how often doctors and nurses wash their hands and studies about the effectiveness of hand washing.

Sure, but I read the whole thing and while it was amusing, I still have no idea "why" doctors don't wash their hands. They forget? They don't want to? They don't believe it's worth it? The article doesn't say at all.

It did, but it's very easy to miss between all the Semmelweis biography.

The article provided a WHO list of "barriers to adherence with hand-washing guidelines", but that isn't the same thing as explaining the behaviour.

What does explain the behaviour? Nobody knows for sure yet, hence the article exists. If we investigate the profession of medicine in the same way as we might approach a diagnostic examination of any other profession or occupation, we uncover a whole category of possibility that the article doesn't explore.

Before I put forward this conjecture, which may shock and repel some of you at first, let me point out that it doesn't necessarily have to be occurring in a conscious mode. With that said, consider the business model of doctors.

Doctors are trained to diagnose and treat disease. They aren't trained in nursing. For that, they rely on nurses, who are their reliable, ever present subordinates. In terms of hours spent at the wheel, doctors are scarcely trained in disease prevention and hygiene at all, which account for only a tiny % of the curriculum in medical schools.

Do you want to know how to eat right, live healthily, and ward off a whole host of diseases? Consult a nutritionist. Doctors aren't trained in nutrition.

https://www.thelancet.com/journals/lanplh/article/PIIS2542-5...

Doctors aren't trained in preventative medicine or public health, unless they choose those as electives or specialties.

Doctors are just primarily trained in anatomy, physiology, disease diagnosis and treatment.

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

exactly

> There was an awkward silence. I expected him to offer a feeble excuse. Blurt out that the woman was crazy, or that she was talking nonsense. Get defensive, say he used the had-rub solution outside her room or washed his hands at the sink by the nurses’ station. But he did none of that. “Tell her I’m sorry,” he said instead. “I’ll ask my colleague to take over her care.”

I wish behavior like this was more celebrated. It's incredibly rare and incredibly difficult.

Agreed. It is shocking to me how rare simply accepting fault is. Maybe, 10% of the time, at best? I wish there were some better incentives to actually behave that way consistently. I often find myself thinking "Man, why am I even trying to be nice or do the right thing here when all these other assholes meander selfishly through life and have great outcomes too?"

I would be really interested in reading a article on "why doctors don't wash their hands" but this ain't it. Interesting stuff on Seimmelweis but otherwise fluff.

I am an EMT and was on a particularly bloody call and noted the paramedic was not wearing gloves... Part of it might be related to the joke that ALS stands for "Aint lifting shite" but if I had more time on the call I might have asked him...

The use of PPE and washing hands are interesting topics and am often interested in things I see wrt this.

I have read the story of Ignaz Semmelweis many times, and pretty much always it is framed as the abhorrent injustice of a comically evil establishment resenting and destroying a saviour-figure out of sheer bloody-mindedness.

This is the first time I have seen sensible explanations, namely that Semmelweis was really bad at promoting his discovies and successes:

> It did not help that Semmelweis was a tactless, difficult, and angry man who lacked people-skills. For one, years after his research, he refused to publish his findings and reasoning, because he considered it ”self-evident.” Further, he openly berated even the most powerful doctors who dared to challenge him or failed to wash their hands.

Really that is still on society for being so fucking insane that they care more about their petty delusions od hierarchies and egos than lives of mothers.

To put it on him is a vile form of victim blaming and tone policing, a tactic of vile bullies to in defiancr of all justice and logic insist it is the fault of the victim for being upset at an outrage. The self evident should be especially obvious given the number of deaths from botched autopsies and self inflicted wounds around corpses. Only an absolute monster would shove a corpse part in the loins of a new mother but they were effectively doing the same thing when even stray cuts could kill. Semmelweis was the only sane man by being so furious. Others were making blood sacrifices to the gods of social norms.

Thanks for proving my point so impressively.

That is not how you make the world a better place. You don't change people's behaviour by villifying and verbally abusing them. You are fully prepared to make blood sacrifices to your own imagined moral superiority.

I'm torn between thinking maybe being shamed by your colleague taking you off a case is an effective punishment and believing that doctors should face more serious punishments for hand washing failure. A doctor failing to wash hands is probably inflicting a similar societal danger as driving drunk - people really could get hurt or die. It doesn't seem like the kind of thing that should just be shrugged off.

The point about hand gel is a good one. I have containers of Purell and find that I enjoy washing my hands with it much more than with soap and water. I actually think of Purell as a slight positive, writing this, I'm considering Purelling my hands just for fun. I think this is probably the best technological solution: make sanitizing hands a fun experience that people want to do rather than a slight cost that people often ignore.

Another potential solution might be applying some kind of coloring agent to hospital surfaces so that doctors who haven't washed in a bit will get increasingly red hands. That's probably less desirable though.

The coloring agent idea is neat, but seems infeasible to me. You'd end up staining documents, clothes, and whatever else, plus you'd have to dedicate custodial staff to reapply it.

Nearly all the negative effects you feel from washing your hands are mitigated by using a good hand lotion like Aveeno. Cleaner hands, healthier skin on your hands, and you specifically get the benefit of rubbing your hands together like with purell.

A good lotion will not leave your hands greasy, which is the main aversion I've heard from people before they get in the habit.

A lot of discussion about Semmelweis, but the actual reasons:

"Some factors that hindered hand-washing were days with busy workload and a feeling of not being watched.

A World Health Organization (WHO) report has also listed other barriers to adherence with hand-washing guidelines, including:

  Working in the ICU, surgical unit, or emergency rooms
  being a nursing assistant (rather than a nurse), or physical therapist
  Sinks are inconveniently located/shortage of sinks
  Lack of soap and paper towels
  Male sex
  Handwashing agents cause irritation and dryness
  Understaffing and overcrowding
  Wearing gloves and the belief that using gloves avoids the   need for hand hygiene
  Not thinking about it/forgetfulness
  No role model from colleagues or superiors
  Skepticism regarding the value of hand hygiene
  Disagreement with the recommendations"

What is 'male sex'? Something about men don't want to be seen as washing their hands too much or?

It doesn't surprise me. Women are generally more likely to follow safety protocols. For example, they are more likely to wear seatbelts and ensure every passenger does the same. It is most likely related to risk taking, which is one trait where there is a statistically significant difference between men and women: women are more risk averse.

Socialization largely most likely. Look at the stereotype of boys being interested in touching crawling,slimy, and gross things while girls are repelled by it. For better or worse the susceptibility to that sort of revulsion would be linked to more handwashing.

thought the same thing - men not washing hands after nookie? And whats this about sinks being too short? Distractingly crappy data categories.

As a certified tall person I can confirm I am less willing to do things low to the ground. So sinks being too short seems legitimate. I do understand the other side (short people) have it harder though - if a sink is too tall for you then it's pretty much impossible to use.

Also, male sex is referencing being of the male gender it has nothing to do with intercourse. Feel free to question the legitimacy of the category, but the category itself is pretty clearly defined.

> So sinks being too short seems legitimate.

Before people get too carried away with this, it said “shortage of sinks”.

yes - bad joke in the vein of "male sex" - the categories are sloppily generated in the WHO example. But you are right - the sinks are in short supply...

sax and violins on tv...

It's probably a BS toxic-masculinity thing - "Only weak men need to wash their hands". I know that toxic masculinity is a controversial topic but I've met lots of folks who think this way and it is such a silly philosophical stance to take.

Being male is considered a barrier to handwashing?

No, it's a correlation, that's all.

This caught my eye, from the article:

>A World Health Organization (WHO) report has also listed other barriers to adherence with hand-washing guidelines, including:

>[...]

>Sinks are inconveniently located/shortage of sinks

>Lack of soap and paper towels

>Male sex

>Handwashing agents cause irritation and dryness

Uh, what? One of these things does not belong.

I was actually curious about this, so I followed the link to the WHO report. It cites two studies as evidence of "male sex" being a factor affecting handwashing adherence. I looked through the full text both of those studies, and...they make no mention of any such thing. One has zero instances of the term 'male' or 'man', the other has three as it comments on the demographics of the studied patients.

All this to say...where did this supposed factor come from?

Both studies[1][2] mention doctor's sex as a factor. "Effect of education and performance feedback on handwashing: the benefit of administrative support in Argentinean hospitals", for example, has these figures (calculated as Number of handwashings/Number of opportunities [to wash their hands?]):

> Male vs female: 46% (1989/4350) vs 53% (5895/11,181)

[1]: https://pdfs.semanticscholar.org/f3c8/bb1914d5226c719df53dd8...

[2]: https://pdfs.semanticscholar.org/8887/835e725b4347a5392e095a...

Thank you! I thought I must have been missing something. I have no clue why my ctrl+f returned only 3 results for the second study. I just trusted that the searches were accurate because the abstracts didn't mention sex as a factor.

There is a lot of confusion about PPE and disinfecting. People wear surgical masks thinking they are making themselves safe - which they arent. I think also people use magical thinking with disinfectants.

I remember one EMT call where my partner got blood on her arm. She impulsively reached for the handsantizer but I told her to wait. Took her back to the hospital (we just left) and let her wash with soap.

I felt in the moment like an alcohol based wash would just irritate her skin and open pores or perhaps breakdown the skin . When the alcohol evaporates much of the crud would still be there whereas washing with soap feels like you will better handle the issue with surfactant. Might have been wrong.

I would guess that having infected blood on you, and potentially smeared in your car and other places, is quite a lot worse than drenching it in alcohol even if not fully cleaned. Why not both?

I wiped a LOT of blood — infected and not — off my fingers, hands, and arms in the course of practicing neurosurgical anesthesiology for 38 years (now retired).

I'd guess hundreds of times.

Often — especially nights and weekends — there's no other anesthesiologist available to come to the O.R. for relief and a chance to wash it off.

In those cases, I'd ask the circulating nurse to get a bunch of towels and run them under hot water at the scrub sink, then give them to me to wipe off as best I could.

I thought most hospitals had hall monitors who were writing people up for not foaming in and out of each room. Maybe that's not everywhere or is just university hospitals.

I unfortunately spent a good deal of time in hospitals from last Christmas (yes, literally Christmas) to mid-March. I noticed no hall monitor even at the university hospital, and having read The Checklist Manifesto, out of curiosity I was paying attention to hand washing. As I recall, most if not all washed hands as one would hope.

I have never, ever seen one of these people. I can't be convinced my local hospital would ever pay someone to do that.

If there was interest in achieving high compliance and the expect reduction in mortality, why wouldn't it be sufficient to randomly spot check hospital staff hands for infectious agents and have a program of escalating fines then suspensions followed by loss of license for persons who are consistently above-threshold?

The aggressiveness could be gradually increased over time to prevent a disruptive loss of workforce given the existing poor practices.

I was not impressed with the lack of handwashing at our local hospital. Last time I was there I noticed they'd put up signs encouraging patients to ask their care provider if they'd washed their hands. I had a nurse come out, bring me in, then start putting in an IV without washing his hands. I asked him if he'd washed his hands and he very quickly answered "yes" and put the line into my vein - while I was calculating the number of doors and surfaces he'd touched coming out to get me and then lead me into the interior rooms. It was excruciating asking him about that.

Most of my doctors visits seem to involve the doctor not washing their hands when they come in, and then not washing their hands after examinations.

I am baffled by this behavior - you would think that they would know the best how important hand-washing is.

It's wild in that article how hard he found it to give feedback to his colleague about his hand-washing. As a patient I find it incredibly uncomfortable mentioning it to medical staff, and yet it is so important.

I wish the article had actually done a deep dive into why this seems so widespread and what could be done to change it.

If possible, I'd try to find another hospital/doctor. My wife (breast cancer surgeon) has the worst skin in the world and it's because she's adamant about washing her hands as she walks into a room and as she walks out of the room (even before COVID). Meanwhile, I have these dainty soft keyboard hands that she is envious of. But, it's not just that she's strict about it, it's that her hospital as a whole is strict about it and minimizing post-op/wound care/consult infections. It's bad for the patient and it's bad for the hospital (re: not profitable).

I've seen it at multiple medical facilities here unfortunately. Maybe it's a Portland thing?

it's possible. it's a change that has to start at the top and most hospitals in an area tend to be owned by the same company

This is absolutely horse shit. My mom is a provider and has always washed her hands before and after every patient. If they're not there is something very wrong with them.

The article did include a link to a study [1] about the low rates of handwashing among doctors and nurses. Although the article neglects to note the second line in the abstract's conclusion heading:

>In general, the study methods were not very robust and often ill reported.

[1] https://www.cambridge.org/core/journals/infection-control-an...

I’ve seen this a lot. It’s sad.

I think doctors don’t wash their hands is like someone who is adapt at washing dishes to know when soap is not needed to wash certain dishes to be good enough to not get you sick. They take a chance but save them a little time. Of course if they just accidentally came in contact with a patients private parts or something “wet” they are most likely to.

Doctors are motivated only by their income, and since washing hands won't add to that, they see it as waste of time in which they could "treat" another patient

Getting the premiums on your malpractice insurance is certainly a strong effect on your income - if they were intelligent actors they would foresee this and wash their hands.

This is just plain old stupidity.

Does anyone ever really know why anyone (including the self) really does or does not do anything?

We can all offer a narrative, but that’s just our confabulation module narrating post hoc. The split brain experiments proved that to be the case.

We are all just advanced versions of GPT3.

Discuss

Why we act at all is not relevant here. The fact is that policy and training produce behavioral outcomes. So if you want to change a behavior in a group of employees, you can train them. What to train them on, how to train them, and how to encourage adherence to the training are the subjects here. You can choose to spend your energy in philosophy or psychology but that's too big a question if you just want to understand how and why doctors wash their hands.

> What to train them on, how to train them, and how to encourage adherence to the training are the subjects here

Yep.

The fact that enough doctors are in breach of the protocol, despite all the training and motivators, suggests we do need to look deeper.

I'm not sure why you would reject psychology or neuroscience insights into the causes of behavior. Aren't those the disciplines that provide a scientific basis for constructing training protocols? Philosophy just tells us that the scientists are limited by conscious awareness, which means they don't have access to the data to be able to determine themselves why they do or don't make a behavior.

Before you rush to the conclusion that I'm trolling, or stupid, consider these

https://www.jstor.org/stable/188684?seq=1

https://www.cell.com/trends/cognitive-sciences/comments/S136...

https://www.edge.org/response-detail/11513

The question of what "causes" behavior is not as simple as you might expect from the ease with which you are able to explain (or provide a narrative about) your own behavior, or someone else's behavior. If it were, the mystery of consciousness would be resolved.

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