Instead of Handshake Hazard: Namaste, Salaam Gestures or Bumping Elbows?
Of course, we all teach our medical students from year 1 that the handshake with the patient is a classic professional act to develop and preserve the doctor-patient relationship. The basis for teaching our students is that an initial handshake is, as I wrote in the thread "A Doctor's Touch" in July 2008, "the handshake, provides the first connection with the patient. It can be represented as the marking of a beginning doctor-patient relationship which is hopefully to continue to the benefit of the patient. The quality of the handshake tells each party, at the onset, something about the other." But these days with greater spread of infection attributed by studies in part related to hand to hand contact, despite emphasis to attend to hand washing, there is an argument in favor that the professional handshake with the patient is now anachronistic and should be eliminated. But what, less infectious but yet courteous behavior is there to replace the handshake?
A recent article on this subject in a May 15 2014 issue of
the online Journal of the American Medical Association discusses the hand shake
which " has evolved over centuries into its currently profound cultural
role. Artifacts from ancient Greece suggest that the handshake began as a
general gesture of peace, revealing one’s open palm as a symbol of honesty and
trust. The custom and technique of this open-palm gesture subsequently evolved
into the modern form of the handshake, now representing an international symbol
of greeting/departure, reconciliation, respect, friendship, peace,
congratulations, good sportsmanship, or formal agreement."
So what might be an alternative, infection-free, method for
expressing a physician's greeting to and acknowledgment of the patient? This
excerpt from the JAMA article provides some alternatives: " Infection-conscious
alternatives to the handshake may be found in a variety of secular and
religiously based gestures from around the world. Some well-established
gestures include the familiar hand wave (using an open palm, and practiced
widely as an informal greeting/departure gesture) and placement of the right
palm over the heart (as practiced in the United States while facing the
American flag). Practiced predominantly in the Far East, the bow symbolizes
reverence and respect but can also have a variety of secular/religious meanings
and may signify greeting/ departure, humility, obedience, submission, apology,
or congratulations. The Namaste gesture, practiced for centuries throughout South
Asia, has become increasingly prevalent in yoga practice throughout the world.
By placing the hands, palms together, against the face or chest, and tilting
the head forward, the gesture symbolizes respect and may carry religious
significance among Hindus and Buddhists. In Thailand, the wai gesture functions
similarly. The salaam (peace) gesture—wherein the right palm is placed over the
heart, sometimes with subtle bowing—has been practiced among some Muslims and
generally represents a symbol of greeting/departure and respect."
But will these substitutes including even the doctor wearing surgical gloves or any of the popular Western actions such bumping elbows
(safe?), or giving a thumbs up sign in any way substitute for a warm handshake?
I think the best physical connection is
made by the extended arm of the physician with the open palm awaiting the
similar action by the patient and with, as we teach our medical students, washing
hands properly with soap and water just before making contact with the patient
and then again on moving on to the next patient. What do you think about the current value of
the handshake between doctor and patient? Should it be easily abandoned in the
name of safety?...Maurice.
Graphic: From Google Images
posted by Maurice Bernstein, M.D. @ 9:38:00 PM
9 comments
9 Comments:
I'm glad this topic came up. I come from a culture where unrelated men and women do not shake hands (or have any casual physical contact). As a provider I will not refuse a hand that is offered to me, because explanations are awkward and put the focus onto me and my beliefs and traditions rather than on the patient. However, I will not extend a hand to a male patient. Being able to use hygiene as an "excuse," or better yet, if some other non-physical gesture became standardized, would be most welcome from my perspective.
Anonymous, I would be interested to know whether in your culture it is only the handshake gesture that is not permitted as "casual contact" but that this cultural avoidance in no way interferes with professional contact (touching and formal palpation) which is all part of the necessary professional duties in the diagnosis and care of a patient. ..Maurice.
Professional contact in the course of examining or treating a patient is considered necessary to preserve health and unlikely to cross the line into inappropriate intimate contact. On the other hand, since that line is difficult to explain to patients, and if I would refuse a handshake it might raise anxiety about my ability to provide care for them in a professional manner, I will not refuse a hand that is offered to me. Initiating a handshake is a different story. My only observation is that if the cultural norm changed so that handshakes are less standard it would make things easier for some of us.----CS
CS, I presume you are the anonymous individual who wrote earlier today.
I can understand your personal professional dilemma as you practice in a different culture.
When you write "Professional contact in the course of examining or treating a patient is considered necessary to preserve health and unlikely to cross the line into inappropriate intimate contact". Do you find that your culture sets any limits to professional contact in terms of that examining and treating of patients. For example, if you are a male physician can you perform a pelvic examination on a woman or if you are a female physician can you examine a male patient's genitalia? ..Maurice.
Yes, I am the initial anonymous poster. No, in my culture there are no limits on professional contact that is necessary for the patient's wellbeing. There is no requirement to seek a same-gender professional or to refuse to render services to opposite-gender individuals. Casual physical contact is discouraged. I would not, for example, hug an opposite-sex colleague or patient, or even tap them on the shoulder.
Very interesting CS but with no informal physical contact, how is physician empathy expressed to the patient beyond simply words? ..Maurice.
First of all, cultural/religious considerations aside, casual physical contact is a minefield. How do you know what level of touch the patient is comfortable with? How will they interpret your touch? Are you certain that what you perceive as casual contact will be perceived the same way by the patient? As to communicating empathy, there are endless ways to do this: eye contact, listening carefully to the patient, giving thorough answers to their questions, being available to them when they need you, etc. My patients rate me high in empathy, that's certainly not an area I struggle in.
In my morning coffee group [an eclectic bunch from drug users to millionaires {at the beach}], the retired Romanian gymnast has initiated the fist bump. I like it because there's no palm contact. However, it's probably too informal for an MD.
BJTNT
BJTNT, a fist bump seems a bit forceful for an initial contact with a patient. So the doctor initiates the physical greeting activity by holding out a fisted hand. It just seems a bit aggressive and a "unwarm" attempt at greeting.. And how would the patient interpret the motion and the fist? Retreat? Hmmn.. a doctor's just sanitized open palm still would be the best introduction or concluding sign for "togetherness". ..Maurice.
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