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Recently, the lay press reported on some research from Aberystwyth University in Wales that documented that a fist bump transmitted fewer bacteria than a high five or a handshake. In the study, a greeter wearing a bacteria-laden glove exchanged a handshake, fist bump, or high five with a sterile-gloved recipient. The least amount of bacteria was transferred during the fist bump, followed by the high five; the most contamination occurred with the handshake. Longer durations and stronger grips were associated with more bacterial contamination.

AAOS Now

Published 9/1/2014
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S. Terry Canale, MD

Give Me a Fist Bump

The fist bump isn’t new—it started in the ’60s and ’70s, primarily in the hip-hop culture—but now it’s become mainstream in a big way. From our own mayor of Memphis fist-bumping the Dalai Lama to John Kerry fist-bumping Snoop Dogg to Barack Obama fist-bumping Michelle, it’s become the greeting of choice for those who want to appear young and culturally astute. Who could have predicted that fist-bumping would become the topic of scientific research and be touted as a health benefit?

I was interested in this study because I had just read an intriguing editorial in the Journal of the American Medical Association (JAMA), as well as some scientific articles and several pieces in the lay press, describing how bacterial-laden and contagious the human “handshake” is; the title of the editorial in JAMA was “Banning the Hand Shake From the Healthcare Setting.”

At first, I thought the author was kidding or writing a satire on how impersonal the patient-physician relationship has become. But, oh no, this was serious stuff. Evidently, even with appropriate hand washing and use of hand sterilizing solutions, colonies of bacteria such as Clostridium difficile are still passed from carrier to carrier via the handshake. I had C difficile secondary to pseudomembranous colitis caused by clindamycin use. It’s something you never want to have—the worst diarrhea you can imagine and extremely hard to get rid of (6 months). In my case, it was brought under control only by metronidazole.

The JAMA editorial suggested bowing, putting a hand over the heart, fist bumping, or waving—none of those seem to “be me.” John R. Tongue, MD; Dwight W. Burney, MD; and I, as well as other teachers of physician-patient communication, have spent a career teaching communication techniques such as how to greet the patient, examine the patient, touch the patient, and “don’t give the cortisone shot through the sweater.” We have taught physicians to greet the “senior” patient differently than the “younger” (more casual) patient, but always with a hands-on approach.

Perhaps now I could pull on my right ear lobe as a welcome greeting to senior patients and pull on my left ear lobe (the one with the earring in it) for younger patients. I mention this because as you age your ear lobes are one of the few thing that get bigger (longer) and, thus, easier to find! (I obviously am not going any farther with this line of thought, other than to say I am getting older.)

What’s the literature say?
I discovered other literature on this topic, most of which concludes that the correct “scientific” thing to do is to avoid human contact such as shaking hands with patients. But is that the traditionally right thing to do? After all, whoever let a little science (research) get in the way of tradition?

Recently, the lay press reported on some research from Aberystwyth University in Wales that documented that a fist bump transmitted fewer bacteria than a high five or a handshake. In the study, a greeter wearing a bacteria-laden glove exchanged a handshake, fist bump, or high five with a sterile-gloved recipient. The least amount of bacteria was transferred during the fist bump, followed by the high five; the most contamination occurred with the handshake. Longer durations and stronger grips were associated with more bacterial contamination.
Recent articles have suggested “no-shake” zones, high fives, Namaste, and fist bumps as alternatives to shaking hands.
Courtesy of Thinkstock

The handshake is one such tradition. Trying to address this problem could cause socially embarrassing situations and possibly be thought to be disrespectful to the patient. “Excuse me, but I need to douse my hands in this cleanser before and after shaking hands with you.” Or, conversely, “Doctor, I hate to ask, but did you wash your hands before touching me?” Not a great way to start a good physician-patient relationship.

There is no doubt that clean hands cut down on hand contamination and passing on of bacteria and infection. A recent article reported that Vanderbilt Hospital instituted a vigorous hand-washing program that involved actually counting the number of hand washes performed. In some areas, the number of hand washes increased by 80 percent to 90 percent. A corresponding decrease in infection rates in certain areas of the hospital was also noted (decreases ranged from 33 percent to 80 percent).

I should be given a “hand” because I reviewed 200 articles on hand sanitation, lengthy directives from the World Health Organization, the Centers for Disease Control and Prevention, and the Canadian Task Force on Preventive Healthcare about hand hygiene cleaners and washing, but found not one word or recommendation about not shaking hands in the hospital, much less in the office. Perhaps these institutions did not want to take on the tradition that dates back at least to the 5th century B.C.E. in ancient Greece and Babylonia.

So, there must be other alternatives. Following are some options I have collected:

  • “No-shake” zones in the office and hospital. Explain to the patient what the no-shake zone means. If you touch anyone in this zone, you get zapped by a drone. Furthermore, I wouldn’t want to be in that zone myself—I might catch something.
  • Fist bump. Probably doesn’t work well with hand patients, especially those with arthritic hands or osteoporosis who may end up with a boxer’s fracture.
  • High five. Not good for shoulder and rotator cuff patients; however, one of the best total shoulder doctors at the Campbell Clinic (Thomas ‘Quin’ Throckmorton, MD) asks total shoulder patients how their postoperative rehabilitation is going. If they say, “Great,” he gives them a high five to “check their motion.”
  • Cheek kissing. Very chic, very European, very contagious through nasal carriers of contaminants like methicillin-resistant Staphylococcus aureus.
  • Namaste. Palms together, slight bow. Seen in yoga classes and Whole Foods stores and practiced by New Agers wearing eco-friendly Birkenstocks®.
  • Disposable gloves. “Excuse me, but I have to put on this pair of gloves so you won’t pass along any contaminants to me. I’ll change gloves to examine your knee so I won’t pass along any contaminants to you.” By the way, those disposable blue gloves don’t work on an iPad, which I use in the office to show patients their radiographs!
  • Dispensers. More “hand hygiene” dispensers. At my institution, we even have a dispenser right above the elevator “up” button, so when you push the elevator button, you get a squirt of disinfectant on your wrist and hand. Unfortunately, it squirts on the dorsal—not the palmar—side!
  • Stand-in greeter. Let a resident, nurse, or medical or physician assistant greet the patient. That’s a great idea; all I need to do is to pay $80,000 to $100,000 for a “greeter.” Maybe I could hire a Walmart greeter—it would be cheaper. Or I could use the new office position called the “scribe.” I’m not sure they do much anyway.
  • Just Skype. That’s what it’s getting down to anyway. The last half of this decade will probably see “office visit by electronics” (including email and Skype). The physician might miss the diagnosis, but it wouldn’t matter anyway, because the patient would not have paid for the visit or the diagnosis. However, the medical liability lawyers might have a field day.

I know I’m being facetious, but I don’t have a good answer. So for now I’m sticking with tradition and will keep on shaking hands with my patients. I am going to shake more hands than New Jersey’s Gov. Christy and Hillary Clinton combined in the next 2 to 3 years. But I also am sure that in 15 years, when relationships between all sorts of people have become so impersonal, someone will comment, “Remember that old coot Canale who used to advocate high fives and shaking hands and giving everyone C difficile diarrhea? Was he crazy or what?!?”

S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org