One of the faculty I am working with is perplexed about howto get doctors to wash their hands in between patients. As the director of Infection Control at a local hospital, she is also enforcing universal precautions and personal protective equipment like wearing gloves when drawing blood and starting IVs, and putting on a mask and gown when visiting patients in isolation. Even one of the senior leaders is resistant to her urging. “He wants the nurse to remind him,” she says, “but the nurse has too much to do.What do they need a mother?”

Even the residents in their training clinics don’t wash their hands. There aren’t sinks in the exam rooms, but there is hand gel and they don’t use it. At one point I used it myself and moved it to the corner of the desk. No one followed my clue.

People are used to following rules and regulations, here, so why this resistance?

Hand washing is Public Health 101. A lot has been written on the topic. Health care associated infections (HAI) are a major threat to patient safety and cause illness and death worldwide. In the US, billions of dollars are spent annually on the problem. Studies substantiate the connection between hand hygiene and HAIs; however, hand hygiene compliance among healthcare workers is alarmingly low, with average rates of only 40 percent to 50 percent, in spite of widespread education and awareness.

Both the Joint Commission, the World Health Organization,(WHO) and the Centers for Disease Control and Prevention (CDC) advise healthcare institutions to implement monitoring systems to enforce hand hygiene practices and provide feedback to all health care workers. Studies suggest these monitoring systems can produce measurable improvements in hand hygiene compliance and is associated with lower HAI incidence in a variety of settings.

I recall handwashing campaigns in US hospitals and clinics, signage in patient rooms, and points lost on clinical exams if medical students didn’t wash their hands.

Can you empower the patients to insist on hand washing? I asked the Infection Control physician. She wasn’t so sure about that. Doctors have a lot of power here and patients expect doctors to tell them what to do.Partnering about health decisions is a new concept, let alone correcting your physician.

In fact a 2017 study looked at empowering US patients to speak up if a doctor did not perform hand hygiene. Just over half of physicians in the West Virginia hospital felt that patients should be involved in reminding them. Most parents (96%) and patients (78%) felt it is their role to speak up if a physician forgets to wash his or her hands, but a lower number (77% of parents and 65% of patients) actually were comfortable doing so.

So physicians are busy multi-tasking and forget, some may have dermatologic side effects, and some are lazy. Likely the same issues are operating here. I have found it helpful to think about hand washing as an opportunity to refocus, or a mindfulness practice between patients, washing away the problems of one patient and preparing to be fully present for the next.

However, here I can’t’ help wondering if it is also a silent protest. One of the few items one may have control over is whether or not I wash my hands in this world where so much is outside of one’s control. Salaries have been on hold for those working for the government. Visas may or may not come through to attend a medical meeting. A checkpoint may or may not be closed, or fly-by checkpoints may suddenly appear. Getting a permit to visit the Mediterranean is so complicated many don’t bother, unless you live in Gaza and there the sea is polluted.

Alas, the olive harvest has started, and families are hard at work in their groves. One of the ways people appear to manage is celebrating time with family and these age old rituals. One of the Family Medicine resident doctors promised me a bottle of fresh-pressed olive oil. I am told there’s nothing like it.