Intended for healthcare professionals

Rapid response to:


Hand washing

BMJ 1999; 318 doi: (Published 13 March 1999) Cite this as: BMJ 1999;318:686

Rapid Response:

Exams should require hand washing

EDITOR - The handwashing liaison group (1999) report that the rate of
handwashing amongst doctors is still very low.1 This is despite the well
accepted view that this is one of the most important and effective
measures for preventing nosocomial infections . Studies have shown that
handwashing occurs, at best, in only one third of patient contact
episodes.2 Attempts to improve compliance by educational or observational
programmes have had limited or temporary effect.3 However, it is noted
that the attitude of senior colleagues is influential in encouraging
junior doctors to wash their hands more frequently.4 In light of these
findings, it is interesting to note that the practice of handwashing,
which is considered fundamental to basic patient care, does not have more
prominence in postgraduate clinical examinations. In the personal
experience of one of the authors (ESRD), there were no facilities or
indeed opportunity to decontaminate hands between the rapid succession of
short cases in the clinical part of MRCP. In all 8 cases it was necessary
to physically examine some part of a patient, at least one of which was an
On questioning 20 colleagues who had sat either MRCP or FRCS/MRCS clinical
exams during the past 3 years this arrangement appears to be the norm for
clinical exams. In all, 24 clinical exams were recalled clearly, 12
medical and 12 surgical. In every episode the physicians stated that there
had not been the opportunity to wash hands between short cases. One
doctor, after palpating inguinal lymph nodes, excused herself to find a
wash basin before the next case but felt she was incurring the displeasure
of the examiners by doing so.
With regard to the surgical exams , one doctor said that alcohol-rub or
hand wash was made available by every short case although it was stated at
the outset that the use of them was 'optional'. Another surgeon said that
hand decontamination was requested by the examiners after leaving one
patient designated a 'dirty case' but was not possible between the other
cases, which included a surgical wound and a scrotal examination. Almost
all doctors questioned remarked that pressure of time simply did not allow
for hand washing.
Clearly time is at a premium when examining such a large number of
candidates, but it seems unfortunate that this basic measure of infection
control cannot be practised on patients who have volunteered to be
examined, some of whom may be very susceptible due to the nature of their
condition. It is also interesting that the practice of infection control
does not appear to contribute to the overall assessment in the way that,
for example, good bedside manner does. One surgeon explained that it was
not practical to stop after each case to use hand rub, 'You have to
remember, the whole exam situation is very artificial.' Agreed, but
unfortunately the patients are not. And if hand decontamination is not
considered sufficiently important to feature routinely in postgraduate
examinations it is perhaps not so surprising that it does not feature more
routinely in medical education and on the ward rounds!

Dr Elizabeth S R Darley
Specialist Registrar

Mrs J Barnett
Senior Infection Control Nurse

Dr E M Jones
Infection Control Doctor

Dept of Medical Microbiology
Southmead Hospital
Bristol BS10 5NB

1 Handwashing Liaison Group. Hand washing. A modest measure - with big
effects. BMJ 1999; 318: 686
2 Albert R K, Condie F. Hand-washing patterns in medical intensive-care
units. N Engl J Med 1981; 304:1465-6
3 Tibballs J. Teaching hospital medical staff to handwash. Med J Austral
1996; 164: 395-8
4 Larson E, Killien M. Factors influencing handwashing behaviour of
patient care personnel. Am J Infection Control. 1982; 10: 93-9

Competing interests: No competing interests

17 July 1999
Elizabeth S R Darley