Touch your patient. Don’t wear gloves.

We’ve run amok with wearing gloves in the hospital.  And by “we” I mean every healthcare worker in sight.  I see people putting on gloves before they’ll give a patient a clean warm blanket.  This is not only ridiculous, it’s actually harmful.  Here’s why.

We learned the hard way in the 1980s, during the early days of the AIDS epidemic, that the HIV virus and other potentially lethal microorganisms are carried in blood and body fluids. The Centers for Disease Control and the World Health Organization developed the concept of “universal precautions”, which applies during all patient-care activities that may involve exposure to blood, body fluids, mucous membranes and non-intact skin.  Observing “universal precautions” means that you always wear gloves in those situations because you may not know ahead of time if a patient carries HIV, hepatitis, or any other infectious disease.  You don’t want to get infected yourself, or inadvertently infect another patient.

But when did “universal precautions” come to mean that you have to wear gloves before you touch your patient at all?

The downside of hand hygiene campaigns is that they discourage us from normal human contact with our patients.  If you’re worried that the hand hygiene police will detect a deviation from protocol and report you to your hospital’s Infectious Disease authorities, there’s an easy way to avoid the problem. Steer clear of the patient.  And with the advent of the ubiquitous electronic health record, doctors and nurses are under tremendous time pressure to complete all the required data entry fields and move patients through the system.  When you think about it, not touching the patient saves time that could be more efficiently spent at the computer keyboard.  There’s a win-win situation, you might think.  But is it really?

There’s an old adage most of us heard in medical school:  “When all else fails, examine the patient.”  What this means is that all the tests, scans, monitoring equipment, and every other marvelous technology at our disposal can’t replace a skilled and experienced physician taking a history and examining the patient.  If you can’t figure out what’s going wrong, go back and examine the patient again.  It’s still good advice.

In anesthesiology, we’re always under time pressure to see our patients as efficiently as possible and get surgery underway.  Years ago, patients came into the hospital the night before surgery, and we had time for a personal interview at the bedside.  Today, patients come in on the morning of surgery even for the most life-threatening operations, and we have only a brief interval to meet the patient, complete an examination, decide on a plan of care, explain it to the patient and family, and obtain consent.  Yet the preoperative assessment is a key component of anesthesia care, and it may be your only chance to learn critical information about your patient.

I’m in the old-fashioned (some might say quaint) habit of wearing a stethoscope around my neck.  I listen to every patient’s heart and lungs before surgery.  On a number of occasions, I’ve heard a heart murmur that caught my attention and sent me back to the patient’s old records for further information.  Heart conditions like aortic stenosis, which increases the risk of anesthesia tremendously, may not always be noted in an abbreviated history and physical done by the admitting orthopedic surgeon or gynecologist who is focusing on the patient’s other problems.

I think, though, that listening to the patient’s heart and lungs is important for another reason:  it’s a time-honored ritual and a moment of personal connection between physician and patient.  It creates a cocoon of silence, however brief, and reassures patients that I understand their physical condition and am fully focused on their problems.  I have only a few moments to convince them that they are in good hands and may safely put their lives in my care.

Do I put on gloves when I place my stethoscope on the patient’s chest?  Of course not, unless the patient has an infection such as methycillin-resistant staph or c. difficile.  There is no healthcare standard stating that gloves are indicated for contact with intact skin.  The downside of using gloves in a brief external physical examination is that it sends this message to the patient:  “You are unclean.  I don’t want to touch you, but if I must, I’m going to protect myself.”  This is not the way to create a patient-physician bond.

After you examine a patient, it’s common sense to wash your hands and wipe down the stethoscope bell before you move on to the next patient.  But what I see happening in the hospital today has gone way beyond common sense.  There is no need to put on gloves before you place a blood pressure cuff or EKG electrodes on a patient.  As the World Health Organization points out, “The use of gloves when not indicated represents a waste of resources and does not contribute to a reduction of cross-transmission.”  And it can’t be good for the environment to have billions of gloves unnecessarily used and discarded.

So here are a few thoughts I’d like to leave with young anesthesiologists-in-training.

            Touch your patient.  Don’t wear gloves.

            Shake hands when you meet, or take the hand of a frail old lady and just hold it for a moment. 

            Listen to the patient’s heart and lungs with a good quality stethoscope that’s your own, not a cheap plastic one you found hanging somewhere.

            Don’t turn your back to the patient in order to type on the computer.

            As you stand at your patient’s head and get ready to induce anesthesia, make sure the room is quiet.  Put a hand gently on the patient’s shoulder, cheek, or forehead before you apply the oxygen mask and start giving medications, to let the patient know you’re there.

            Remember that your voice and your touch are the last thing the patient consciously experiences.  Make your words calm and reassuring, but don’t lie.  Never say, “You’re going to be fine,” because truthfully you don’t know that.  It’s better to say, “We’ll be right here with you,” because that’s a promise you can keep.

There was a time when touch and comfort were about all that a physician or nurse could provide for most patients, since effective medicines were few and technology nonexistent.  Thankfully, we don’t live in those times.  But some of the physician’s art  can’t be replaced.  If we let gloves or anything else come between us and our patients, everybody loses.

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For an excellent presentation on the art and deeper meaning of the physical examination, listen to Dr. Abraham Verghese’s TED talk, “A doctor’s touch”

23 COMMENTS

Neal Koss

Right on as always…but we may be dinosaurs. I think it’s OK to hold the hand of a frail old man also 🙂

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karen

Point taken, Dr. Koss! Thank you as always–

Karen Sibert

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[…] Dr. Karen Sibert has written a terrific blog post on wearing gloves while caring for patients titled “Touch your patient. Don’t wear gloves.” […]

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Mary DeForest

I have a doctor that seldom touches. One day we left the office and were walking down the hall. He was behind me, there was a nurse there. Nothing inappropriate, but he reached out and patted me on the back. I freaked out. I actually jumped. While I appreciated the act of showing comfort-I taught gang bangers-was stabbed in the back of my neck. If a doctor takes the 10 seconds to touch a patient when they come in or leave-the doctor won’t have a screaming patient that jumps, turns around and is ready to defend in anyway possible. I told him that I wasn’t scared, but it was behind my line of vision, and I was stabbed. I don’t think that he believed me——

He’s a good doctor most of the time. He spent quite a few years in an ER-and I can understand germaphobia working there-everybody that I met that worked at that place seem to have germaphobia. I had another doctor that worked there, and she was the same way.

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Daniel J Sexton MD

As a hospital epidemiologist I agree 100% with every point and comment made in this essay. And reading this essay gave me hope that some doctors are carrying on the great tradition that preceded all of us in our profession. Maybe there is hope for both us and our patients.

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karen

Dear Dr. Sexton:

Thank you so much for your kind comments. It has been very gratifying to me that the piece has been favorably received and shared by the website “Controversies in Hospital Infection Prevention”, and will be reprinted online August 28 in “Hand Hygiene, Infection Prevention and Food Safety Blog.” Perhaps there’s a tiny bit of hope that common sense may prevail!

Karen Sibert

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[…] Karen Sibert wrote a post on wearing gloves while caring for patients titled “Touch your patient. Don’t wear gloves.” Not only is it a good read but it also gives an insight to how this provider is feeling about the […]

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You speak on two issues and i would like to respectfully comment on both. I agree completely and have always felt it important to use touch as a display of compassion and empathy for my patients, especially as I’m putting them to sleep. You can feel them completely relax when you just place your hand on their arm or shoulder.
The only thing that may concern me that is not addressed concerning the gloves is what we may be bringing to our patients from our homes in the way of pathogens. It may be hard to believe, but not all health care workers live their home lives in a relatively clean environment. We would assume that people in our industry would at least protect their families, but that is not always the case. It would be difficult to track or promote change in some of these individuals. When I am a patient, I like to see them placing the gloves on or even using the gel soap, and I think that patients are scared of nosicomial infections and have greater expectations from their health care providers, and in 30 years of practice, I’ve not had any complaints when trying to protect patients, their families or even me and my family. Thank you!

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karen

Thank you so much for your interest in this topic. Again, though, the most important issue is hand-washing, not gloves. If you don’t wash your hands, putting on gloves makes absolutely no difference except to protect you (maybe) from the patient, rather than the other way around. The pathogens you bring from home, unless one’s home is really a cesspool, are likely to be benign normal flora, and aren’t any serious source of risk to anyone. The “dirty glove” phenomenon is getting to be a topic of real concern to epidemiologists, as it creates an illusion of good technique which may not be the case at all. Even sterile gloves don’t necessarily protect patients completely–witness the recent case of a cardiac surgeon with an infected finger who unwittingly infected the new heart valves of several patients due to micro-performations in the gloves. So if you’re taking care of me, please wash your hands and clean the stethoscope. You don’t need to wear gloves. In fact, I’d much rather you save money and the environment by wearing gloves only for contact with body fluids, blood, non-intact skin, and mucous membranes. This is what is supported by the science behind “universal precautions”.

All the best–
Karen Sibert

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Melissa Barthold, MSN, RN-BC (@MelissaBarthold)

Dear Karen –

Thank you!!! I’ve been practicing for over 40 years and I’m a firm believer in the power of touch.

My husband recently had back surgery and I was appalled at the lack of touch. There were 4 people that slid him from the stretcher to the bed (post op) and every one of them wore gloves….for what, I have no idea.

I’ve cared for AIDS patients – and didn’t wear gloves ever time I touched them. (I wasn’t planning on exchanging any bodily fluids, so I felt pretty safe with no gloves.) I promise — all of my co-workers had gloves on. I can’t imagine — the poor man is ‘cared for’ by many different healthcare workers — but no one touches him — they all wear gloves. How lonely that must be, at a time when support is so very needed.

I do hope that your words will go viral! We need to go back to the recommendations for wearing gloves –and it’s not ‘every time you touch a patient for any reason’!!

Thanks — Melissa

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Gail McFarland

My sentiments exactly, Dr. Sibert! It’s time to take off our gloves and shake hands with our patients

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I have been an Internist for over 40 years and I have used gloves only in urological exams, open sores and active bleeding but my hands are part of who I am as a human being and probably the only thing I have to express tenderness, respect, comfort to the patient who is entrusting their bodies and minds so that they can feel better from what is troubling them. The neck requires very gentle palpation since it is one of the most sensitive areas of the body. Your touch must transmit gentleness. It is not easy to be examined by anyone. Only the touch with your hand can detect nodes or feel vibrations on a blood vessel. It is incredible what the fingers can palpate or feel. Yet it is sad how so many physicians use gloves throughout the exam. Such an act humiliates the patient. It makes them feel like an object. I call these people technocrats whose practice of medicine is rigid. cold and robotic and are missing the most important attribute a physician must have…Empathy. If you are not able to feel the hurt and feelings of your patients; then you are not a medical doctor but merely a medical technocrat who mastered science but not the art of medicine.

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Gail DiFiore

Thank you for a call to common sense, and to putting patients first.

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Melissa Barthold

I was helping to administer flu shots in our yearly flu shot event…and really having trouble remembering to wear gloves…because I wasn’t expecting to exchange bodily fluids with anyone. I started discussing this silly ‘glove for every time you touch a patient’ that has overtaken healthcare. The med student told me that they’re being taught to glove EVERY TIME THEY TOUCH A PATIENT. For any reason, regardless of the possibility of exposure to bodily fluids….just wear gloves. Now, that is ill-advised, expensive, interferes with caregiver/patient relationship…..it is just making me shudder to think about it.

I had a procedure yesterday…and the only time the nurse put gloves on was to start my IV. She put on SCD’s, gave me a blanket, took VS, checked heart and lung sounds…with bare hands. I promise you…I really complimented her!

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Seth Loofbourrow

Dear Karen,
I come from an EMS perspective and am just starting medical school. Since we are imprinted to wear gloves every time for somewhat obvious reasons in pre hospital care (no history, no sink on the ambulance etc), I have often felt that disconnect that comes from a lack of contact with my patients. There have been many times I have pulled off the gloves to reassure a child or an elderly person, up to this point I had not put my finger on why this seemed so natural, but you hit it dead on! thanks for the eye opening post!

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Christa

I LOVE this, especially coming from an MD. I am a nurse and frequently have nursing students with me who glove up for EVERYTHING. Don’t get me wrong, gloves are great for instances when you may come into contact with blood or other bodily fluids, or with pts on contact precautions, but seriously, people get extreme. I have had students ask me, do I need to wear gloves (to take vital signs), or ask why I am not wearing them. I tell them as far as the NCLEX is concerned, yes, wear gloves and use the hand sanitizer like 10 times all while you are in one room touching the same patient. But in real life? this is excessive and stupid, and there is nothing wrong with human contact without latex in between. Just wash your hands on the way out.

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Gina

With all due respect, I totally disagree. Hygiene nowadays seems to have gone by the wayside and I for one will be wearing gloves when I touch a patient. When hospitals start requiring that the rooms are cleaned WELL after every patient including all parts of the bed, when they START using disposable equipment from patient to patient, when they START enforcing NO SMOKING rules on the hospital premises so that the patients won’t roll their IV poles outside and then bring the filth back in, when they START holding those accountable who do not wash their hands before leaving a room of a patient who has C-diff, then I may consider touching a patient.

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karen

Dear Gina,

You must do as you think best. Howver, I’m impressed by the WHO guidelines. They make the point that hand-washing actually is WORSE when the glove guidelines aren’t followed. People substitute gloves for hand-washing and then EVERYTHING is contaminated. Best practice still is to wear gloves when there is a likelihood of contacting blood or body fluids, or if a patient is known to be infected. Otherwise, simple skin-to-skin contact with unbroken skin does not require gloves and facilitates normal human interaction.

At least once a day I think to myself that twenty years from now we will have a planet covered with at least 3 feet of disposable gloves, many of which were used unnecessarily.

Thank you so much for writing!

All the best,
Karen Sibert

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Melissa Barthold

I respectfully disagree. I’ve been a practicing nurse for more than 45 years. Touching is part of the art of nursing. (And I’ve never caught anything from a patient.)
.
What really concerns me is the way that people use gloves. They put them on –and touch anything–and then touch everything. They seem to use the gloves to protect themselves, but they’re spreading germs around because the gloves are protection.
I think that they way that many people use gloves contributes to the spread of infection. If they used them correctly – maybe. But, right now — they’re simply a security blanket.

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Ankat

oh my goodness… “the filth”? sounds like you fear your patients to the point that you would wear full-body protective gear… if it was available.

If contact with live humans is so traumatic, an office-based career is probably more appropriate (just as I was writing this, I realized that offices are also full of humans, some of whom smoke and “bring back the filth”)….

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Thank your valuable sharing
I prefer not to wear gloves when in contact with patients
It feels intimate closeness with patients
It is an invisible link between doctors and patients

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Rebeca McNamara

I recently overheard a Professor of Health Assessment instructing BSN students on patient assessment. I was shocked to hear him say, “wear gloves for all patient interactions…you don’t know what those patients may have…” keep yourself safe, so just wear gloves all the time…”
I interrupted this lecture to ask, “when will we have the human connection, if we are always wearing gloves?” I also interjected the WHO and CDC stance on gloving appropriately.
This is fast becoming an issue among staff because overuse of gloving is offensive to many patients and a cost-containment issue.
I am so grateful for this article, because this issue is of great interest to myself. I hope we are not becoming task masters and losing sight of the humanistic aspects of caring and healing our patients through touch and building bonds of trust.

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