Sunday, September 24, 2006

If doctors wont do it ...

This week's Freakonomics column in the New York Times (click here) reports on the difficulties in getting doctors to wash their hands and not spread bacteria.

It may seem a mystery why doctors, of all people, practice poor hand hygiene. But as Bender huddled with the hospital’s leadership, they identified a number of reasons. For starters, doctors are very busy. And a sink isn’t always handy — often it is situated far out of a doctor’s work flow or is barricaded by equipment. Many hospitals, including Cedars-Sinai, had already introduced alcohol-based disinfectants like Purell as an alternative to regular hand-washing. But even with Purell dispensers mounted on a wall, the Cedars-Sinai doctors didn’t always use them.

There also seem to be psychological reasons for noncompliance. The first is what might be called a perception deficit. In one Australian medical study, doctors self-reported their hand-washing rate at 73 percent, whereas when these same doctors were observed, their actual rate was a paltry 9 percent. The second psychological reason, according to one Cedars-Sinai doctor, is arrogance. “The ego can kick in after you have been in practice a while,” explains Paul Silka, an emergency-department physician who is also the hospital’s chief of staff. “You say: ‘Hey, I couldn’t be carrying the bad bugs. It’s the other hospital personnel.”’ Furthermore, most of the doctors at Cedars-Sinai are free agents who work for themselves, not for the hospital, and many of them saw the looming Joint Commission review as a nuisance. Their incentives, in other words, were not quite aligned with the hospital’s.

Now, as a parent you might be thinking: if they can't get doctors to wash their hands, how on earth will we get our children to do so?

In our household, hand washing is an activity of high importance; certainly more so than before we had children. Basically, before and after any child has any meal (defined here as bit of food) hand washing occurs. The before is for the bacteria. The after is for the furniture.

Basically, our system involves extensive monitoring -- especially for the 5 year old. He has the most need for washing and the least inclination. So we have to engage in a comprehensive system of auditing, i.e., hand smelling. Fortunately, the 7 year old has adopted this as a habit and so is compliant. The 2 year old has adopted hand washing as a regular part of life; so much so that she often assists us as the enforcer. She often reminds her parents (mostly me); again exhibiting her future dictatorial tendencies.

As the NYT article explains, for the doctors monitoring didn't work, direct application as they arrived to work didn't work, motivational posters didn't work, and coffee vouchers didn't work. What finally worked was a scan of the offending hand and how much crap was on it. Data was the key.

It occurred to me that this type of scanning machine would work well in our household. Imagine having to put your hands on some device and then you get a hand rating. While the child may not understand the consequences, they could be taught to understand the rating. Keep doing this at an earlier age and they will become nicely obsessively compulsive about not doing anything without a 'green' (or whatever) rating and habits will be formed.

Now if the hospitals wanted to invest in inventing this scanner, I am sure that as it is refined, it will find a decent home and school market too.