Dr Phil Hammond, broadcaster and GP returner in Bristol

It only takes 13 steps to wash your hands properly

Do you know how to wash your hands properly? If, like me, you qualified 20 years ago and have never read anything published by the National Patient Safety Agency (NPSA), then the answer is probably ‘no’. However, a little laminated sheet from the NPSA’s ‘cleanyourhands’ campaign1 has somehow made it onto my desk. And what a delight it is to digest!

Handwashing with soap and water is now a mere 13-stage process starting with ‘wet your hands with water’. You then apply enough soap to cover all hand surfaces. This much I agree with. Soap is slimy and awkward to have on your hands so if you put it all over them, chances are you will rub it all off out of irritation, thus cleaning them in the process. However, according to the best available evidence, you have to rub hands palm to palm, rub the back of each hand with the palm of the other hand while fingers are interlaced, rub palm to palm with fingers interlaced, rub each thumb clasped in the opposite hand using a rotational movement, rub the tips of the fingers in the opposite palm with a rotational movement and then rub each wrist with the opposite palm.

Are you still awake? The good news is that once you have rinsed off your hands, turned off the tap with your elbow (or knee, whichever is easier) and dried thoroughly with a single-use towel, the whole process should take a mere 15–30 seconds. Medical students are now taught this technique like automatons but a more interesting approach would be not just to teach handwashing as if it were an Olympic sport, but to understand why doctors still do not do it despite the overwhelming evidence of its importance.

In the mid-1800s, Ignac Semmelweis proved that the mortality rate from puerperal fever could be drastically reduced if doctors washed their hands between examining different women, but it is not just the hands that need attention. Many GPs do not wash their thermometers between use for one patient and the next—that’s both oral and rectal (well, I have only got the one). And when you stick an otoscope in an ear and say ‘You’ve got a little bit of wax in there’, do you honestly know who’s wax it is? As a locum, I often do an earpiece check and at least half are full of last week’s wax.

One theory for dirty doctors is that, until recently, most of us were men, and men just do not wash. In a random sample of my household, the women wash before meals and after toileting, and the men have to be reminded. I was taught by a microbiologist who never washed after a wee. His theory was that urine is sterile and as he showered every day, his dangly bits were cleaner than his hands.

He also taught me to be inspired by bacteria. There are far more of them inside us than human cells and they communicate better than most medical students. They live, often harmoniously, in multiracial communities. They talk to each other, hold board meetings to decide on plans of action, protect each other, share news, and pass on tips for fighting antibiotics. They even talk to you and you talk back to them. Each of us is in a state of continuous conversation with the bacteria that share our lives, determining whether we live in a state of truce or war.

And when there is a war, it is usually started by us throwing toxic chemicals and antibiotics at them. But we can never win. Stronger and more powerful antibiotics ultimately only ever lead to stronger and more powerful bacteria and the problems they cause are entirely predictable. So the onus returns to handwashing, the one thing that works and has the fewest side-effects—if only we did it. What we need are guidelines…

  1. www.npsa.nhs.uk/cleanyourhands/the-campaign/latest-news/ G

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