Stacey Hoffman always watches the doctor's hands. At a recent appointment, she studied her family physician as he squirted sanitizer into his palms. Only then did they shake hands. After the exam, the Maple Grove woman saw him "foam out" before leaving the room to see other patients. "If you see them do it, then I feel better about it," she said.

Diligent attention to hand hygiene isn't a given in every medical setting. That's why one California doctor is calling on hospitals and clinics to establish "handshake-free zones" to stop the spread of germs.

"We're here to get patients well, not give them warm fuzzies," said Dr. Mark Sklansky, a pediatric cardiologist and professor at the University of California, Los Angeles.

His case against the handshake — that time-honored greeting used to seal a deal or to convey warmth — has touched off a lively debate among doctors since appearing this summer in the Journal of the American Medical Association.

The notion of outlawing the doctor-patient handshake pits two values sacred to the medical profession against each other: do no harm vs. compassionate care. Many doctors say banning this small yet meaningful connection would erode the human touch central to the medical practice.

"It's a really important part of being a caregiver," said Dr. Robert Quickel, a surgeon at Hennepin County Medical Center in downtown Minneapolis.

But there's no shaking it: Our germ-carrying palms are under fire.

Sanitizer dispensers are ever-present in the corridors of HCMC, with signs reminding staff and visitors to "always foam in and foam out." At Park Nicollet Clinic, surveys ask patients to report if doctors and nurses did not clean their hands in the exam room. And while there may be no handshake-free zones at Twin Cities area hospitals, there are doctors who make a point not to shake hands.

One alternative — the fist bump — recently received a scientific stamp of approval. Researchers in Wales discovered that the popular knuckle tap spreads only one-twentieth the amount of bacteria as a handshake.

The attention to hands is well-deserved, argued Sklansky: "We touch keyboards. We touch phones. We touch doorknobs. We touch our own eyes and mouths. We have to go to the bathroom and such. … That's how germs end up on hands."

Keeping it clean

Quickel routinely offers his hand to patients as a way to connect with them.

His hands are often still wet from washing them when he approaches a patient. "Wet, but clean," he tells them with a smile.

Given how much hospitals stress hand washing, he's not sure what all the hand-wringing is about. In the surgical ward, doctors and nurses typically have a 95 percent rate of compliance with hand hygiene policies, according to internal monitoring programs at HCMC.

"There are so many other things that we [should] focus on first, like neckties, lanyards and sleeves," he said. "Those things get really dirty and don't get washed."

Still, after reading Sklansky's take on handshakes, Quickel said the topic should be studied to see if eliminating handshakes would really make a difference in curbing infections.

In the clash of health care values, those opposed to handshakes argue that "do no harm" should win. Sklansky suggests there are other, perhaps better, ways for doctors to show good bedside manner. "Sometimes the handshake can be somewhat perfunctory. Sometimes, people do that in place of a smile and warm contact."

Alternatives to the handshake include: the Namaste gesture, hand waving, bowing or using the "salaam gesture" — putting your hand on your heart. (See box below.)

Carol Kanaly of St. Paul sat in an exam room at HCMC one recent afternoon, waiting to see a doctor about her tendinitis. A handshake between doctor and patient is all right by her, she said, adding that she doesn't worry about getting sick at the hospital from hand-to-hand contact.

"If I'm going to catch it, I'm going to catch it — whether it's here or on the street," she said.

Across the hall in another exam room, Vincent Lewis said he'd understand if doctors stopped shaking hands for fear of spreading germs. "I wouldn't look down on them," he said, shrugging. "Nowadays so many things [can] be passed."

His favorite alternative: "Maybe we could do a fist bump," he said. In fact, Lewis mostly fist bumps when meeting new people because he's leery of germs.

Shaking off a social norm

Park Nicollet collected more than 4,000 hand-hygiene surveys from its patients last year, revealing a 93 percent compliance rate among medical staff at all clinics, said Amy Priddy, a registered nurse who led the hand hygiene project.

At this point, Park Nicollet officials have no plan to ban handshakes. It's such a new idea, Priddy said, and there are a lot of variables to consider.

"There are patients going through some very difficult times with new diagnoses," she said. "Having that human connection is something we would need to consider if we were ever going to go down that path of banning handshakes."

Handshake-free zones aren't necessary so long as care workers are meticulous and consistent about hand hygiene, argued Dr. Pritish Tosh, an infectious disease physician and researcher at Mayo Clinic in Rochester.

"It is true our contact with each other, especially within hospitals, has the potential for transmitting organisms," he said. "But rather than focusing on not shaking hands, the focus really needs to be on hand hygiene."

He often uses a handshake to welcome his patient and signal that they're in caring hands, he said, adding that he always cleans his hands before and after examining a patient.

"I'm confident I'm not spreading infection through my hands, and at the same time I'm still greeting the patient with the respect they deserve," he said. "Before we start thinking about fist bumps or other things, we just really need to focus on making sure that everybody is washing their hands, before and after every patient contact."

An ingrained custom

Despite resistance, Sklansky remains committed to his cause.

Although he has tried to avoid shaking hands with patients and colleagues, it's a tough mission to accomplish. "Sometimes I do it, but it is awkward," he said. Often, people are insulted if he doesn't accept an extended hand. "I understand it's awkward because the handshake is so ingrained in our social custom."

In his mind, individual doctors won't be able to turn the tide. He thinks it has to be done at an institutional level. That's why he believes handshake-free zones are needed.

In keeping with his charge, he is looking for a way to study the impact of these zones to bolster his case. They're still very rare, but he said he knows of a private family practice near his office that is testing it out.

Dr. Sam Ives, also at HCMC, said he doesn't support banning the handshake between doctors and patients.

"It would just be odd," he said. "I think people would find it distasteful."

He frequently shakes hands with patients, as well as with their family members. And, yes, he makes sure he always washes, he said. That moment where you look into someone's eyes and connect through touch is important, he said.

"On some level, it's a way of trying to get to know someone. The handshake is an opportunity to remind myself of what I'm doing — and that this is a person."

Allie Shah • 612-673-4488