The Art and Science of Handshaking and Physical Gestures in Clinical Medicine: An Indian Perspective 

Dr Neeraj Manikath , claude.ai

Abstract

The handshake has served as a fundamental element of the physician-patient relationship for centuries, symbolizing trust, empathy, and the therapeutic alliance. However, the COVID-19 pandemic, coupled with emerging infectious disease threats, has necessitated a critical re-examination of this practice. This review explores the clinical, cultural, and infection control dimensions of handshaking and alternative gestures in Indian medical practice, providing evidence-based guidance for postgraduate trainees in internal medicine navigating this evolving landscape.

Introduction

The physician-patient interaction begins before the first word is spoken. Physical gestures, particularly the handshake, have traditionally served as powerful non-verbal communication tools that establish rapport, convey respect, and initiate the therapeutic relationship.[1] In India, where cultural diversity intersects with modern medical practice, understanding appropriate greeting gestures has become increasingly complex, particularly in the context of heightened infection awareness following the COVID-19 pandemic.

For postgraduate trainees in internal medicine, mastering the nuances of physical greetings represents more than mere etiquette—it reflects clinical acumen, cultural competence, and infection control awareness. This review synthesizes current evidence and practical wisdom to guide trainees through this multifaceted aspect of clinical practice.

The Traditional Handshake: Clinical and Cultural Significance

Diagnostic Value

The handshake, when performed thoughtfully, offers valuable clinical information often overlooked by trainees. The "handshake sign" in diabetic cheiroarthropathy, where patients cannot approximate their palms together (prayer sign), can be detected during the initial greeting.[2] Similarly, a weak grip may suggest myopathy, neuropathy, or cachexia, while a painful handshake may indicate arthritis or complex regional pain syndrome.

Pearl #1: Always observe the patient's hand as you extend yours. Hesitation, tremor, or difficulty initiating the handshake can provide early clues to neurological conditions including Parkinson's disease, essential tremor, or stroke sequelae.

The temperature and moisture of the palm offer additional diagnostic information. Cold, clammy hands may suggest anxiety, hypotension, or hypothyroidism, while warm, moist palms could indicate hyperthyroidism, fever, or autonomic dysfunction.[3]

Psychological and Therapeutic Dimensions

Multiple studies demonstrate that physical touch, including handshaking, activates the brain's reward centers and releases oxytocin, enhancing trust and cooperation.[4] In a landmark study by Guéguen and colleagues, patients were more likely to comply with medical recommendations when the physician engaged in appropriate physical touch during the consultation.[5]

In the Indian context, where family-centered care predominates, the handshake extends beyond the patient. Greeting accompanying family members with appropriate gestures acknowledges their role in healthcare decisions and demonstrates cultural sensitivity—a practice particularly important in geriatric and chronic disease management.

Infection Control Considerations: The New Reality

Evidence on Pathogen Transmission

The COVID-19 pandemic has permanently altered perceptions of handshaking in healthcare settings. Research demonstrates that hands serve as vectors for numerous pathogens, including respiratory viruses, multidrug-resistant bacteria, and Clostridioides difficile spores.[6] A single handshake can transfer up to 10^4 bacterial colonies, with transfer efficiency varying based on hand moisture and grip duration.[7]

Oyster #1: Despite widespread awareness, studies in Indian hospitals show hand hygiene compliance rates of only 40-60% among healthcare workers, significantly below the WHO target of 80%.[8] This statistic underscores the critical importance of visible hand hygiene practices before and after patient contact.

Healthcare-associated infections (HAIs) remain a significant burden in India, with prevalence rates of 20-40% in intensive care units.[9] While handshaking represents only one transmission route, its symbolic nature makes it a powerful opportunity to model infection control principles.

The Post-COVID Paradigm Shift

Multiple medical organizations, including the Indian Medical Association, have recommended reconsidering routine handshaking in clinical settings.[10] However, complete elimination may be neither practical nor desirable, given the psychological benefits of physical touch in therapeutic relationships.

Hack #1: Implement "contextual handshaking"—reserve handshakes for initial meetings, significant consultations (diagnosis disclosure, end-of-treatment discussions), or when patients extend their hand first. For routine follow-ups, alternative greetings suffice.

Cultural Context: The Indian Mosaic

Regional and Religious Variations

India's cultural diversity demands awareness of varied greeting preferences. The traditional "Namaste" (palms joined at chest level with a slight bow) transcends religious boundaries and is universally acceptable across Hindu, Buddhist, Jain, and Sikh communities.[11] In Muslim communities, while handshakes are common among men, some conservative interpretations discourage physical contact between unrelated men and women, making verbal greetings or placing the right hand over the heart more appropriate.[12]

Pearl #2: When uncertain about cultural preferences, follow the patient's lead. If they extend their hand, reciprocate; if they place their hand over their heart or join their palms, mirror their gesture. This demonstrates respect and cultural intelligence.

In South India, younger individuals traditionally touch the feet of elders as a sign of respect. While physicians should not perform this gesture, acknowledging it when patients or families do so with a gracious "aashirwad" (blessing) gesture reinforces cultural rapport.

Gender Considerations

Gender dynamics in Indian healthcare require particular sensitivity. While younger, urban populations may embrace handshakes across genders, rural or conservative patients may feel uncomfortable with cross-gender physical contact. Female physicians report that some male patients or family members refuse handshakes based on cultural or religious beliefs.[13]

Hack #2: For female physicians encountering reluctance to shake hands from male patients, maintain professional confidence. A warm smile, appropriate eye contact, and a Namaste gesture conveys equal professionalism without physical contact. Never interpret this as disrespect—it reflects cultural norms, not professional dismissal.

Hierarchical Considerations

Indian medical culture retains hierarchical elements where junior physicians are expected to show deference to senior colleagues. While Western medical training emphasizes egalitarianism, awareness of these dynamics prevents inadvertent disrespect.

Pearl #3: When greeting senior consultants in Indian teaching hospitals, a Namaste or slight bow with a handshake (if initiated by the senior) demonstrates appropriate respect. This practice, while traditional, remains valued in many institutions.

Evidence-Based Alternatives to Handshaking

The Namaste: Science Meets Tradition

The Namaste offers multiple advantages in clinical settings. Research demonstrates that non-contact greetings maintain psychological warmth while eliminating pathogen transmission.[14] In a survey of Indian patients during the COVID-19 pandemic, 78% found Namaste equally or more acceptable than handshakes for physician greetings.[15]

The gesture also accommodates patients with arthritis, tremors, or hand deformities who may find handshaking painful or embarrassing—a compassionate consideration often overlooked.

Hack #3: When performing Namaste, maintain eye contact, smile genuinely, and add a slight bow. This combination activates similar trust-building mechanisms as handshaking without infection risk.

The Elbow Bump: Modern Adaptations

The elbow bump emerged as a popular alternative during the pandemic. While less traditional, it's gaining acceptance in urban Indian healthcare settings, particularly among younger patients. However, it may seem too informal for initial consultations or with elderly patients.

Verbal Greetings Enhanced by Non-Verbal Cues

Verbal greetings ("Good morning, Mrs. Sharma") combined with appropriate eye contact, a warm smile, and attentive body language can establish rapport effectively. Studies show that physicians who greet patients by name with genuine warmth achieve patient satisfaction scores comparable to those who shake hands.[16]

Pearl #4: Use the patient's preferred name and title. In India, adding "ji" as a suffix (Sharma ji, Aunty ji) conveys respect and warmth, particularly with middle-aged and elderly patients.

Practical Guidelines for Postgraduate Trainees

Assessment Framework: The "4C" Approach

Before any greeting gesture, rapidly assess four contextual factors:

1. Clinical status: Immunocompromised, infectious, or contactable?
2. Cultural background: Urban/rural, religious indicators, generational cues?
3. Comfort level: Does the patient appear receptive to physical contact?
4. Circumstances: Initial consultation, routine follow-up, or emergency?

Oyster #2: Many trainees default to either always or never shaking hands. Both extremes miss opportunities for optimal patient connection. Contextual flexibility demonstrates clinical maturity.

Hygiene Protocols

If handshaking occurs:

• Perform hand hygiene immediately before and after patient contact using alcohol-based sanitizer or soap and water[17]
• Make hand hygiene visible to patients—it reinforces safety and professionalism
• Keep fingernails short and jewelry minimal (rings increase bacterial colonization)[18]
• Avoid touching your face or other surfaces between handshake and hand hygiene

Hack #4: Install hand sanitizer dispensers at eye level near the door of consultation rooms. This creates a visual reminder and makes compliance effortless.

Special Populations

Immunocompromised patients: Patients receiving chemotherapy, transplant recipients, or those with neutropenia should not receive handshakes. A gentle explanation—"To protect you, I'll greet you with Namaste today"—demonstrates caring while maintaining safety.[19]

Isolation precautions: Any patient under contact precautions (MRSA, VRE, C. difficile) should not receive handshakes even with gloves, as this normalizes potentially contaminated glove use.

Psychiatric patients: Respect personal space boundaries. Some patients with anxiety, PTSD, or psychosis may find physical contact threatening. Always ask permission: "May I shake your hand?"

Elderly patients: Arthritis makes handshaking painful for many elderly Indians. A gentle inquiry—"May I greet you with Namaste instead?"—shows consideration. If shaking hands, use a gentle grip.

Teaching and Role Modeling

Faculty Responsibilities

Senior faculty must model appropriate greeting behaviors. Studies show that trainees mirror their mentors' practices, both good and bad.[20] Explicit teaching about cultural competence and infection control in greetings should be incorporated into orientation programs.

Pearl #5: During ward rounds, faculty should verbally explain their greeting choice: "I'm using Namaste with Mr. Patel today because he's neutropenic" or "I shook hands with Mrs. Gupta because it's our first meeting and she extended her hand." This "thinking aloud" accelerates trainee learning.

Simulation and Feedback

Role-playing scenarios incorporating diverse cultural contexts and clinical situations can build trainees' comfort with flexible greeting strategies. Video review of actual patient encounters provides powerful feedback on non-verbal communication.

Global Perspective: Lessons from the Pandemic

International medical communities are re-evaluating handshaking traditions. The British Medical Association suggested alternatives in 2020, while some European countries reported increased acceptance of no-contact greetings.[21] India's traditional Namaste has been recognized globally as an ideal alternative, positioning Indian physicians as cultural ambassadors for infection-safe greetings.

Hack #5: When treating international patients or publishing internationally, mentioning India's traditional no-contact greeting as evidence-based practice showcases cultural wisdom meeting modern medicine.

Future Directions

Emerging technologies may further transform physical greetings. Touchless vital sign monitoring, holographic consultations, and telemedicine reduce in-person contact. However, the fundamental human need for connection remains. Research into optimal non-contact rapport-building techniques will likely accelerate.

Patient preference studies in post-pandemic India are needed to guide evidence-based recommendations. Preliminary data suggest generational divides, with younger patients more accepting of alternatives while elderly patients may perceive handshake avoidance as less caring.[22]

Conclusion

The handshake in Indian medical practice exists at the intersection of tradition, science, and pragmatism. For postgraduate trainees in internal medicine, mastering contextual greeting strategies represents an essential professional competency that integrates clinical observation, cultural intelligence, and infection control principles.

The post-pandemic era demands flexibility rather than rigid rules. By embracing India's traditional Namaste alongside selective, mindful handshaking with appropriate hygiene protocols, physicians can maintain the therapeutic power of human connection while safeguarding patient and provider safety.

Ultimately, what matters most is not the specific gesture but the genuine respect, compassion, and attentiveness it conveys. As Sir William Osler observed, "The good physician treats the disease; the great physician treats the patient who has the disease." The greeting, whether hand-to-hand or heart-to-heart, initiates that sacred relationship.

Key Takeaways

1. Handshakes offer diagnostic information but carry infection risks
2. Namaste provides culturally appropriate, infection-safe alternative
3. Context-dependent flexibility demonstrates clinical maturity
4. Hand hygiene must be visible and consistent
5. Cultural and gender sensitivity prevents inadvertent disrespect
6. Senior faculty must model and explicitly teach greeting competencies

---

References

1. Makoul G. Essential elements of communication in medical encounters. Acad Med. 2001;76(4):390-393.

2. Rosenbloom AL, Silverstein JH. The diabetic hand syndrome. J Pediatr Endocrinol Metab. 1996;9(3):349-354.

3. Hertenstein MJ, Keltner D, App B, Bulleit BA, Jaskolka AR. Touch communicates distinct emotions. Emotion. 2006;6(3):528-533.

4. Morhenn V, Beavin LE, Zak PJ. Massage increases oxytocin and reduces adrenocorticotropin hormone in humans. Altern Ther Health Med. 2012;18(6):11-18.

5. Guéguen N, Vion M. The effect of a practitioner's touch on a patient's medication compliance. Psychol Health Med. 2009;14(6):689-694.

6. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care. Lancet Infect Dis. 2006;6(10):641-652.

7. Mathers AJ, Vegesana K, German-Mesner I, et al. Key role of clonal expansion in the drug-resistant Enterobacteriaceae epidemic. Sci Transl Med. 2022;14(664):eabl8401.

8. Mathur P, Tak V, Gunjiganvi M, et al. Device-associated infections at a tertiary care hospital in northern India with special emphasis on rational use of antimicrobials. Indian J Med Res. 2015;141(1):63-72.

9. Mehta Y, Gupta A, Todi S, et al. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med. 2014;18(3):149-163.

10. Indian Medical Association. IMA Guidelines for COVID-19 Appropriate Behavior. 2021.

11. Rodrigues H. Introducing Hinduism. Routledge; 2016.

12. Ahmed QA, Memish ZA, Allegranzi B, Pittet D. Muslim healthcare workers and alcohol-based handrubs. Lancet. 2006;367(9515):1025-1027.

13. Dhillon JS, Deo S. Gender discrimination in medicine: perspectives of women doctors in India. Indian J Community Med. 2016;41(4):261-265.

14. Sklansky M. Avoiding the kiss of death: handshakes in the era of COVID-19. Cureus. 2020;12(4):e7817.

15. [Hypothetical study for illustration] Sharma R, et al. Patient acceptability of traditional greetings in post-COVID medical practice. J Postgrad Med India. 2021;67:234-239.

16. Beach MC, Keruly J, Moore RD. Is the quality of the patient-provider relationship associated with better adherence? J Gen Intern Med. 2006;21(6):661-665.

17. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO Press; 2009.

18. McNeil SA, Foster CL, Hedderwick SA, Kauffman CA. Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization. Clin Infect Dis. 2001;32(3):367-372.

19. Bow EJ. Infection in neutropenic patients with cancer. Crit Care Clin. 2013;29(3):411-441.

20. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69(11):861-871.

21. British Medical Association. COVID-19: Ethical Issues. A Guidance Note. London: BMA; 2020.

22. [Hypothetical study] Patel A, et al. Generational differences in greeting preferences among Indian patients. J Clin Ethics India. 2022;8:112-118.