Are the sick and dying really the critical control point for disease transmission in a hospital?

Maureen Dowd of the New York Times wrote last week about how her brother went into the hospital with pneumonia, quickly contracted four other infections in the intensive care unit, and sadly, died.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.

“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.

A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.

A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a “bare below the elbow” dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.

The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a “poor” record of obeying hand-washing rules.

A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.

Commenting on the new report on hospital errors, CNN’s senior medical correspondent, Elizabeth Cohen, instructed viewers to “ask doctors and nurses to wash their hands” if they haven’t.

“They sometimes will actually give you a hard time, believe it or not,” she said, “and they say, ‘My gloves are on. I’m clean.’ ‘Well, I didn’t see you put those gloves on. What if you put those on with dirty hands?’ ”

I called Cohen, the author of “The Empowered Patient,” to ask her the best way to confront those taking care of you or family members. She said that you have to get over the “waiter spitting in your soup scenario,” that the medical professionals will somehow avenge themselves, by giving less attention, if you insult them.

Dr. Peter Pronovost of Johns Hopkins has been able to prove in a national program that you can curb infections and reduce mortality rates in I.C.U.’s by adhering to checklists, creating accountability and fostering a culture where patients, their families and even nurses and residents feel freer to challenge doctors.

We’ve had some success using a mixture of shock and shame – shock being gross photos, shame being social embarrassment – in hospital, teaching and food service environments.

Yesterday, several letter writers voiced their views.

Steven Kussin, a gastroenterologist, is the author of the forthcoming book “Doctor, Your Patient Will See You Now” wrote that asking, “Did you wash your hands?” is not the way to start off the conversation. Doctors or staff members who respond “no” are guilty of a grave medical lapse. If they didn’t wash and then lie to you, they’re also guilty of a grave ethical lapse. Either way, the question raises their defenses and their hackles. Instead, if you didn’t witness a hand-washing ritual, then assume it didn’t happen. You’ll probably be right. Physician hand-washing compliance runs about 33 percent.

When they, or anyone, approach your bedside, give them notice of your intent. Hold out a bottle of sanitizer with a big smile. As you squirt them say: “I know how busy you are, and I am sure you’ve already done this a million times a day. But I’m terrified of those infections I’ve been reading about. I hope you’re O.K. with this.”

Theresa Merrill Anovick of Ridgewood, N.J.,writes, “I send back food in restaurants all the time, and never let a doctor shake my hand until I see him wash his in front of me! Do I get a lot of attitude and resistance? Absolutely. That’s O.K.; then I know that this is not the doctor I want caring for me.”

But is it really up to the sick and dying to enforce basic sanitation?