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Emergency physician W. Frank Peacock discusses his article, “What if a doctor didn’t wash their hands between patients?” He explores the critical role of hand hygiene in preventing hospital-acquired infections while exposing a major gap in infection control: unwashed stethoscopes. Frank highlights how stethoscopes, often overlooked in sanitation protocols, can transfer pathogens between patients, rendering rigorous hand hygiene efforts ineffective. He critiques disposable stethoscopes for their poor acoustic quality and high misdiagnosis rates, advocating instead for single-use disposable barriers that create a touch-free, aseptic environment. Tune in to discover why standard cleaning methods fail and how innovative solutions could revolutionize medical hygiene.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Frank Peacock. He’s an emergency physician, and today’s KevinMD article is “What if a doctor didn’t wash their hands between patients?” Frank, welcome to the show.
Frank Peacock: Good morning.
Kevin Pho: All right, let’s start by briefly telling the audience a little bit about yourself and then the KevinMD article for those who didn’t get a chance to read it.
Frank Peacock: OK, so I’m an emergency physician. I’ve been doing this for like 35 years. I was research director at Baylor for the last decade and a half. And so I got involved in stethoscope hygiene about, you know, five years ago because this crazy friend of mine said it was a problem. I didn’t believe him. We did some research. It’s a problem. So, that’s what this is about.
Kevin Pho: All right, so tell me about how you got interested in stethoscope hygiene and some of the data that suggests that it’s a problem.
Frank Peacock: Yeah, so it’s like all good stories. There were four of us sitting in a bar talking, and what happened was one was a cardiologist. I’m an emergency doc. I do a lot of cardiology work. One’s a business guy and one’s a supply chain person, and we’re going like, the supply chain person says, “Hey, you know, I’ve never seen my doc wash his stethoscope.” And me and the cardiologist look at each other and go, “Yeah, probably true. And how can that be?” And so we got into hand washing and all that, and it’s like, well, what if you didn’t wash your hands? Well, we have hand washing police in my ER. They look like administrators. They got a suit jacket and a clipboard, and they run around and they say, “Hey,” and if they don’t see you wash your hands going in and out of a room, you get a checkbox that says you’re a bad doctor. You get a couple of those checks and you got to go talk to your chairman, who then says, “God, will you please wash your freaking hands because otherwise I got to fire you.”
And so that’s how that works. And then you go see your patient, and you wash your hands, and you then take out your stethoscope, and you listen to them, and set it back in your chest and go on. And you do that on every single patient. And if you ask people, it’s interesting, and you do a survey, and you say, “When’s the last time you washed your stethoscope?” and he goes, “Oh, I do it all the time. Yeah, all the time.” And then you culture them, and they’re dirtier than stink. They have bugs on them you don’t even want to know about.
If you do an ambush trial, where you go up to them and say, “Do you wash your hands or wash your stethoscope?” They say, “Oh, yeah.” And then you culture it immediately. You’ll find out that the ones who say they wash it all the time, that number suddenly is a lot lower, but the culture rates are unchanged between those who say, “I wash it between every patient,” and the ones who said, “I haven’t washed it since medical school.” About 80 percent of them have bugs on them. There are no very few clean stethoscopes. And when you look at the bugs, it’s Pseudomonas and MRSA and stuff you don’t want on you. And during COVID, I certainly don’t want that.
And so when you look at those bugs, you go, “Well, heck, if you wash it, why didn’t it clean?” And the problem is, you know, you can wash your hands pretty well. It’s hard to get under your fingernails, but that’s not a part you rub on your patient anyway. The stethoscope has that little rim between the metal retention ring and the diaphragm. You can’t get in there. So even when you wash it, and this has all been published when it’s been washed really well, 50 percent of the stethoscopes still have bugs on them. But then you go and rub on your patient. And we’ve known since 1861—that’s Ignaz Semmelweis published the first hand washing thing—that when you have a thing that you rub on a patient and rub on a patient and rub on a patient, the third patient has the same stuff the first patient did. The stethoscope’s no different. The idea we’re going to wash your way out of it is not going to happen, because even if you’re diligent and you truly wash it and you go to the next patient, you can’t get it all. It’s going to be there.
And so that’s a challenge. The answer has been, by a lot of administrators who don’t see patients, is, “Hey, well give me these disposable stethoscopes. They’re only 3, and you can use them in that patient’s room.” The problem is, in my article I said they have the acoustic properties of a potato. They’re useless. They’re sold by Toys R Us for a reason. They’re a toy. It’s not a tool.
And I did a study on this. Took SimMan. These are the coolest things in the world. They have all those speakers and dials, and you can turn up, you can put heart sounds in the chest, and you can control the volume to be whatever you want it to be. It can be loud, it can be soft, and you can do heart and lung and belly. So we ran an entire emergency medicine residency class through this at the University of South Alabama, and we gave them a Littman 3200—it’s a recording stethoscope, you can turn it up, it’s a great stethoscope, it’s probably the gold standard, I’m sure Littman loves me saying this, but it’s a nice stethoscope. So they all ran through that, and listened to the chest, and they tended to do pretty good—in fact their diagnosis rate was 100 percent.
So then we put this disc cover, it’s a condom for your stethoscope, on the Littman. And they still got 100 percent, didn’t do anything different. Then we gave them disposable stethoscopes and suddenly the misdiagnosis rate went to 10.9 percent. Number needed to harm is 10. And what they usually miss are the soft systolic murmurs and all the diastolic murmurs. So you become a really crappy doctor immediately with a disposable stethoscope. And my contention on this is that they’re a time out to malpractice. If you’re doing them, you can’t be—there’s no point. You can barely hear it.
And then all the ultrasound people said, “Well, we got ultrasound.” I was like, “Yeah, you do, and it’s really good at doing what it’s really good at, and it’s terrible on the airway.” When you listen to asthma with an ultrasound, it’s useless. COPD—you can’t hear wheezes. COVID—I have no clue. It’s really good for looking at the heart. I use it every day that I work in the ER. It’s good if you have effusions, you can see B lines. They’re great. But it’s no good for the airway. Intubate somebody, which side is the tube in? Is it down the right main? I don’t know. Can’t tell with the ultrasound. So ultrasound and stethoscope are friends. They’re not competitors. You need them both. Welcome to 2025.
And so the problem is, what are you gonna do with your dirty stethoscope? And the answer we’ve come up with is, you can put a barrier on it. These things cost a few pennies. They’re not expensive. They’re disposable as long as you don’t touch them with your hands. They’re sterile as they come out of the machine. So you walk the machine a bit, put it on there. It doesn’t change the sound of the stethoscope. You still have your good stethoscope. You don’t have to share it with anybody.
I didn’t talk about that. You know, Kevin, I like you a lot, but I wouldn’t share your silverware or your underwear, and when you start sharing stethoscopes, we culture these things. You know what’s in there? Pseudomonas. It’s in your ear hole. I don’t want what’s in your ear hole in my ear hole. I don’t share my stethoscope anymore. As soon as I learn it, it’s like, the residents say, “Can I use your stethoscope?” No. Go get your own. You can leave for a minute. Go get your own. I’m not using yours. So anyway, that’s where we are with this, is that here is a machine that spits out an aseptic barrier that makes your stethoscope clean. So why not use it? Why spread some? Anything that goes from patient to patient should not be dirty. And there are new CDC guidelines that are supposed to come out in 2024. Yes, I know it’s 2025. CDC seems to be a little bit behind, but there are draft guidelines available today on the internet that say you should use a clean device on every patient. You shouldn’t be using some dirty thing that you used in the last 52 patients.
Kevin Pho: Before we talk about that solution in terms of the data with stethoscopes, are they linked to things like hospital-acquired infections and really patient outcomes with these dirty stethoscopes?
Frank Peacock: So that’s really hard to say, because if a patient gets MRSA, did he get it from the stethoscope? Did he get it from the orthopedic surgeon who came in and checked out his wound? Did he get it from his wife who came and gave him a hug? So you don’t really know the source. But what we do know, and we do have some early data, is that in situations where there are high CLABSI rates—you know, central line-associated bloodstream infections—using a stethoscope barrier with chlorhexidine dressings makes the CLABSI rate go to zero. People ask, “How can that be?” It’s like, well, when you take a dirty stethoscope and you rub it on the chest—oh, by the way, the central line’s up here—now there’s whatever it is on the chest, next central line.
So that’s one of the studies we have. They did some studies out of the VA in Cleveland where they took C. diff and they put it on a patient, and they rubbed it on the stethoscope and put it on the patient, and then went to the next patient. They were able to demonstrate that that C. diff ended up on the next patient. And they’ve done a lot of data with different kinds of bacterial tracers, like, there’s a cauliflower mosaic virus that doesn’t infect humans, it infects cauliflower, and they can put it on patients. And then what they find out is down the hall, three patients down, this guy’s got cauliflower mosaic virus all over him. How did that happen? Well, they washed their hands, and the stethoscope was a vector. So we don’t have perfect data, because there’s been no hospital that took it over and said, “We’re going to do stethoscope barriers for everybody and then look at the rate,” because you have to do the whole hospital. If you do one floor, it just doesn’t—well, you can see there are differences in transmission, but it’s hard to make them responsible for that one stethoscope.
So that is the problem. We do have cost analyses, which are really interesting. We published this in Clinical Experimental Emergency Medicine a year ago, and in cost analysis, assumptions arise, so you have to look at them with a, you know, a sort of funky perspective. So what we said is, well, C. diff costs about 25,000 if you get a case—one case. And if you had it on your stethoscope, alcohol will never kill it because it has spores that are immune to it. And so you might spread it around. And normal people don’t get infections. You can put C. diff—I’m sure I’ve had C. diff on me. But if the rate of transmission is 1 percent, which is pretty freaking low, in a normal ER, 20-bed place, it sees, you know, 35,000 patients a year, how many would that be? Well, it would be like 15 cases a year of patients if only 1 percent actually got an infection. But what does that add up to? That’s like 150,000. Sorry, 300,000 a year just because you didn’t wash your stethoscope. And that’s just C. diff. And if you want to state MRSA, that number comes out to 1 million a year. And then if you want to do immunocompromised patients—I’m assuming that normal people don’t get infections. Even if I put MRSA on you, you’ll be fine. But immunocompromised people are different animals. And so some guy comes in, and he’s got a kidney transplant or he’s got cancer, and he’s on chemo, that transmission rate goes up by a lot, probably not 1 percent, we’ve guessed 10 percent. And suddenly you’re into millions of dollars a year because you’re spreading bugs around. If we did it with our hands, you’d be fired, but you can do it with your stethoscope. And the new guidelines are going to say don’t do that anymore.
Kevin Pho: Now, just to go back to some of the data that you mentioned in terms of the different modalities of cleaning the stethoscope, whether it’s with whatever—soap, germicidal cloths—the different ways that we think about cleaning stethoscopes, universally relatively ineffective. Is that what you’re saying?
Frank Peacock: Right. That’s been studied by a guy named Pito. And what they did is they took stethoscopes and they cleaned it with—they used 70 percent alcohol, which is more than we use. In the hospital it’s usually about 60 percent that comes out of those machines in front of every room, the foam. And they rubbed them. And if you rub less than 60 seconds with higher concentrations of alcohol than we currently have, you get about a 50 percent clean rate. If you go for a full 60 seconds, you get a 28 percent—your clean rate will leave about 28 percent of stethoscopes with pathogens on them. So with higher alcohol for longer times, you can make a dent. It never gets to be clean. There’s never been a study—and I pulled every single one of them, and there’s like 35—there’s never been a study that shows that you can clean your way out of it. It isn’t going to happen. We can try, and it looks good. The patients love it to see you washing. You know, that’s why we wash our hands in front of the patients. It’s a public relations ploy. It’s not just to keep them clean; it’s to show that we’re clean and you can be safe here. Same thing with stethoscopes. There have been studies on patient satisfaction. They love to see a barrier on there because they know that you’re taking care of it. And they love to see you wash it, even though we know it doesn’t work. They don’t know it doesn’t work, and they’re happy. Those are the things that Press Ganey looks at, to find out that you’re being taken care of, that you’re secure in your environment. You know, that’s why the walls are white, so that everything looks clean. That’s one of our jobs.
Kevin Pho: Now, is there a difference in terms of the setting where people use the stethoscopes? You obviously work in the emergency department. I’m going to assume perhaps there’s a higher rate of things like pseudomonas compared to what I do in a primary care outpatient clinic. Any difference the setting makes in terms of the pathogens that are cultured from a stethoscope?
Frank Peacock: Yeah, that’s not so good, because most of the trials have been done in places where you can get a whole bunch of cultures all at once. Yeah, and the ER is good at that. What we can say is that your patient population is probably not as immunosuppressed as mine, and my population is not as immunosuppressed as a cancer hospital. And we went over to MD Anderson and looked at that, and you know, everybody they see is on chemo, so I think there is a level of concern that goes up when you move into ICUs, transplant centers, cancer hospitals, and that sort of thing. The risk for that patient goes up.
As to the bugs, the rate of bugs is determined by the population that you’re seeing, and you know, a primary care population in an office where people are there for other reasons—they’re there to get their cholesterol checked—they probably don’t have much candida auris on them. You go to a nursing home where there’s candida auris—that’s one of the worst bugs ever. It’s a bug we don’t have a cure for. You know, it’s 1940, the pre-antibiotic era. You get an infection on your toe, what do you do? We’re gonna have to cut it off because we got no other way to save your life. So that’s, you know, you have to look at your environment and decide what your risks are.
Kevin Pho: All right, about the barrier for the stethoscope. Tell us how that works.
Frank Peacock: Absolutely. So it’s just basically a machine that you go up and you wave your hand at it, and there’s a window, and this barrier moves into the window. You stick your stethoscope on it and walk away. You never touch it. The key is, hands are dirty, and even if they look clean, there may not be. It’s the same thing as everything, and so this comes out as aseptic. We’ve done culture studies; there’s no bugs on it, and it’s impervious, and that’s sort of important.
We did this trial where we took a bunch of stethoscopes and we covered them with stool, infected urine, infected blood, snot—everything, all the stuff that my infectious disease friends have in their freezer. We put that on the stethoscopes, and we randomized them to barrier, yes or no, and threw them into an incubator, and every few hours we pulled them out and cultured them. The ones that didn’t have a barrier obviously had E. coli and all the stuff you find in all those fluids, and the ones with barriers were sterile every time. We did this for a week, and a week into it—now the barrier is supposed to be disposable, it’s not supposed to go for a week—but a week later, they were still sterile. So as long as you don’t contaminate the front of it, it’s sterile when you hit your patient. And we talked about the fact that they don’t change the sound. So from a stethoscope use perspective, they are impervious to bugs. So whatever is already on your stethoscope that you couldn’t clean off yesterday will not touch your patient.
And they don’t affect the quality of the auscultation, which is key, because if you turn it into a disposable stethoscope, I’m done. It doesn’t help. So that’s the point. The other thing is, it’s almost—you know, in the house of medicine, people talk about cost of hundreds of dollars for antibiotics. This thing is pennies, and it’s this big, you know, it’s a tiny thing, so it has a very small footprint. We’ve done—you know, everybody is worried about recycling and extended use of stuff. The consequence of a disposable stethoscope for the medical waste chain is enormous—a huge piece of metal, hard plastic that cannot be recycled at all, and this big long tube. It just goes in the garbage after every patient. This thing is a tiny little thing. There is something like 500 uses to equal one disposable stethoscope. It’s a silly formula, but the point is these are single-use aseptic. They take about a second to put on. You just walk on. If you’re going to clean your stethoscope, you’re supposed to clean it for a full 60 seconds, and on a busy shift, I’ll see 50 patients. I can’t. That adds an hour to my day. I don’t have another hour to give. So we need a solution that is not wash it for 60 seconds between every patient.
Kevin Pho: Now, how common are devices like this? Because this is actually the first I’ve heard of an approach like this. How common is it in different emergency departments?
Frank Peacock: Well, it only became available in the past couple of years, and they’re now spreading across states. And it’s not just emergency departments. We find the places that use this have been ICUs, places that get it. So ICUs pick it up frequently, post-op places, emergency departments. I would think labor and delivery would be all over it. They have not been all over it. I’m surprised at that, since they were the ones who described hand washing requirements. But that seems to be where it’s going. And then there have been primary care offices that have picked this up, and there’s a bunch down in Southern California. And the reason is, they see sick people. They also see this as a great patient satisfaction augment tool, because what happens is once a patient has seen it once, and then the doctor comes out with the stethoscope, “Where’s the barrier you’re going to be with that thing?” They don’t know what I know about all the bugs in the stethoscope, but they know they don’t want to be touched with something that’s not clean. It’d be like coming to, you know, someone’s exam. I don’t examine patients anymore without gloves on because I gave up touching people in COVID. I don’t touch them anymore. I always wear gloves. The idea that I’d touch them with my bare hands is like—and patients feel that way too. They’re going like, “Did you wash?” You know, there are signs in my elevator at my hospital that say—and they’re directed to the patients—”Ask your doctor if you washed his hands.” So the patients are, you know, they’re educated now. They’ve got the internet just like me.
So anyway, they’re crawling into standard practice. I think the last map I saw was about 15 states using it. There are places like Montana which don’t use it at all. But, you know, the flow of medical knowledge starts at the academic centers and spreads outwards as education occurs.
And in terms of the barriers, is it simply a lack of knowledge? Is it a cost factor? So what are some of the reasons that some states and hospitals aren’t adopting something like this? Well, I think it’s absolutely a lack of knowledge. There’s never been a publication in the New England Journal on it, so, you know, those are the big—JAMA—those are the biggies. And so as this goes slowly, it’s word of mouth. There are about 30 publications on it, so it’s not from lack of publications, but, you know, medicine changes slowly. You know, the only drugs that have had a greater than 5 percent per year adoption—you know what they are? There’s two of them. It’s Viagra and marijuana, and those are the two that rocketed up to such huge market penetration. But all the other drugs, even the ones that save lives, have about a 5 percent per year penetration of the market. And so that’s where we are with this, is it’s about a 5 percent per year, but at some point you hit critical mass and it rockets. And the feeling is we’re getting really close to that, because there have been a couple of publications in the legal literature that say if your patient has been exposed to an infection and they’re not using some kind of stethoscope barrier, you can attribute it to that, and they won’t be able to prove they didn’t do it, and you will be legally liable for that. That’s not something I like to talk about. Emergency physicians are targets. I don’t like this part of the world, but it’s the cost of doing business. So protecting yourself that way is not unheard of.
Kevin Pho: We’re talking to Frank Peacock. He’s an emergency physician. Today’s KevinMD article is “What if a doctor didn’t wash their hands between patients?” Frank, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Frank Peacock: Yeah, you’re not going to wash your way out of this. Your stethoscope is dirty, and you just can’t clean it. You’re going to have to do something better than spread pathogens among your patients and yourself.
Kevin Pho: Frank, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Frank Peacock: Thanks, Kevin. Good luck.
