• Accreditation
• Ambulatory care
• Attitudes

To the editor,

Cohen1 provides a thoughtful and heartfelt clinical anecdote that complements our review of the shortfalls around hand washing among physicians.2 We agree that hand washing shows care and diligence in patient treatment. It also conveys an image of being calm rather than rushed, humble rather than self-important and wanting contact rather than distance. Unfortunately, the metaphor of just-washed warm-hands may no longer apply to modern hand sanitisers that chill the skin from evaporation. We commend Cohen for his good intentions and yet a fundamental point in behavioural research is that intentions, no matter how emotionally poignant, can fail to translate into action.

In a classic study, seminary students were recruited to deliver a sermon on the parable of the Good Samaritan.3 By random assignment, half were told they were easily ahead of schedule whereas the others were informed they were running late. On the way to the sermon, each participant encountered an ostensibly injured man planted in an alleyway and seeming to need help. The majority of student who had time to spare decided to offer help whereas only a minority who felt hurried decided to offer help (63% vs 10%, p<0.05). Notwithstanding the extended formal training and good intentions, simple time pressure proved critical to the decision to help a suffering man.

We suspect that shortfalls in patient care are more common and difficult than suggested by Cohen's assertion ‘It's not all that complicated really’. The majority of Americans wish to retire in comfort, yet nearly half have no retirement savings. Many Americans intend to exercise and eat healthy, yet four in five do not get the recommended daily amount of exercise and one in three are obese.4 One aim of modern behavioural economics is to find ways (eg, automatic retirement savings accounts, new cafeteria designs) that facilitate behaviour consistent with individual attitudes.5 People have lots of good intentions yet easily stumble on the gap between intentions and action.