Infection Control & Hospital Epidemiology (2018), 39, 1269–1276 doi:10.1017/ice.2018.189


Letter to the Editor


Hospital epidemiologists and the art of salesmanship Daniel J. Sexton MD, FIDSA, FSHEA Duke Infection Control Outreach Network, Duke University Medical Center, Durham, North Carolina


To the Editor—A recent editorial in The Wall Street Journal by Stewart Easterby, a management consultant, entitled “Climate Activists Are Lousy Salesmen”1 led me to suspect that poor salesmanship is a common flaw among American hospital epidemiologists. Even successful hospital epidemiologists routi- nely encounter nurses, physicians, other healthcare workers and administrators who are dismissive of many evidence-based pro- tocols for infection prevention. Could this failure to communicate be due in part to our lack of skills in salesmanship? Stewart Easterby argues that politicians, scientists, and the


media—collectively defined as “climate activists”—have failed to convince most Americans that the Earth is on a path to “cata- strophe.”1 Repeated calls for radical remedies have fallen on tens of millions of deaf ears for multiple reasons. First, a proportion of prominent “climate crusaders” lack clarity and a human touch when advocating for radical economic and social changes. Use of vague words like “climate change” baffle the public. Only a few members of the public understand or can assess the scientific validity of climate research. And many studies and models cited by qualified experts as scientific proof of climate variations have not been explained in clear layman’s terms. The public has grown weary of sensational news stories of


climate studies that have subsequently been debunked or dis- credited. And millions of average citizens believe that they cannot change the climate even if they fully embrace complicated, expensive, and inconvenient remedies to problems that will persist well beyond their natural lives. Finally, and most importantly, millions of Americans become


resentful when climate crusaders proclaim that “climate deniers” are a major reason that many policies, laws, and treaties have failed to either be enacted or be effective. This synopsis has similarities and parallels in our world of


hospital epidemiology. Although time pressures, inadequate staff education, and inadequacies in human factors engineering com- monly lead to noncompliance with infection prevention mea- sures, most of us hospital epidemiologists have at some time blamed our colleagues for the sorry state of poor compliance with prevention measures such as hand hygiene, isolation protocols, sterile techniques, and surgical infection prevention protocols. Our colleagues know this and often resent it. Virtually all healthcare workers want to do the right thing, but often they are too busy, improperly educated, or rightfully annoyed with cum- bersome processes such as using gowns for isolation that they believe add no value to the care they provide.


Box 3605, Durham, NC 27710. E-mail: Sexto002@mc.duke.edu.


Infection Control & Hospital Epidemiology 2018, 39, 1269–1270. doi: 10.1017/ice.2018.189 Author for correspondence: Daniel J. Sexton MD, Duke University Medical Center,


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. Cite this article: Sexton DJ (2018). Hospital epidemiologists and the art of salesmanship. Hospital epidemiologists have made clarion calls about their


deep concerns regarding emerging antimicrobial resistance. However, our remedies too often strike clinicians as impractical, inconvenient, unproven, invalid, and/or futile. Antimicrobial resistance has been evolving for over 75 years


and, like climate “deniers,” clinicians and nurses, even those who realize and admit that “bad bugs” are a big problem, are “ ... naturally disinclined to obsess daily about a phenomenon that started long before they were born and won’t reach fruition until long after they die.”1 As a result, large numbers of clinicians, while acknowledging the problem of antibiotic resistance, con- tinue to overprescribe antibiotics in their daily practice. Perhaps the disconnection between our concerns about patient


safety, infection prevention protocols, and antimicrobial resis- tance and their half-hearted acceptance by many of our colleagues can be explained by our lack of expertise in salesmanship. How can we change the status quo? To begin, we should


directly acknowledge that we are unable to definitively and temporally determine the cause or causes of transmission of numerous pathogens because of the complexity of modern healthcare, the enormous numbers of personal touch interactions between staff and patients and the movement of patients within the modern health system. Indeed, studies employing whole- genomic sequencing methods have illustrated the complexity of unresolved questions about the transmission of Clostridium difficile, carbapenem-resistant Enterobacteriaceae, and methicillin- resistant Staphylococcus aureus.2–4 Our lack of evidence on these fundamental points results in widespread skepticism when we propose that implementing a “bundle” will reduce infections or that handwashing is a panacea for reducing infections in complex and highly contaminated environments full of sick patients receiving extraordinarily complex care. As Easterby suggests in the editorial cited above, we may


attract more supporters and believers if we create a clear, con- sistent call to action using convincing spokespersons with local and/or national credibility. Overtly strident or overconfident hospital epidemiologists who advocate unproven protocols or policies are unlikely to stimulate cooperation from healthcare workers. Although simple measures and multipart bundles often improve outcomes, such bundles will not solve many refractory and vexing problems related to preventing transmission of healthcare pathogens nor will they work in all healthcare settings or systems. We need to better “label” our programs, policies, and protocols.


These labels and our terminology should be credible, accurate, consistent, logical, and understandable. For example, slogans such as “getting to zero” are not plausible, and our colleagues know this. On the other hand, honest and humble messages that emphasize


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