By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

Dr. Kemper reports no financial relationships relevant to this field of study.

SOURCE: Klompas M, et al. Universal masking in hospitals in the Covid-19 era. N Engl J Med 2020;382:e63.

Recently, while sitting in the intensive care unit, I noticed one of our renal specialists was adjusting her mask and complaining that it was uncomfortable to wear all day. I inquired why she was wearing it. She seemed puzzled, and responded, “Because of coronavirus.” I had to tell her she was not really protecting herself, she was protecting me. She said, “Why am I wearing it?”

Experts are divided as to whether all healthcare workers (HCWs) — nay, everyone on the planet should be wearing a mask. After a local academic center announced their universal mask policy last week, our facility felt arm-twisted into proceeding with similar guidance for our HCWs to mask in clinical areas. But when is it logical to initiate such a measure for HCWs? The pros and cons for this measure are as follows:

Pros

  • Psychological benefit to the wearer. Right or wrong, people are psychologically more comfortable wearing a mask right now, allowing them to better focus on their jobs, even if they are physically more uncomfortable. Unfortunately, masks are a component of full personal protective equipment (PPE), including gowns, gloves, and face shields. By themselves, masks may provide only minimal protection to the wearer.
  • Wearing a mask helps protect those around you. Data suggest a mask reduces the risk of potential transmission from an asymptomatic or minimally symptomatic HCW to fellow workers and patients. Notably, it is unclear to what degree such individuals may contribute to overall transmission.
  • Reduced stigmatization for those wearing a mask who come to work with minimal or ambiguous symptoms. At least they feel more comfortable donning a mask if everyone else is.

Cons

  • Masks are a valuable resource. Until sufficient masks are available for every HCW, every day, they should be conserved for more necessary duties.
  • Is it rational (or even ethical) for me to wear a mask every day to work when colleagues in New York are at risk for running out of PPE? I do not feel comfortable with this.
  • Masks are uncomfortable. Data suggest mask wearers touch their face and mask more often than those without a mask. Requiring employees to don a mask only in clinical areas guarantees they will be donning and doffing that mask all day, putting it down on a surface, or stuffing it in their pocket during lunch. Like clothing, I bet by the end of the shift that mask will be covered with various bacteria or viruses.
  • If the goal is to reduce transmission to other employees, why is it recommended to remove the mask in nonclinical areas?
  • On the other hand, if the goal is to reduce transmission to patients, then why are many hospital workers with limited or no contact with patients wearing a mask?
  • Will it be practice or policy for HCWs to wear a mask in the healthcare environment? Is this one more thing a hospital is supposed to enforce? Just as there are some HCWs who desperately want to wear a mask, there are some who do not. Can you force them to wear a mask?

I do not see where personal comfort enters into this discussion. Good healthcare must be rational and based on sound principles, not fear. There must be some balance between the prevalence of disease in the population, the risk of transmission from asymptomatic individuals, and disease severity that leads to this decision. It feels like this decision is just masking our anxiety.