Patients are more likely to trust surgeons wearing a clear mask rather than one obscuring the mouth, according to new research.1

Surgeons who wore clear masks were considered to be better at demonstrating empathy, showing respect, and communicating clearly, says Muneera R. Kapadia, MD, MME, study co-author and an associate professor of surgery at the University of North Carolina at Chapel Hill.

“We asked surgeons who were willing to participate to wear either a clear mask or a standard covered mask, depending on their randomization,” she says. “After the clinic encounter with new patients, one of our researchers went into the examination room and said, ‘We’d like to ask you some questions about your surgeon’s communication behaviors.’”

Researchers asked patients how well the surgeon explained things, how much they trusted the surgeon’s decisions, and how comfortable they were in meeting the surgeon. The study stemmed from Kapadia’s own experience as a surgeon, wearing masks while trying to optimize patient rapport and communication.

“Last summer, I had a patient [who had colon surgery], and at the end of his three-day hospital stay, he said to me, ‘Doc, you’ve taken out half of my colon, and I don’t know what you look like. I’ve never seen your face,’” Kapadia recalls. “I’ve had a long-standing interest in surgeon-patient communication, so it got me thinking about what is the effect of us as providers, as surgeons, wearing masks? How does it affect communication between us and our patients?”

During the COVID-19 pandemic, it was not feasible to randomize surgeons to wearing a mask or not wearing any mask.

“We started to think about whether there was another way [to cover] your face. Dr. Ian Kratzke came on board and provided us with the ideas of clear masks, which we could use as a proxy for not wearing masks,” Kapadia says.

Patients’ impressions of the masks also showed a higher rating for the clear mask. Patients of surgeons who wore the clear mask offered unanimous positive ratings. But this was not true of covered masks. “We asked patients on a scale of 1 to 4 to rate the clear mask and the covered mask,” Kapadia says. “Four was highest, 1 was lowest, and the patients in the clear mask group gave it a 4 rating.”

The study’s most surprising finding was there were so many differences in patients’ opinions about their surgeon based on which mask the surgeon wore, Kapadia notes.

“We didn’t have surgeons change anything else besides their masks, and we found lots of differences where the clear mask was rated significantly higher,” she says. “When we asked patients about their trust in the surgeon’s decisions, when surgeons wore a covered mask [their trust] was significantly lower than when they wore a clear mask.” Then, researchers asked patients, “How comfortable are you with the surgeon operating on you?”

“What we’re concerned about is that patients were saying, ‘I trust you a little less when I can’t see your face, but I guess I’ll still let you operate on me,’” Kapadia says.

On the Likert scale about trust, a 4 was considered a positive answer, and researchers hoped to see that score across the board. Even though that was not the case, Kapadia notes a score of 3 indicated trust existed, just not to the extent researchers might have hoped.

“Ultimately, for me as a surgeon, that’s concerning,” she says. “We want our patients to go into the relationship with the highest trust. It should take a lot of trust for a patient to say, ‘Yes, doctor, I’m going to let you operate on me.’ The fact that patients are reporting diminished trust when we’re wearing masks is concerning to me.”

Kapadia and colleagues also asked surgeons whether they would choose the clear mask over their standard covered mask. A majority (53%) said they would not. Surgeons responded to open-ended questions about what they thought of the clear mask and how likely they were to use it again.

“There’s definitely a disconnect between patients and surgeons,” Kapadia observes. “Patients loved the clear mask. With surgeons, it was lukewarm at best.”

Surgeons cited fit, fogging, and concerns about protection. The study authors chose one clear mask type because it allowed people to see most of the physician’s face, and it was rated for safety similar to standard surgical masks. Still, if one is talking to a COVID-19-positive patient, or someone showing signs of infection, Kapadia says it might be best for surgeons to stick with standard masking protocols, not the clear mask. Nevertheless, it appears Kapadia and colleagues uncovered an issue that should be addressed — namely, improving communication between surgeons and patients. Wearing a clear mask could be one solution.

“There are other solutions that we could study — spending more time with patients, using more empathetic statements,” Kapadia offers. “These are other potential solutions that may be just as effective.”

It is possible patients like clear masks because they can see surgeons’ facial expressions. Some patients also might be relying on lip-reading. “When we cover our mouths, those patients no longer have an extra cue to tell what you’re saying,” Kapadia observes. In fact, the authors recorded specific statements on this issue, such as “If somebody is going to operate on you, it’s very helpful to see their face,” and “[Clear masks] really helped to communicate.”

Kapadia and colleagues did not address the impact of nurses and other clinicians wearing clear masks, which could be included as part of future investigations.

“One might have a hypothesis that given the overwhelming positive response from our patients when surgeons wore the clear mask that patients would appreciate other people wearing the clear mask, but that’s far outside of our study,” Kapadia says. “What is important to me is understanding the impression that wearing a mask has on patients and ... [the] effect on the patient-surgeon relationship.” 

REFERENCE

  1. Kratzke IM, Rosenbaum ME, Cox C, et al. Effect of clear vs standard covered masks on communication with patients during surgical clinic encounters. JAMA Surg 2021; Mar 11. doi: 10.1001/jamasurg.2021.0836. [Online ahead of print].