This study is the first to examine the effect of a surgeon's mask on communication with patients in the clinic setting.
UNIVERSITY OF NORTH CAROLINA HEALTH CARE
IMAGE: NORMAL MASK VS. CLEAR MASK, DEMONSTRATED BY IAN KRATZKE, MD view more
CREDIT: UNC SCHOOL OF MEDICINE
CHAPEL HILL, NC - A first-of-its-kind study out today in JAMA Surgery suggests that patients have a more difficult time understanding and building trust with their surgeons when they cannot see the surgeon's entire face due to masking requirements. These findings have major implications for not only how surgeons are viewed and rated by their patients, but also how well a patient does during and after a surgical procedure.
"At beginning of pandemic I had a patient say, 'Dr. Kapadia, it's odd you've taken out a big part of my colon and I don't even know what you look like,'" Muneera Kapadia, MD, the study's senior author said. "It made me realize we don't have much information on how masks are effecting surgeon-patient communication and relationships."
Kapadia, an associate professor of surgery in the UNC School of Medicine, found a way to study how the new masking protocols during pre-operative meetings are affecting patients' perception and trust of their surgeons. Study organizers utilized clear masks so that patients could see a surgeon's entire face, while still following safety protocols.
The randomized clinical trial included 200 patients that were recruited from 15 surgeon's clinics, spanning seven subspecialties. Surgeons were randomized to wearing clear masks versus covered masks for each new patient clinic visit. After the clinic encounter, patients completed a verbal survey including validated Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions, and additional questions about surgeon empathy and trust, and the patient's impression of the surgeon's mask.
"When surgeons wore clear masks as opposed to traditional masks, patients rated their surgeon significantly higher in how well they provided an understandable explanation, knew the patient's history, demonstrated empathy, and built trust," said Ian Kratzke, MD, a resident in the department of Surgery at the UNC School of Medicine, and first author of the study.
Patients reported improved communication when surgeons donned a clear mask, suggesting that not seeing the surgeon's face may have negative consequences on the surgeon-patient relationship. And simply put, patients prefer to see their surgeon's face.
While donning clear masks for these interactions can be a solution, Kapadia says the study is more about raising awareness.
"Our face is how we connect with other people," Kapadia said. "We react to people with facial cues, which are being covered by the masks, and that's having a big impact on communication."
"We need to be cognizant that patients are having more difficulty connecting with us as providers. I think knowing that before interacting with them will help mitigate the issue by reminding us to spend more time getting to know our patients, and making sure they understand what we are trying to convey."
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This study was sponsored by the Department of Surgery in the UNC School of Medicine.
Benefits of Clear Masks in Communication With Patients
Adapting to new safety standards during COVID-19 has likely been easier for surgeons who are accustomed to wearing a mask. Although wearing masks outside the operating room has become the new normal, it may not be as easy for patients as it is for us. In this issue of JAMA Surgery, Kratzke et al1 demonstrate that patients whose surgeon wore a clear mask were significantly more likely to give a top-box rating (4 on a Likert scale of 1-4) for providing easy-to-understand information, knowledge of patient information, displaying empathy, and generating trust.1 Although there was no significant difference in patient-reported comfort with the surgeon operating on them, it is unclear whether this study was powered to detect such a difference.
This evidence should motivate us to consider why patients reported a striking difference in communication, particularly in a field (clinical communication research) that is chronically hamstrung by measurements with high ceiling effects. Because each surgeon served as their own control, the content of communication about disease and treatment, ie, information and knowledge, was presumably the same in each group. Thus, information transfer may not be as important as we think; technical details about illness or treatment may be less salient for patients than developing an interpersonal connection. Surgeons might view the surgical consultation as transactional, a time to exchange information, but patients may be inclined to see it as relational. Because human expressions are a critical component of emotional exchange, visual cues such as a smile, frown, or other facial gestures likely contributed to patient-perceived rapport and higher ratings despite similar informational content.
The findings may also point to what covered masks lack rather than what clear masks provide. When surgeons wear covered masks, patients may sense a lack of transparency, viewing the mask as a form of disguise or concealment. With limited visual cues, patients are left to determine how the surgeon is thinking or feeling. Many also noted it was easier to hear the surgeon, suggesting compensation for hearing loss or sensory preferences with visual cues. Study findings may also reflect pandemic fatigue. Masks are a reminder of innumerable hardships over the past year, and clear masks represent extra effort by surgeons to mitigate patient discomfort and increase engagement.
Alongside the disastrous effects of COVID-19 on everyday life, do clear masks really matter? They might. Trust is the cornerstone of surgical care. Without it, patients would not let us operate on them or trust our judgment to forgo surgery. And how we speak may be more important than what we say. As surgeons, we do many bold things because they improve patient care, and wearing a clear mask with new patients should be one of them.
Corresponding Author: Margaret L. Schwarze, MD, Department of Surgery, University of Wisconsin-Madison, K6/134 CSC, 600 Highland Ave, Madison, WI 53726 (schwarze@surgery.wisc.edu).
Published Online: March 11, 2021. doi:10.1001/jamasurg.2021.0848
Conflict of Interest Disclosures: Dr Schwarze reported grants from the National Institutes of Health and Greenwall Foundation and reports that her spouse has ownership interest outside the submitted work. No other disclosures were reported.
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