How Face Masks May Be Hurting Doctors' Bedside Manner

Let's get it out of the way up front: COVID-19 isn't going anywhere anytime soon. I say this not to be glib but because that means, in all likelihood, face masks are now as much a part of every doctor's uniform — in every clinical setting — as a white coat and stethoscope.

Universal masking for both doctors and patients is likely to do some very real good. Beyond helping to stunt the next COVID spike, we may see fewer community-acquired respiratory infections. That said, this change may also have some unanticipated negative consequences.

Beyond ear discomfort; eyeglass fog; and let's call it "confrontational obstinacy" from vocal, mask-refusing patients, our bedside manner is now impaired. As a medical student, I am still learning how to create a good rapport with those in my care. I was specifically trained to knock on the door and introduce myself with a smile when greeting patients for the first time. Now that we're prevented from shaking hands and grinning when meeting, these encounters feel less personal, like we are just strangers sitting in a room together.

I know this is far from the most pressing issue we currently face. Still, we owe it to those who come to us at their most vulnerable to consider how a face mask may further widen the already problematic gap between doctor and patient and how we might fix that problem.

Casualties of Face Coverings

A mask can be far more disruptive than I ever expected. Recently, a young patient with headaches came to the pediatric clinic at which I was rotating. He was accompanied by his grandmother. After the typical line of questioning, I asked for more background information on falls and head trauma. She began to respond but then cut herself off mid-sentence, choked by emotion. For the first few years of the boy's life, he was physically abused by his biological parents.

What she disclosed would pull on anyone's heartstrings. But I would be lying if I said that I immediately appreciated the emotional gravity, despite sitting across from her. It wasn't until she reached up to wipe tears from her eyes that I knew just how upset she really was. The mask prevented me from better reading her face, from fully being in that moment with her.

Beyond acting as barriers to emotional connections like these, face coverings can have other detrimental effects. Patients with hearing impairment often need healthcare workers to raise their voice, and that's without the dampening effect of a mask. Obviously, lip reading is impossible with one's face covered, and too many of us are unfamiliar with American Sign Language. Even patients without hearing impairment are affected by the obstruction of masks. Language barriers, for instance, require the full complement of nonverbal communication.

Although I may be new to medicine, even I know that poor communication and its adverse effects on patient satisfaction and outcomes were a problem long before COVID-19 put a fabric wall between us and those in our care.

Masks can also impair the finer points of the physical examination itself. "We miss out on nonverbal cues, not to mention subtle findings," Eli Zimmerman, MD, a neurologist at Vanderbilt University Medical Center in Nashville, Tennessee, told me. What we can't see behind a patient's mask may even mean a missed diagnosis. "For instance, watching a patient's face as they talk, laugh, or smile during normal conversation may show subtle evidence of a stroke."

None of this is to say that masks aren't currently essential and ultimately outweigh their negatives. That said, most doctors were not trained in how to routinely overcome what are now everyday obstacles. Those of us who are still learning medicine have less experience adapting to sudden variations in clinical settings. We all need to work on improving this situation.

Rethinking Patient Interactions in a Masked Era

Although some specific ideas and solutions are available, the biggest immediate thing that doctors and students can do is acknowledge that this is a problem. Being aware of how masks may impair bedside manner allows established physicians to adapt in real time and encourages trainees to seek guidance in how best to address the situation.

I have already learned to rely heavily on intangible things that are now blocked by masks. Take something like assigning a name to a face when that face is mostly hidden. Even before everyone was masked, I saw both patients and caregivers forget which surgeon performed an operation, which cardiologist would manage their grandfather's heart failure, or which hospitalist recommended specific discharge information.

One possible solution for inpatients would be creating a routinely updated roster of the team members responsible for their care. A nurse or social worker could print this physical list with one-liners describing each healthcare worker's role. A more sophisticated option might be developing a secured smartphone application that registers a patient's admission code. Every doctor who accesses the chart could be displayed, along with their department or specialty. This could include photos with and without a mask, for added clarity.

Some solutions don't require app developers. Research on how our body language affects patient care is readily available, even if it is infrequently emphasized. Various courses are available online. Institutions associated with universities have ample access to communication scholars. We definitely don't need to burden doctors with more educational requirements, but encouraging everyone in medicine to further develop nonverbal communication skills would pay big dividends with patients, even if masks are eventually excused from our uniforms.

Although practicing physicians would also probably benefit from increasing their knowledge in this area, at least they can draw from their ample experience. Students and interns are not yet practiced in reading subtle patient behaviors. We need specific training. Again, research is available to draw from. Medical school curricula should consider assessing body-language recognition in standardized patient scenarios, just like they do with other physical examination skills. Video analysis of such interactions measuring the amount of eye contact, distance from patient, and time spent at eye level could provide a baseline level of competency and a means to track improvement. You know it's a serious issue when a med student is asking to be tested on something else…

When all is said and done, the ultimate solution may simply be to find a better mask for our routine, daily, face-to-face patient encounters. ClearMask might be an option. The US Food and Drug Administration recently cleared the use of this fully transparent, surgical-grade face mask. Although its adoption has not been widespread enough to conclusively determine its efficacy compared with other alternatives, this see-through option may represent an elegant and easy solution to many of the bedside manner problems brought on by other face coverings.

I never imagined training in the middle of a scourge like this. In a way, I feel a sort of kinship with those in medical school during the height of the AIDS crisis and anthrax bioterrorism events. Both sparked panic and ushered in profound changes to medicine, including blood banking, organ donation, and public health infrastructure. It is likely the pandemic will forever change how we interact with patients. If the "new normal" means indefinite universal masking, those of us still in training must learn more than pathophysiology and differential diagnoses; we must also learn new ways to communicate with our patients.

Kolin M. Meehan is a fourth-year medical student at West Virginia University School of Medicine. His other publications for Medscape include How to Mentor Millennials in Medicine: Bridging the Intergenerational Impasse and Doctors Give Millennial Students a Bad Rap. He is pursuing a residency in neurology.

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