A creative and important study was published today in JAMA Surgery looking at the effect that mask wearing has on communication in medical settings. More specifically, the clinical question for this study was whether healthcare providers wearing clear (see-through) versus covered masks had any effect on communication between surgeons and patients.

This effort was a randomized clinical trial in the outpatient setting of a large academic medical center. New patients were recruited from outpatient clinic visits and randomized to visit a surgeon who wore either a clear or covered face mask. The clear face mask allowed the patient to see both the mouth and the nose of the surgeon, while the standard covered mask did not. The primary outcome was patient perspectives of their surgeon, including trust and empathy, which were measured by survey questions, as well as validated tools measuring patient satisfaction. The study used clear masks that have been shown to be as effective as the opaque surgical masks. In cases where a patient was deemed to be at too high a risk of SARS-CoV-2 infection or transmission, surgeons wore N95 masks. Those encounters were not included in the analysis.

200 patients were enrolled across 15 surgeons' clinics. Perhaps not surprisingly, outpatient clinical encounters with a surgeon wearing a clear face mask were associated with higher scores for providing understandable explanations of patient care, knowing the patient history, demonstrating empathy, and building trust. No significant difference was noted between surgeons who wore clear versus covered face masks for the categories of listening, answering questions directly, showing respect, amount of time spent with the patient, and comfort with the surgeon who would be operating on them. 

Moreover, patients preferred their surgeon to wear a clear face mask compared to a standard covered face mask. Interestingly, 8 of the 15 surgeons (53 percent) who participated in the study did not prefer wearing a clear face mask.  

The overall results suggest that patients may prefer surgeons who wear clear masks in the outpatient setting, though it remains to be determined whether these results would remain stable in other clinical settings, such as pre-and-post surgical care units, emergency departments, inpatient settings, and other locales. Furthermore, it is uncertain whether patient preference for clear masks has any impact on surgical outcomes; although surgeons who wore clear masks were perceived by patients to be better communicators, have more empathy, and elicit greater trust, there was no difference between the groups with regards to patient comfort, feeling respected, or ability of the surgeon to listen. 

This study adds a necessary and needed humanistic component to the seemingly endless influx of pharmacotherapy studies, laboratory-based science, and epidemiological behavioral studies related to covid-19. Given that perception is the lens by which we view reality (as some physicians might say: patient perception is reality), it may be worth it to wear clear masks in the clinical setting to bolster the clinician-patient relationship during the pandemic.

The covid-19 pandemic has caused historically high numbers of deaths among adults of all ages. The number of elderly people in the US who have died in the last year well exceeds anything we've seen in the modern era. But nursing homes in particular have been the setting for what were at times apocalyptic scenes. While fewer than 1 percent of all US residents live in long-term care facilities, around 34 percent of all covid-19 deaths occurred among this population. Therefore, policies that limited or banned visitors made sense at times.

That said, denying visits between families and loved ones and long-term care facility residents who may not have long to live is about as depressing a policy as one could imagine. That's why the new "Revised Visitation Recommendations" for nursing homes and other long-term care facilities, published Wednesday, is so welcome. 

The document is a collaboration between the US Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services. Now that over 3 million coronavirus vaccine doses have been administered in the relevant facilities, the easing of strict policies makes sense. Per the policy, "responsible indoor visitation" should be permitted "at all times and for all residents," regardless of vaccination status of either the resident or the visitor. Thus, the default position is "yes, visits are allowed," unless particular problems are noted; the named exceptions to the policy are as follows:

1. For unvaccinated residents, if the positivity rate for SARS-CoV-2 tests within the county where the facility is located is greater than 10 percent and less than 70 percent of residents in that facility have yet to have been fully vaccinated.
2. Residents with test-confirmed SARS-CoV-2 infection (regardless of vaccination status) until they have met the usual criteria for ceasing of precautions for infected persons.
3. Residents in quarantine (regardless of vaccination status) until the usual quarantine period/criteria have been met. 

In fact, these rules are even more aggressive than they initially appear. That's because the caveats listed above apply to "regular" nursing home residents only. The guidance goes even further for residents who are gravely ill and at risk of imminent death or a change in their overall health. For those residents, even the above restrictions should not apply.

These new policies reflect the reality that herd immunity in nursing homes, at least, may be in sight. If so, nursing homes have gone from becoming the most dangerous epicenter of this crisis, to among the safest locales. That's what vaccine rollouts can achieve.