Wearing a mask during patient encounters is now the new normal for pediatricians. This article reviews the medical literature regarding the effects of wearing a mask on physician-patient relationships in the pediatric setting.
The Impact of Masking
Human facial muscles are capable of producing myriad combinations of postures and movements that lead the observer into understanding a person's emotional state. These movements generally relate to one of six basic emotional categories: happiness, surprise, sadness, anger, fear, and disgust. These six emotions, when combined, lead to facial expressions that represent 23 discrete emotional states (eg, happily surprised, fearfully angry).1 The upper and lower halves of the face each play an important role in conveying emotion, and when shrouded can impair the observer's ability to interpret another person's feelings. Sunglasses, for example, represent a pre-pandemic era upper face impediment but a reversible one in that a patient or parent could usually be asked to remove these; masks and other facial personal protective equipment (PPE) represent fixed barriers that block the lips, cheeks, mouth, teeth, and chin of the wearer. It is estimated that face masks obfuscate as much as 60% to 70% of the facial elements necessary to interpret a person's emotion.2 Anger and disgust are most commonly mistaken for one another when the bottom segment of the face is concealed, although additional emotional misreads also occur.2
Given the well-described limitations on interpreting another's emotions when part of the face is covered, masking obviously presents challenges to wearers with regard to establishing rapport between patients and physicians. Many years prior to the pandemic, researchers in Hong Kong published a randomized controlled trial assessing the impact of physician mask-wearing on more than 1,000 adult outpatients' perceptions of the doctor-patient relationship.3 Two important findings arose from this study: first, physicians wearing face masks were rated with statistically significantly lower empathy scores by their patients, but second (and perhaps more importantly), the negative impact on patient-rated empathy scores for physicians were much more pronounced for those patients who reported that they previously knew their doctor well.3
Implications from this study for pandemic-era practice are particularly striking. For one, physicians who have prior relationships with their patients actually face a steeper challenge in conveying empathy through a mask, suggesting that a patient's memories of encounters when the physician did not wear a mask raise the expectation for empathy that the mask, across contexts, diminishes. Although mask-wearing has been the norm for many months at this point in the pandemic, pediatricians should remember that the expectation for rapport-building may paradoxically be more challenging for those patients who have not presented to their office since before the onset of the pandemic than for those patients who have only ever known them through a mask. Additionally, no research exists to date that examines “dual-masking” (when patients in addition to physicians wear a mask). It has been plausibly hypothesized that the limitations of the patient-physician relationship would be multiplied under dual-masking scenarios.4 Beyond the patient having trouble feeling validated, the physician may legitimately struggle to understand how the parent or child is feeling, making care planning much more difficult.
Pediatric anesthesiologists, as a cohort of physicians whose relationships with patients before the pandemic typically involved exclusively masked interactions, offer starting points for rapid rapport-building with children through a mask. Storytelling, distraction, and misdirection with the child and posing history-taking questions with use of vivid, age- and imagination-appropriate imagery are all well-recognized strategies of experienced pediatric anesthesiologists and have applications for all pandemic-era clinical encounters.5 Across medical disciplines, hospital-based health care providers have employed wearable enlarged personal photos of their whole face to humanize themselves for frightened patients and to differentiate themselves as patients struggle to identify who is caring for them. A similar modified approach could prove to be helpful in the outpatient pediatric office, as well, to help patients and families feel more connected to office staff with whom they will interact repeatedly.
Certain clear face shields or other physical barriers, when used without a face mask, may present workarounds for pediatricians at times when in-person encounters are brief, physical distancing is able to be maintained, and aerosols are not actively being generated in the examination room. Beyond allowing the conveyance of emotion through facial expression, use of such PPE may allow a pediatrician to situationally communicate with parents or patients, such as for those whose hearing impairments require lip-reading for effective comprehension. Nevertheless, telehealth technology, in addition to presenting advantages for evaluating a patient outside of the clinic, office, or hospital more safely and reliably, offers the opportunity for patient, parent, and pediatrician to see each other's full face.4
Beyond encounters between a single physician and patient, telehealth has presented a key workaround for permitting unmasked time between providers and their patients in the hospital setting during the pandemic. Incorporating “telepresence” into family-centered rounds presents the added benefit of combating overcrowding a small hospital room and reducing physical distancing. A single physician enters the hospital room masked to interface with the patient and the physically-present masked parent or guardian using a screen-based platform that allows the other parent or guardian, consultants, nurses, medical students, and residents to join rounds. Although telehealth encounters with patients and physicians in different locations can add scheduling inefficiencies if examinations and tests are needed, telepresence from within the office suite might allow for longer face-to-face maskless discussions with families from down the hall. Additionally, some health care encounters that tend to lend themselves toward telehealth, including visits addressing mental health, likely benefit from the earnest and unfettered delivery of facial expressions at the expense of sharing a physical space with the patient and family.
Acknowledging that masks may muffle speech and lead to errors of comprehension for both patients and physicians is important. Employing well-accepted forms of comprehension checks, such as the “teach back method” in which the physician asks the parent or patient to summarize in their own words what was just explained, can also help ensure that no mask-induced miscommunication took place with regard to home care instructions. Beyond being a best practice for medicine at all times, these strategies ensure that errors are reduced and patient outcomes remain optimized during the pandemic.
As it pertains to conveying empathy, specifically, medical providers can do well to do our own version of “Teach Back” by naming for patients the emotion or experience we hear them sharing or notice them conveying through other physical cues or mannerisms. Without our patient's full facial expressions, we may not always get it right either, so the summary is an opportunity for the physician to clarify and for patients to feel the extra intention to validate their experiences. This narration can also help prioritize care plans and recommendations. Although empathy and bedside manner are an important aspect of therapeutic relationships, truly understanding etiologies of distress is especially important amid the pandemic as pediatric mental health stress and somatization are particularly prevalent.
Face masks, although an inconvenient barrier to optimal patient-physician communication and relationship-building, are an essential reality for today's pediatrician and will likely be an unavoidable component of the delivery of health care to children for many more months or even years in certain clinical contexts. Speak clearly, narrate your actions and expressions, and “smile with your eyes” when engaging in lengthier conversations. And, if truly all else fails, remember that you are a pediatrician. You have as much professional latitude as anyone else to go to work in costume with a mask and build instant rapport with at least the child, perhaps even winning a mask-concealed smile on their parent's face as your nursing staff tells them, “Dr. Ant-Man will be in to see you shortly.”
- Du S, Martinez AM. Compound facial expressions of emotion: from basic research to clinical applications. Dialogues Clin Neurosci. 2015;17(4):443–455. doi:10.31887/DCNS.2015.17.4/sdu [CrossRef] PMID:26869845
- Carbon CC. Wearing face masks strongly confuses counterparts in reading emotions. Front Psychol. 2020;11:566886. doi:10.3389/fpsyg.2020.566886 [CrossRef] PMID:33101135
- Wong CK, Yip BH, Mercer S, et al. Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. BMC Fam Pract. 2013;14(1):200. doi:10.1186/1471-2296-14-200 [CrossRef] PMID:24364989
- Ghosh A, Sharma K, Choudhury S. COVID-19 and physician-patient relationship: potential effects of ‘masking’, ‘distancing’ and ‘others’ [published online ahead of print September 11, 2020}. Fam Pract. doi:10.1093/fampra/cmaa092 [CrossRef] PMID:32914855
- Crowe AL. Communication skills with children in paediatric anaesthesia: challenges while wearing a face mask. BMJ Paediatr Open. 2020;4(1):e000846. doi:10.1136/bmjpo-2020-000846 [CrossRef] PMID:33134563