Why My Patient Chose Not Wear a Face Mask

A few months ago, when my office manager informed me that one of my long-time patients was in our waiting room, and refusing to wear a face mask, I initially thought how selfish my patient was acting because I was concerned, like many of the other patients in our waiting room, and my staff members, that this particular patient could potentially inoculate others with the SARS-CoV-2 virus, or even contract the virus herself. So, masked up like I had been since early in 2020, I went out to talk with this patient, and to ask her to accompany me to a treatment room where I could further explain our concern and our institution's health policy related to the use of masks and social distancing. She told me, with some trepidation, that she understood the rationale for the use of a mask, but that she chose not to wear one because, after an approximately 45-pack year history of cigarette smoking, and having quit smoking cigarettes less than two years earlier, she suffered with emphysema and feared that a mask would prevent her from getting enough oxygen. I knew that she had COPD, and I could see that she was concerned, and it seemed to me that she wanted to use a mask but that she was truly worried about her ability to breathe and aerate adequately if she did. I could also see that she was not in any acute distress, and it seemed to me that she would be amenable to using the mask if she could be reasonably assured that she would not encounter dyspnea or shortness of breath when doing so. When I asked, she denied any current shortness of breath or chest pain. And, having worked in our hospital's COVID-19 surge tent during the height of the pandemic back in April and May of 2020, I remembered using a pulse oximeter to check the oxygen level in the peripheral circulation of the patients presenting to our Emergency Department. So, I thought, if she would let me check the oxygen saturation of her peripheral blood with the use of a digital pulse oximeter, first without and then, very carefully, with a face mask, we would be able to see if use of a mask would cause her oxygen saturation to drop. She consented to this, and without a face mask, the measurement was 94%, and after wearing the face mask for about 4 minutes, it was 95% (yes, it went up). She was calm and remained comfortable as we checked her peripheral oxygen saturation with the pulse oximeter, and after doing this, she seemed to be relieved and said that she felt better, because now she believed that she could safely wear a mask and not feel like she was being antisocial when she went out in public.

This encounter made me think about other people who refuse to wear a mask, or choose not to comply with social distancing recommendations or pursue any of the many guidelines that society places on us as we struggle through a period of rampant COVID-19. When it comes to our patients, I think that it is important for us to keep in mind that each is an individual, and to understand that even in the clutches of a global pandemic the US Constitution requires that the public health responses to the crisis (wearing a mask, quarantining, isolating, required examination, etc.) take into consideration the civil rights of the individuals involved. Recently, too, a great deal of attention has been paid to healthcare epidemiology and its relationship to civil rights and the role that the law plays in promoting public health. If interested, I suggest that readers consider visiting the CDC's Public Health Law Academy (https://www.train.org/cdctrain/course/1063977/, last accessed 05/25/2021), or read the article by Ransom et al (1). In some instances, moreover, like the one that I had with my patient, it can be very helpful if we know our patients and talk directly with them.