The Effects of Face Masks on the Doctor-Patient Relationship in Orthopaedics

Abstract

Background

Since the onset of the COVID-19 pandemic, the widespread use of face masks has grown exponentially. There is limited data highlighting the patient perception of face mask use during this pandemic, specifically in orthopaedic clinics. The purpose of this study was to determine the patient’s perception of the implementation of face masks in the orthopaedic clinic during a period of mask mandates and if this change impacted the success of their interactions with physicians. The secondary aim includes measures of patient satisfaction such as the ability to understand conversation and communicate effectively with the physician.

Methods

Participants were recruited on the day of their appointment at our institution’s orthopaedic clinic and provided with instructions via email. The online, anonymous survey included the CARE questionnaire - a tool to examine patient satisfaction by assessing perception of empathy and was conducted using Qualtrics.

Results

Does patient preference to have their physician wear a face mask impact the success of their interactions with physicians? Overall, the use of face masks by physicians did not negatively impact patient encounters. CARE scores for patients who preferred masks (37.2) were similar to those who preferred their physician did not wear a mask (37.5). Is patient satisfaction affected by the use of face masks in the orthopaedic clinic? Patients who preferred that their doctor wear a face mask stated that it had no negative impact on the effect of communication or conversation with the physician. Other factors such as how well the patients knew the physician and patient gender had a greater impact on the CARE score than masks did.

Conclusion

Our study determined that the preference of face masks by patients does not impact the success of their interactions with physicians using the CARE score. The findings of this study are valuable in informing orthopaedic physicians about patient attitudes towards mask use and could influence decision making for not only the COVID-19 pandemic, but also future infectious outbreaks that may arise.

Level of Evidence: III

Introduction

Since the onset of the Coronavirus (COVID-19) pandemic, the widespread use of facemasks has grown exponentially across the globe. Along with this abrupt change, came significant debate on the efficacy of face masks. The face mask discourse revealed, amongst many things, the discrepancies in the general public’s trust in healthcare and skepticism of adhering to medical advice. While the intention of its use was to reduce the spread of respiratory transmission, the impact of personal protective equipment (PPE) including face masks by physicians in the context of the current pandemic is a multifaceted discussion that has yet to be fully examined.

Recent literature supports that physician use of face masks has a significant impact on the verbal and nonverbal communication between the doctor and patient. In a 2013 study conducted in Hong Kong primary care clinics, a survey using the Consultation and Relational Empathy (CARE) measure revealed that when doctors wear masks during visits, patients perceive diminished empathy, which negatively affects the therapeutic relationship between patient and provider.¹ The doctor-patient relationship is an essential cornerstone in healthcare that is built on trust and compassion and remains one of the most important factors in the long-term outcome of a patient’s health. Incorporation of PPE into this equation must be analyzed to ensure that the doctor-patient relationship is uncompromised and respected by both parties. Furthermore, a 2019 study interviewing patients to determine their understanding of the purpose of face masks revealed that patient acceptance was higher when he/she understood the importance of reducing disease transmission, and it highlighted patient complaints such as the reduced ability to hear doctors who wear masks.² The behavioral inconveniences of face masks have been extensively reported including the discomfort with wearing them, the impediment to verbal communication (unclear conversation, quieter sound etc.), and the lack of important nonverbal cues such as facial expressions. A 2016 study during the peak season of Influenza in Hong Kong explored the sociocultural meanings of masks pre and post SARS outbreak.³ It was determined that the experiences of patients with providers who wore masks was critical in shaping patient attitudes toward the use of masks in the clinic during and after an infectious disease outbreak. Overall, there is limited data highlighting the patient perception of facemask use during the current pandemic, specifically in orthopaedic clinics.

We sought to ascertain patient attitudes towards the use of face masks and personal protective equipment (PPE) by orthopaedic surgeons in the clinic to help physicians balance reducing disease transmission and communicating with patients during the COVID-19 pandemic. The purpose of this study was to determine the patient’s perception of the implementation of face masks in the orthopaedic clinic during a period of mask mandates and if this change impacted the success of their interactions with physicians. The secondary aim includes measures of patient satisfaction such as the ability to understand conversation and communicate effectively with the physician. This information in the context of COVID-19 could provide a deeper understanding of how an orthopaedic surgeon’s use of facemasks affects the trust, empathy and communication needed to facilitate a successful patient encounter.

Methods

Study Population

Participants were recruited from November 2020 – January 2021 on the day of their in-person appointment at our institution’s orthopaedic clinic. Participants were from an urban population. To be eligible for inclusion, patients had to have a current scheduled appointment with one of our orthopaedics physicians and be older than 18 years of age. Patients who met these inclusion criteria were sent a survey via email in December 2020 and again in January and February 2021. Patients were provided with instructions for the survey after their visit by a member of the research team and were given the opportunity to opt out of the survey if they no longer wanted to participate. Patients were excluded from study participation if they belonged to vulnerable populations such as minors, the cognitively incapacitated, and/or prisoners. This project was granted an exemption by the Institutional Review Board at our institution, as no identifiers or personal information were collected. The IRB determined that this study meets the criteria for exemption based on Federal Regulation 45 CFR 46.104.

Survey Design

The online survey (Table I) was composed of questions about demographics, the CARE questionnaire, measures of verbal/nonverbal communication and the general acceptance of masks. The surveys were conducted using the validated questionnaire tool Qualtrics (Provo, Utah), and responses were anonymous. The survey was designed to require only 2-5 minutes to complete. Participants assessed their doctor’s patient-related empathy using the CARE Measure, a tool developed in Glasgow and Edinburgh University that has successfully been used by healthcare professionals to assess empathy in the context of the doctor-patient relationship.^4,5,6 Our specific survey consists of 10 questions ranking the patient’s perceived experience from 1 “poor” to 4 “excellent”. Each participant’s individual CARE score was calculated by taking the average of the 10 questions’ scores for a maximum score of 40. This method of calculating CARE scores has been used in multiple studies to assess patient satisfaction of perceived empathy and shown to be a valid and reliable measure.^1,4,5

Table I.

Patient Survey

DEMOGRAPHICS

Age

18-20

20-30

30-40

40-50

50-60

60-70

70+

Gender

Male

Female

Other:

Education

Some High School

High School

Bachelor’s Degree

Master’s Degree

Ph.D. or Higher

Trade School

Prefer Not to Say

General Health Over the Last Few Months:

Very Bad

Bad

Fair

Good

Very Good

How well do you know the physician saw you today?

Not Well

Neutral

Well

Very Well

Nature of the Problem:

New (acute)

Old, ongoing (chronic)

Both

Other: ________

Duration of Consultation:

<15 minutes

15-30 minutes

30-45 minutes

45 minutes – 1 hour

> 1 hour

CARES QUESTIONNAIRE
How good was your physician at:	Poor	Fair	Very Good	Excellent	Does Not Apply
1. Making you feel at ease (introducing him/herself, explaining his/her position, being friendly and warm towards you, treating you with respect; not cold or abrupt)
2. Letting you tell your “story” (giving you time to fully describe your condition in your own words; not interrupting, rushing, or diverting you)
3. Really listening (paying close attention to what you were saying, not looking at the notes or computer as you were talking)
4. Being interested in you as a whole person (asking/knowing relevant details about your life, your situation; not treating you as “just a number”)
5. Fully understanding your concerns (communicating that he/she had accurately understood your concerns and anxieties; not overlooking or dismissing anything)
6. Showing care and compassion (seeming genuinely concerned, connecting with you on a human level; not being indifferent or “detached”)
7. Being positive (having a positive approach and a positive attitude; being honest but not negative about your problems)
8. Explaining things clearly (fully answering your questions; explaining clearly, giving you adequate information; not being vague)
9. Helping you to take control (exploring with you what you can do to improve your health yourself; encouraging rather than “lecturing” you)
10. Making a plan of action with you (discussing the options, involving you in decisions as much as you want to be involved; not ignoring your views)
Comments: If you would like to add further comments on this consultation, please do so here.

VERBAL & NONVERBAL COMMUNICATION

Do you believe that the use of facemasks and protective personal equipment has negatively affected your ability to understand your physician’s conversation?

Greatly

Moderately

Not at all

If so, how?

I am unable to hear the conversation properly

I am unable to see my physician’s face and expressions

I cannot understand my physician’s body language

Other: ______________

2. Do you feel comfortable asking your physician for clarification or repeating advice?

Yes

No

Other: ____________

ACCEPTANCE OF MASKS

Do you prefer that your physician wear a mask and protective personal equipment in the clinic?

Yes

No

Do you believe that masks are essential to preventing the spread of respiratory transmission in the clinic?

Yes

No

Other: ________________

Statistical Analysis

We conducted analyses of the characteristics of patients in the doctor-wearing (Mask) and non-mask wearing (No Mask) clinical consultations (Q18). The survey was emailed to 658 patients over the three-month timeline. 211 (32%) of patients consented to participate in the study. Of the 211 participants who submitted the electronic survey, 178 (84%) completed all the questions. Participants who did not complete all questions were excluded.

The primary outcome in this study was the CARE score, which measures the patient-related experience. The total CARE score for mask vs. no mask was calculated as the average score for each cohort.¹ The results of the CARE score were then analyzed by question and significant patient characteristics.

All analyses were performed using Qualtrics Stats IQ and all statistical tests were performed using a significance level of 0.05. The patient characteristics included age, gender, education, familiarity with the doctor, and duration of consultation. Furthermore, three Chi-square tests were run to analyze patient satisfaction vs. perceived mask efficacy, perceived mask efficacy vs. preference for physician to wear masks/PPE and patient’s preference for physician to wear masks/PPE vs. patients’ comfort in asking for clarification/repetition. All three tests were statistically significant and were followed up with a Fisher’s exact test due to the small, expected cell counts. Ranked ANOVA tests were used to compare the average CARE score to each variable.

Results

Descriptive statistics were produced for the entire sample of 178 patients. Of the 178 patients in our analysis, a majority (157/178, 88.2%) preferred that their physician wear a mask and PPE while only 11.8% (21/178) preferred no mask and PPE to be worn in the clinic (Table II). The categorical variables of education level, gender, and how well the patient knew the doctor are summarized in Table III with frequencies and percentages. Age and duration of visit are summarized in Table IV, which displays the sample size and percent for each variable. The mean CARE score for all patients (n=178) was 37.24, (standard deviation 4.79) with a minimum score of 16 and maximum score of 40 (Table V).

Table II.

(Q18). Patient Preferences of Physician Wearing Mask/PPE in Clinic (n=178)

Mask/PPE Preference	N (%)
No Mask/PPE	21 (11.8%)
Mask/PPE	157 (88.2%)

Table III.

Descriptive Characteristics of Patients in the Doctor-Mask Wearing (Mask) and Non-Mask Wearing (No Mask) Clinical Consultations

Education Level	Mask N, (%)	No Mask N, (%)
Some high school	5 (100%)	0 (0%)
High school	36 (90.0%)	4 (10.0%)
Bachelor’s degree	56 (84.8%)	10 (15.2%)
Master’s degree	25 (89.3%)	3 (10.7%)
PhD or higher	19 (95.0%)	1 (5.0%)
Trade school	11 (84.6%)	2 (15.4%)
Prefer not to say	5 (83.3%)	1 (16.7%)

Gender	Mask N, (%)	No Mask N, (%)
Male	61 (89.7%)	7 (10.3%)
Female	98 (89.0%)	12 (11.0%)

Knowing the Doctor	Mask N, (%)	No Mask N, (%)
Not well	39 (84.8%)	7 (15.2%)
Neutral	37 (92.5%)	3 (7.5%)
Well	50 (87.7%)	7 (12.3%)
Very Well	31 (88.5%)	4 (11.5%)

Table IV.

Continuous Characteristics of Patients in the Doctor-mask Wearing (MASK) and Non-Mask Wearing (No Mask) Clinical Consultations

Age (years)	Mask N, (%)	No Mask N, (%)
20-30	14, (100%)	0, (0%)
30-40	13, (76.5%)	4, (23.5%)
40-50	21, (84.0%)	4, (16.0%)
50-60	53, (88.3%)	7, (11.7%)
60-70	41, (87.2%)	6, (12.8%)
70+	15, (100%)	0, (0%)

Duration of Visit	Mask N, (%)	No Mask N, (%)
< 15 minutes	28 (90.3%)	3 (9.7%)
15-30 minutes	90 (90.0%)	10 (10.0%)
30-45 minutes	25 (80.6%)	6 (19.4%)
45 minutes – 1 hour	7 (77.8%)	2 (22.2%)
>1 hour	7 (100%)	0 (0%)

Table V.

CARE Scores - This Table Illustrates the Responses For Each Question of the CARE Survey and How Each Response Was Scored

CARE Question How good was your practitioner at:	Poor (score =1) # responses	Fair (score =2) # responses	Very Good (score =3) # responses	Excellent (score =4) # responses	No Response # responses	Total # responses
1. Making you feel at ease	0	1	17	157	3	178
2. Letting you tell your “story”	0	5	23	147	3	178
3. Really listening	0	3	23	151	1	178
4. Being interested in you as a whole person	0	9	29	136	4	178
5. Fully understanding your concerns	0	3	28	143	4	178
6. Showing care and compassion	2	4	26	141	5	178
7. Being positive	0	4	21	152	1	178
8. Explaining things clearly	0	0	30	147	1	178
9. Helping you take control	1	4	29	134	10	178
10. Making a plan of action with you	1	6	20	145	6	178

Preference of Masks/PPE (Q18)

The average CARE Score of participants who preferred their physicians to wear masks/PPE was 37.2, while the average CARE Score of participants who preferred their physicians to not wear masks/PPE was 37. There was not a statistically significant relationship between average CARE score and preference for physicians to wear a mask/PPE (p=0.692, Cohen’s F-statistic = 0.0569).

Belief in Reduction of Transmission of COVID-19 (Q19)

The average CARE Score of participants who think masks reduce transmission was 37.1, while the average CARE Score of participants who think masks do not reduce transmission was 37.3. There was not a statistically significant relationship between average CARE score and belief that wearing masks helps reduce the transmission of COVID-19 (p=0.969, Cohen’s F-statistic=0.0953).

In both analyses of the CARE measure, the groups who prefer the doctor not wear a mask and do not think masks help reduce transmission of COVID-19 had higher CARE scores.

How well patient knew the doctor (Q9)

Higher CARE scores were seen in patients who knew their physician better. (Table VI). (p<0.00001, Cohen’s F-statistic=0.436).

Table VI.

CARE Score and Knowing the Physician

How Well Patient Knows Physician	Average CARE Score (std)
Not well	34.2 (6.5)
Neutral	37.4 (4.6)
Well	38.2 (3.5)
Very well	39.3 (1.6)

Gender

A chi-squared test was run between gender of the patient and average CARE Score. According to the CARE score measure, male patients felt significantly more at ease with their physician in comparison to female patients (p=0.00358). The male total score for feeling at ease was “excellent” (5 points) in comparison to the female score, which was distributed between “fair”, “very good” and “excellent” for a lower overall score on question 1 of the CARE measure. Overall, the average CARE score for men was 38.4 (CI 37.6-39.1) and for women it was 36.5 (CI 35.5-37.5) (Table VII). The difference in CARE scores between men and women was statistically significant (p=0.00358).

Table VII.

CARE Score and Gender

Gender	Count (n)	Average CARE Score
Male	63	38.4
Female	111	36.5

There was not a statistically significant relationship between age, education level, and duration of visit and average CARE score.

Patient Satisfaction Analysis

The majority of patients who believe masks are essential in preventing the spread of COVID-19 reported that the physician wearing a mask had no negative impact on their patient visit (n=129). In comparison, patients who do not believe masks are essential in preventing the spread of COVID-19 reported that the physician wearing a mask moderately impacted their visit (n=4). (p=0.000643)

Furthermore, the majority of the patients who believe masks are efficacious in preventing the spread of COVID-19 preferred for their physician to wear a mask and other appropriate PPE during the visit (n=152). On the contrary, patients who do not believe face masks help reduce the transmission of COVID-19 preferred that their physician not wear a mask or any other PPE (n=6, p<0.0001, 95% CI 13.8-50%).

Similarly, patients who prefer for their physician to wear a mask/PPE felt comfortable asking their physician for clarification or repeating advice (n=145), while patients who prefer for their physician to not wear PPE/mask did not feel comfortable asking their physician to repeat or clarify (n=7, p=0.0306, 95% CI 15.2-64.6%)).

According to the CARE score measure, the majority of patients (n=117) felt that the use of face masks and PPE did not interfere with the physician’s ability to understand his/her concerns during their visit (p=0.00720). The average overall CARE score for this group was 38.17.

Discussion

Effective communication is essential for a successful patient encounter and a vital foundation for improved patient outcomes. The widespread use of face masks in orthopaedic clinics during the COVID-19 pandemic has caused both patients and physicians to adapt to the changes required to reduce respiratory transmission, while maintaining the doctor-patient relationship. This study determined the patient perspective of the effects of face masks on doctor-patient interactions and patient satisfaction in orthopaedic clinics.

Does patient preference to have their physician wear a face mask impact the success of their interactions with physicians?

The CARE measure is a tool used to examine patient satisfaction by assessing patient perception of empathy during face-to-face interactions. Literature shows that CARE scores are valid and reliable measurements of assessing patient experiences of interpersonal skills during their physician encounter.^5,6,7 The questionnaire has been carefully designed to include wording that is comprehensible to patients of all socio-economic backgrounds to produce a standardized score that is a meaningful evaluation of empathy.⁴ Overall, the use of face masks by physicians did not negatively impact patient encounters. CARE scores for patients who preferred masks (37.2) were similar to those who preferred their physician did not wear a mask (37.5). Similarly, CARE scores for patients that do not believe face masks are efficacious in stopping the spread of COVID-19 (37.3) and those who do believe in the efficacy of face masks (37.1) were similar. Patients stated they felt comfortable asking for clarification or for the doctor to repeat himself or herself regardless of their preference of masks. The consistency of perceived empathy, trust, and compassion as seen in the almost identical CARE scores amongst patients who differ in their belief in the use and efficacy of face masks may be explained by physicians actively working to communicate with patients despite the mask/PPE barrier to nonverbal communication. Since the onset of the pandemic, recent literature has been continuously promoting the preservation of effective conversation and delivery such as by physicians using transparent masks⁹ to allow for patients to see their facial expressions and using gestures and maintaining eye contact.¹⁰ Our finding that face masks do not have a significant effect on the perceived empathy and communication is consistent with previous studies analyzing the perception of face masks by patients.^1,3,4

Is patient satisfaction affected by the use of face masks in the orthopaedic clinic?

Patients who preferred that their doctor wear a face mask stated that it had no negative impact on the effect of communication or conversation with the physician. Other factors such as how well the patients knew the physician and patient gender had a greater impact on the CARE score than masks. Higher CARE scores were seen in patients who knew their physician better. Patients who stated that they did not know their physician well had significantly lower CARE scores (34.2) than those who stated that they knew their physician very well (39.3). Therefore, how well the patient knows the physician may be a confounder for the CARE score’s ability to measure the impact of masks on patient experience.

Gender of the patient was also a variable impacting the average CARE scores. Male patients felt significantly more at ease with their physician and had higher CARE scores in comparison to female patients. All physicians in our study were male, potentially contributing to gender being a confounding variable in the analysis.

Limitations

This study is limited by the small sample size of 178 patients who opted-in to participate and completed the entire survey. A large majority of patients preferred the use of masks/PPE with less responses of those who do not prefer masks and PPE. Further studies with more participants who question the use of masks would be needed to create a more accurate representation of this group. Participants who did not complete all questions were not included which also limited the responses used for statistical analysis.

Furthermore, the surveys were distributed from November 2020 - January 2021. Opinions from before and after COVID-19 or earlier in the pandemic such as in March of 2020 may differ than those collected in this survey due to the later acceptance and education on the topic of masks.

The CARE scores were higher in groups that prefer their physician not wear a mask/PPE and who do not believe masks help reduce the transmission of COVID-19. This data could be confounded by how well the patient knows the doctor. On average, the better the prior relationship between the physician and patient the higher the CARE score. Additionally, certain components of the CARE measure including “comfort” were significantly higher in males than females so gender could be another confounding factor.

Conclusion

Our study determined that the preference of face masks by patients does not impact the success of their interactions with physicians through the use of the CARE score to determine perceived empathy and communication. This elucidates patients’ attitudes and perceptions of the change towards the use of face masks and PPE in the orthopaedic clinic. The findings of this study are valuable in informing orthopaedic practitioners about patient attitudes about mask use and could inform decision making about preserving the doctor-patient relationship while using face masks and PPE for not only the current COVID-19 pandemic but also future infectious outbreaks that may arise.