Unmasking the Problem

In the spring of 2021, as a third-year medical student in the midst of the pandemic, I worked on a research thesis while continuing to build my clinical skills. Every other week, I would visit the endocrinology clinic and see patients with my research mentor.

It was a day like any other at the clinic. Wearing the usual blue surgical face mask, I knocked on the exam-room door, and asked permission to enter. After sanitizing my hands, I began my introductory spiel while heading to the computer. Sitting down, I glanced at my patient, Jim—a man in his fifties, sitting across from me.

When I saw Jim’s American-flag cloth mask and matching baseball cap, I felt my muscles tense and my smile grow weaker. He hadn’t yet said a word, but my mind had already begun speculating. Given how the pandemic had unfolded, I couldn’t help but assume that his beliefs featured anti-mask rhetoric and noncompliance with public-health guidelines.

The thing is, I was used to patients like Jim—the ones who drove from the countryside, hours away, to an urban, quaternary referral center where they could receive specialized care for their malignant disease. I’m an immigrant Black woman with an East Coast upbringing, forging a life in a midsize Midwest city, and these individuals’ sociopolitical beliefs tend to differ from mine. As much as I appreciate these differences, I shuddered at the thought of having to address any potential disagreements with Jim.

I pictured him saying what I’d heard far too many say: that the vaccine had been made too hastily; that there wasn’t enough evidence for its safety and effectiveness; that the FDA had given the vaccine emergency-use authorization but not full approval. Some people simply wanted the freedom to make their own decisions.

However, Jim was surprisingly pleasant, talkative and engaged. It was easy to elicit his history, medical concerns and long-term goals for care. I found myself enjoying our conversation. He told me about his family, his farm and his simple lifestyle, which was in stark contrast to mine. Having parents and grandparents who had also come from humble backgrounds, I resonated with Jim’s stories.

Soon we got to the topic of COVID-19.

“I probably was exposed a few months ago,” Jim said, “but I didn’t have any symptoms.” He suspected that one of his family members had had the virus, but no lab testing had been done to confirm this.

“It’s good that you didn’t have symptoms,” I said encouragingly. “But you do need to take care of yourself!” This turned our conversation in an unexpected direction.

“You know, I’m not sure I believe in COVID,” Jim confided. “I don’t really wear masks. I social distance when I can, but it’s not something I do unless I have to.”

“Hmm…” I said, giving him time to say more. But he stayed silent, watching me as I watched him. I knew I had to break the ice.

Taking a deep breath, I said, “You know, masks have been shown to be pretty effective! That’s why we use them here in the hospital and encourage them everywhere else.”

“Yeah, but it’s not like you guys were wearing masks before,” he replied. “Before COVID started, I don’t remember seeing any of my doctors wearing masks in the hospital.”

What could I say? It was an astute observation.

“That’s right!” I said. “But that’s because we weren’t in the middle of a pandemic with a highly contagious virus. We actually do wear masks in situations where we know a patient’s infection is contagious. We also always wear masks in the operating room.”

“Yeah, but you know, these masks make me uncomfortable,” Jim said, a bit irritably. “Every time I wear them, my asthma flares up. I feel like I can’t breathe.”

This complaint has become all too familiar, and it’s one that I haven’t always successfully navigated. I could have made one of several replies–some that would likely have seemed accusatory–but this time, I somehow found a loophole.

“I wonder if it has to do with the type of mask you’re using. I see that you’re wearing a cloth mask today.”

“Well, yes, but this one is actually better than those,” he said, pointing to my mask. “I think mine has a filter in it.”

“A filter is useful,” I agreed. “But these masks are medical grade and are certified to protect against viruses like COVID-19. They’ve been specially tested.”

At this point, I expected Jim to write me off and get on with living his life just as he had before entering our clinic doors.

“Okay,” he said.

Shocking. No pushback, no counterargument; just a simple phrase of acceptance. Jim’s demeanor was calm and attentive, his body language open and relaxed. Elated that I’d actually made persuasive use of my motivational interviewing skills, and trying not to let my enthusiasm burst through my mask, I took a moment to gather my thoughts.

“I think you might do better wearing one of these masks,” I said. “I know they sell them at some pharmacies. How about we explore using these masks and see if it helps your breathing?”

“I think I could do that,” he said. Our visit ended soon after, and I wished him a safe trip home, feeling relieved that his concern had been about equipment at least as much as it was about beliefs. All I’d needed to do was take the time to listen and provide a safe space for sharing.

I truly believed that Jim would go home and try to find a more suitable mask to wear. I wanted to think that the only hindrance was the masks’ discomfort, rather than a lack of belief in the CDC’s recommendations. But I also had to remember my patient’s social climate and the rhetoric he’s exposed to each day. He’d come into our clinic not quite believing in COVID-19, and it had taken a rather in-depth discussion to challenge that.

It would take a lot for Jim to completely embrace an opposing view. But at least I could say that I’d tried. I wanted the best for him based on my clinical experience, just as he wanted the best for himself based on his personal experience.

There are plenty of reasons why people might choose not to wear masks. Although many of these are selfishly motivated, I need to remember that, even so, I’m occasionally graced with the opportunity to help someone reframe their mindset.

To do this, I need to be willing to set aside my own assumptions and approach the encounter with an open mind. Then, sometimes, I may be able to fully unmask the problem.