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Verbal Communication and Masks

Verbal Communication and Masks

Masks have long been important barriers between infectious disease and humans. This is especially true in hospitals where the infection is at the highest risk. In hospitals, wearing masks can save a life. By wearing one you can protect yourself and others.  

While face masks have been important in preventing the spread of the virus, they’ve had negative effects on verbal communication. Not seeing the whole face of a person can make it hard to see facial expressions. Many patients and doctors also believe it’s a bit “dehumanizing” since you don’t know whether the person is smiling or frowning. 

The Study

This study focuses on the consequences of mask-wearing on communication between patients and doctors during surgery. It specifically aims to analyze the effectiveness of clear masks and covered masks. 

What are clear masks? 

Clear masks work just like covered masks but they have a clear panel in front of the mouth. This makes it easier for people to read lips and see facial expressions. 

Study Design 

The study examined communication between doctors and their patients who wore clear versus covered masks at a medical center. The surgeons were appointed to wear either a clear mask or covered mask for each new patient based on a randomization plan. 

The primary outcome measures patient perceptions of surgeon communication, trust in the surgeon, quantitative assessments, and qualitative assessment regarding patient impressions of the surgeon’s mask. 

Patients also underwent a verbal survey which includes a validated group of questions: Clinician and Group Consumer Assessment of Healthcare Providers and Systems. The questions centered on surgeon empathy, trust, and the patient’s impression of the surgeon’s mask. After the data was collected, it was analyzed and compared using Cochran-Mantel-Haenszel tests. 


There were a total of 200 patients enrolled from the surgeons clinic of seven subspecialties. When wearing a clear mask, patients rate their surgeons higher for providing understandable explanations  (clear, 95 of 100 [95%] vs covered, 78 of 100 [78%]; P < .001), demonstrating empathy (clear, 99 [99%] vs covered, 85 [85%]; P < .001), and building trust (clear, 94 [94%] vs covered, 72 [72%]; P < .001). 

Patients clearly preferred clear masks (clear, 100 [100%] vs covered, 72 [72%]; P < .001), citing improved surgeon communication and appreciation for visualization of the face. Conversely, 8 of 15 surgeons (53%) were unlikely to choose the clear mask over their standard covered mask.


Surgeons at the same educational facility were recruited via email. Their schedules were reviewed for new, in-person, outpatient clinic visits for patients who had no prior relationship with the surgeon. The researchers used a group generator just before the clinic opened. The surgeons were randomized to whether to wear a clear versus a covered mask type for new patients. Their clear masks are ASTM level 3 which is similar to a standard surgical mask.  The inclusions for patients were the following: 

  • At least 18 years of age
  • Speaks English fluently 
  • Have the capacity to make his own medical decisions

If a patient was deemed high risk, an N95 respirator was recommended based on hospital policy. The patient data and demographics were collected via electronic health record. Patient participation includes a scripted 10-question verbal survey with 4-point Likert scale responses. The survey was adapted from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey questions that measure communication (from 1, indicating not at all, to 4, indicating completely).The researchers also included questions that would assess surgeon trust and empathy. 

After the study was complete, the surgeons were asked a single 4-point Likert-scale question regarding their likelihood of choosing the clear mask in the future. Additionally, surgeons were asked to provide feedback regarding their experience with wearing the mask.

The research was approved by the institutional review board at the University of North Carolina at Chapel Hill. It also follows CONSORT reporting guidelines. After the completion of the clinic visit, the surgeon met with the patient to get verbal informed consent for study participation.

Surgeon and Patient Demographics

There were a total of fifteen surgeons in the study. Two had specialties in gastrointestinal, Two for general surgery, one for plastic surgery, three for surgical oncology, three for thoracic surgery, two for transplant surgery, and two for vascular surgery. Six of the surgeons were women and nine were men. Their race and ethnicities included 2 black African American, 2 Asian, 9 white, and 2 Hispanic. 

There were a total of 200 patients in this study starting from September to November 2020. 

Of the patients, a total of 114 were women and 86 are men. Around 127 were white and 66 were black or African. 


The responses were analyzed by question for covered vs. clear masks. The answers were converted from Likert-scale to dichotomous data. They were also grouped as positive vs negative which is also called the top box method, an evaluating standard for CG-CAHPS data. The top choice of 4 was considered positive whereas the ratings of 1 to 3 were negative. 

Based on trends noted in the data from the first 50 patients, sample sizes were calculated per question, and variables were assumed to be dichotomous. An α level of .05 and power of 90% were used in the calculations. A minimum sample size of 180 patients was calculated, with 90 patients per group. Because of the exploratory nature of this study, the decision was made to terminate the trial at 200 patients. All of the questions were analyzed using  Cochran-Mantel-Haenszel tests, stratified by surgeons to remove potential individual surgeon bias to the results. All P values were calculated using χ2 tests and deemed significant at less than 0.05.

Both the patient and surgeon’s open-ended responses were analyzed by multiple investigators through open coding in order to create a codebook. Using thematic analysis, they expanded and collapsed 23 codes to ensure accurate data. Comments were also categorized by the tone and analyzed the percentage as a whole. 

Strengths and Limitations of the Study 

The study’s strength was that it was the first research to carefully examine the effect of covered masks on surgeon-patient communication.  The study was also done in a randomized fashion which minimized bias. There was also a large pool of patients with a diverse demographic that had no prior relationship with the surgeon.

The limitations of the study were mostly on the part of the surgeon. Even if the surgeons were not aware of the patient’s questions or responses, they may have been blinded to their mask type and caused bias in their patient interactions. 

On the same note, the researchers who were in charge of surveying patients were not blinded to mask type. This might have influenced patient response despite a verbal script being  followed. Since patients were asked to immediately answer after their clinic visit, their responses might have been more positive than if they did the survey later in an anonymous form. Another limitation is that the researchers only used one type of clear mask style when there are many face-covering styles that are actually available.


The use of masks, while critical to health, can have negative effects on verbal communication. This study is the first to examine the effects of masks on communication between surgeon and patients. 

The study shows that patients want to see their surgeon’s face. Surgeons who wore clear masks were perceived more positively by patients. They were described as good communicators, empathetic, and trustworthy. 

Also, patients who interacted with surgeons wearing clear masks felt better understood. They are also able to understand the surgeon’s explanation about their condition more clearly. Although the surgeon didn’t change the way he explained concepts to his patients, the patient’s perceptions changed based on the mask they wore. 

Covered masks pose a huge problem as many patients experience difficulty when hearing their surgeons through covered masks. Despite both masks “muffling” the voice of the surgeons, patients claim that they can understand their surgeons better when they have clear masks. 

Another important finding in this study is that surgeons who wore clear masks were perceived as more empathetic. This shows that empathy is not only shown verbally, and facial expressions have a large role in communicating it. Since masks will be an almost permanent tool in our health care landscape, it’s so important that they can preserve good communication. Effective communication is beneficial to both patient and physician. It can improve patient understanding and adherence to treatment recommendations, superior clinical outcomes, and higher patient and clinician satisfaction.

Communication is key to success in surgeon-patient relationships. It’s the most important tool in developing trust and relaying important information to patients. With effective communication, surgeons are able to manage their patient’s concerns and expectations. 

The long-term use of masks, despite having a protective benefit, may have a negative effect on communication. There is evidence that they can affect patient-physician relationships. The study’s hypothesis is that masks can create communication barriers between surgeon and patient and clear masks can solve this problem.  


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