Behind the Mask

Today I saw a patient I have known for years. He suddenly pulled his mask down and said, “I’d like to know what you think I should do about this”.

On his nose was an 8 mm (1/3”) brownish red flat spot with a crack or scrape through it.

“How long have you had it”, I asked.

“Oh, a while now” he answered. That is about the least helpful time measurement I know of. I asked him to pin it down a bit more precisely. He settled for about a year. I prescribed a cream and made a two week followup appointment for either cryo or a biopsy. It’s probably just an excoriated, premalignant, actinic keratosis.

Back when life was different, this would not have gone unnoticed. But, of course, we’ve been wearing masks for over a year and a half now, so no wonder I wouldn’t have noticed it just talking to the man.

I walked down the hall and told my new partner what just happened.

“Oh, yeah”, she said. “Same thing happened to me – a basal cell cancer. And I find it difficult sometimes to assess things like state of emotion with no facial expressions. And, even worse, I’ve got a lot of patients that are new to me that I don’t even know what they look like.”

“Of course, you started here six months before the pandemic”, I registered. “That really must feel weird.”

Telemedicine is considered better than telephone medicine just because you can judge demeanor, facial expressions and so many other things better visually than with your hearing only. So where do masked in-person visits fall on that spectrum? Of course we can see head shaking and shoulder shrugging, so masked visits win over telephonic, but my next thought here is that maybe I should reconsider my scepticism about a former colleague I heard about just the other day.

This doctor will now have a patient sit in the exam room while she herself sits in her office. In front of the patient is a computer and the two of them basically do the first part of the visit as if they had a “regular” telemedicine consultation. Then, the doctor may or may not step into the office in order to do whatever physical exam the clinical situation requires.

I suddenly see at least a little bit of logic in that approach. Because that way they can both talk without masks on. (Or should you, with what we now know about aerosol transmission in the exam room and all…)

3 Responses to “Behind the Mask”

  1. 1 Spring Texan November 6, 2021 at 10:48 am

    Yeah, I think masks are AWFUL for interaction. I have a new doctor; because my old one started making everyone see the NP, and she seems very capable and knowledgeable and focused; and I’m certainly favorable on that count, but I have no idea of her personality or demeanor, with a masked visit, which is jarring.

  2. 2 Spring Texan November 6, 2021 at 10:50 am

    With most people vaccinated, I honestly think it is a mistake to maintain mask requirements as long as community rates are not super-high. There is so much lost with masks and while transmission can occur, it’s less serious with everyone vaccinated and I think more is lost than gained.

  3. 3 Sherryl C Copeland November 14, 2021 at 8:01 am

    I agree with Spring Texan

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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