Patients asking for mask exeptions

[Nines]

I practice in a state with a statewide mask mandate. The state allows for exemptions for medical condutions but gives no further guidance on what medical or psychiatric conditions should qualify a person for an exemption. I had a patient ask for a letter to their employer excusing them from wearing a mask at work due to anxiety. Has anyone encountered this during the pandemic? How do you handle it? Are their particular diagnoses or situations in which you would write such a letter? I feel like there should be a high bar for giving a patient license to ignore a public health order during a pandemic, especially in their workplace, but I'm curious to hear people's thoughts.

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[Attending1985]

I practice in a state with a statewide mask mandate. The state allows for exemptions for medical condutions but gives no further guidance on what medical or psychiatric conditions should qualify a person for an exemption. I had a patient ask for a letter to their employer excusing them from wearing a mask at work due to anxiety. Has anyone encountered this during the pandemic? How do you handle it? Are their particular diagnoses or situations in which you would write such a letter? I feel like there should be a high bar for giving a patient license to ignore a public health order during a pandemic, especially in their workplace, but I'm curious to hear people's thoughts.

I will not grant them. I ask the patient to acclimate to the mask at home. Wear it where you watch tv clean whatever.

 

[Sushirolls]

 

[wolfvgang22]

I will not grant them. I ask the patient to acclimate to the mask at home. Wear it where you watch tv clean whatever.

100 percent agree. This is the approach of all the doctors at my hospital. I've had a patient try to manipulate me, saying "I'll have a panic attack and it will be your fault I lose my job."
I said I would write a letter recommending reassignment to an isolated area, take some time off, etc. The law is the law. People made excuses like this about car seat belt laws, no smoking laws, etc. People did this in 1918 pandemic. See Anti-Mask League of San Francisco - Wikipedia
Nothing new.

 

[box8psych]

Time for some exposure therapy!

 

[Sushirolls]

Soon the ESA letter mill websites will also have a link for mask exemptions. $100 per consult letter...

 

[Bartelby]

I agree with the above, I would not write a letter stating that a mask exemption should be granted based on anxiety. I like wolvgang's approach of considering other reasonable accommodations.

I also agree with the above comment that exposure therapy is often the best approach to anxiety. For individuals who currently believe they cannot tolerate a mask due to anxiety exposure seems like the way to go.

 

[calvnandhobbs68]

Soon the ESA letter mill websites will also have a link for mask exemptions. $100 per consult letter...

Ugh I can't wait for all the telemedicine NP letters for mask exemptions.

I think the no mask exemption policy is the policy of most rational physicians. Worst way to treat anxiety is to give someone a blanket exemption from encountering the thing that makes them anxious.

In my part of practice, the only thing I would give an actual exemption for is for developmentally disabled patients or patients with significant autism spectrum disorder (we're not talking Level 1/Asperger's here) who simply cannot tolerate wearing something on their face (in the same way 2 year olds just keep ripping their masks off). This would come with the disclaimer in the letter that the patient should be limiting contact with others for essential needs only (no family romps to Disney World without a mask the whole way using my letter) and a discussion with the family that the patient should at least be trying a face shield to protect others a bit, which some patients are actually able to tolerate in a way that they can't with masks directly on their face.

 

[Fan_of_Meehl]

I practice in a state with a statewide mask mandate. The state allows for exemptions for medical condutions but gives no further guidance on what medical or psychiatric conditions should qualify a person for an exemption. I had a patient ask for a letter to their employer excusing them from wearing a mask at work due to anxiety. Has anyone encountered this during the pandemic? How do you handle it? Are their particular diagnoses or situations in which you would write such a letter? I feel like there should be a high bar for giving a patient license to ignore a public health order during a pandemic, especially in their workplace, but I'm curious to hear people's thoughts.

One thing to consider is that there are cognitive-behavioral approaches to treating panic disorder (where shortness of breath is a prominent symptom) that utilize breathing through a cocktail straw as part of the exposure to the bodily sensations it elicits as a treatment that addresses the catastrophic misinterpretations of benign bodily sensations which underlie the core pathology. That is to say, if the concern is 'anxiety' as a result of wearing the mask, the treatment of choice would--all else being equal--be exposure and/or cognitive restructuring.

 

[hallowmann]

Agree with all of the above. The only people I have seen give exemption letters (I've only had two patients that had ones) were PAs. It honestly sounded like they just wrote something verbatim with what the patient requested and attributed it to "anxiety". When the patient (with no pulmonary or cardiac pathology) told me a long story of how they "pass out" whenever they wear a mask, all I said was "that's too bad", and moved on with the visit.

 

[Nines]

I'm glad to see that there appears to be a consensus on this issue. To be honest my first thought when the nurse relayed the request to me was thinking about how I would feel if the patient I exempted subsequently contracted covid or if I later heard of an outbreak at their place of work and feeling that I could have contributed to it. This pandemic is no fun.

 

[Liquid8]

Some of my non-psych medical colleagues here are getting similar requests - eg. new patients who suddenly complain of a new onset “claustrophobia” wanting an exemption as well as various forms of new anxiety. Our state government had initially not required one to have a medical certificate for an exemption, but too many people were taking advantage of that so this rule has changed. As a collective, we’re taking the line that anyone unable to wear a mask should really be staying at home.

My feeling is that the truly anxious are more concerned about how the consequences of not complying with Covid19 regulations will impact others or being judged by the majority of the population. One of my trauma patients with a chronic phobia of vomiting triggered surprised me when they told me they’d been tested after some mild respiratory symptoms. I figure if someone like this is able to subject themselves to the Covid throat swab by putting their concerns for others above their own fears, then most people trying to get out of the requirements really have no excuse and are behaving in line with selfish/sociopathic tendencies. Fortunately the vast majority of my patients are prepared to do the right thing and the anti-maskers probably have negative views on psychiatry so will do their best to avoid us.

The only exemption letter that I’d be likely to write is for someone who is deaf and relies on lip reading to communicate – but that’s a letter that would let others not wear a mask.

 

[TexasPhysician]

Won’t write such a letter for any reason.

Even if you agreed with writing the letter, consider the liability. You are essentially providing an accommodation over treatment that causes harm. In the event of a severe infection, a lawsuit would be incoming, and there would be no shortage of physicians willing to testify against you.

 

[Nines]

Won’t write such a letter for any reason.

Even if you agreed with writing the letter, consider the liability. You are essentially providing an accommodation over treatment that causes harm. In the event of a severe infection, a lawsuit would be incoming, and there would be no shortage of physicians willing to testify against you.

I was looking at how some other countries are approaching this. It looks like in the UK people who feel that they have a conditon that exempts them from masking up can register with the gov and "self certify" that they have a condition that exempts them. They can get receive a card that they can carry around to prevent getting fined. I think there are a host of problems with that system and obviously there is a high potential for abuse but at least it removes the doctors from the equation. Any liability would have to be borne by the patient if they misrepresented their condition or lied to get an exeption.

 

[Fan_of_Meehl]

I was looking at how some other countries are approaching this. It looks like in the UK people who feel that they have a conditon that exempts them from masking up can register with the gov and "self certify" that they have a condition that exempts them. They can get receive a card that they can carry around to prevent getting fined. I think there are a host of problems with that system and obviously there is a high potential for abuse but at least it removes the doctors from the equation. Any liability would have to be borne by the patient if they misrepresented their condition or lied to get an exeption.

"There are a host of problems with that system..."

From the perspective of an ethical clinician, YES, there are tons of problems with that system.

From the perspective of a government bureaucrat/politician, it's a perfect system: you 'win' by a) giving the people 'what they want' while simultaneously b) reinforcing the practice/ expectation that citizens can do what they want as long as they ask/get permission from a government bureaucrat. No clinician need be involved nor exercise clinical judgment. More power to the bureaucrats, eliminating the authority of the clinician...been witnessing this dynamic at work at the VA for years.

 

[deleted480308]

"There are s host of problems with that system..."

From the perspective of an ethical clinician, YES, there are tons of problems with that system.

From the perspective of a government bureaucrat/politician, it's a perfect system: you 'win' by a) giving the people 'what they want' while simultaneously b) reinforcing the practice/ expectation that citizens can do what they want as long as they ask/get permission from a government bureaucrat. No clinician need be involved nor exercise clinical judgment. More power to the bureaucrats, eliminating the authority of the clinician...been witnessing this dynamic at work at the VA for years.

Why have a rule if literally anyone for any or no reason can declare themself exempt

 

[Fan_of_Meehl]

Why have a rule if literally anyone for any or no reason can declare themself exempt

To reinforce lack of virtue in the society (and, conversely, to punish virtue) and to make it clear who has the authority to grant or deny privileges or liberties. Not to mention that such rules are often arbitrarily and selectively enforced.

 

[Nines]

"There are a host of problems with that system..."

From the perspective of an ethical clinician, YES, there are tons of problems with that system.

From the perspective of a government bureaucrat/politician, it's a perfect system: you 'win' by a) giving the people 'what they want' while simultaneously b) reinforcing the practice/ expectation that citizens can do what they want as long as they ask/get permission from a government bureaucrat. No clinician need be involved nor exercise clinical judgment. More power to the bureaucrats, eliminating the authority of the clinician...been witnessing this dynamic at work at the VA for years.

I looked into it in more detail and its actually even worse. In the UK you can just go to a gov website and print out an exemption card template that you can carry around with you. Basically renders the mask mandate meaningless. Makes me wonder why the US gets so much criticism on the mask thing. Clearly there are other places that are also approaching this issue in a problematic way, in some cases moreso than here. And I think I saw some data showing that mask wearing is actually more prevalent in the US than in the UK and some other European countries.

 

[Fan_of_Meehl]

Adopt

I looked into it in more detail and its actually even worse. In the UK you can just go to a gov website and print out an exemption card template that you can carry around with you. Basically renders the mask mandate meaningless. Makes me wonder why the US gets so much criticism on the mask thing. Clearly there are other places that are also approaching this issue in a problematic way, in some cases moreso than here. And I think I saw some data showing that mask wearing is actually more prevalent in the US than in the UK and some other European countries.

{affects Obi Wan Kenobi voice}:

"You've just taken your first step into a larger world..."

 

[Merovinge]

Won’t write such a letter for any reason.

Even if you agreed with writing the letter, consider the liability. You are essentially providing an accommodation over treatment that causes harm. In the event of a severe infection, a lawsuit would be incoming, and there would be no shortage of physicians willing to testify against you.

Hard to agree with this for me. I have a pretty ASD/ID/DD heavy patient panel (as I suspect most CAP do) and these are the exact cases for which an exception makes sense. I think it's pretty hard to argue that someone with a known sensory processing disorder that can hardly handle wearing 90% of clothing articles without punching a hole through a wall would be able to always wear a mask if they just had exposure therapy and that there is negligence in providing a letter stating that they may not always be able to maintain masking as currently required.

Of course like everyone else, I'm providing zero such letters for someone with anxiety that does not fall into the above categories. Even the majority of my ASD/ID patients do well with masks but certainly some do not.

 

[TexasPhysician]

Hard to agree with this for me. I have a pretty ASD/ID/DD heavy patient panel (as I suspect most CAP do) and these are the exact cases for which an exception makes sense. I think it's pretty hard to argue that someone with a known sensory processing disorder that can hardly handle wearing 90% of clothing articles without punching a hole through a wall would be able to always wear a mask if they just had exposure therapy and that there is negligence in providing a letter stating that they may not always be able to maintain masking as currently required.

Of course like everyone else, I'm providing zero such letters for someone with anxiety that does not fall into the above categories. Even the majority of my ASD/ID patients do well with masks but certainly some do not.

My area is a relative hot spot. Masks in my state are required for >10 years old in places of business. Public schooling can be virtual. There are mask equivalents like face shields, hats with shields, etc. Mask material is not regulated. Grocery stores have curbside.

With the many accommodations in the midst of a pandemic, I fail to see why child psychiatrists should determine the risk/benefit analysis of a mask with a deadly virus.

While I understand that masks are more difficult for those with ASD/ID/DD, I’m not their pediatrician, infectious disease doc, etc to allow this person to place themselves and their caretaker at greater risk of death.

Hypothetical case: 27y/o ID patient is primarily cared for by 57y/o married parent. Patient gets your permission to be exempt from mask mandate. Patient and primary caregiver get Covid and caregiver dies. Primary caregiver is no longer and spouse is overwhelmed. End result is a much worse outcome for the ID patient and your odds of a lawsuit are very high.

The farthest I would consider going is something like: Patient X has a diagnosis of X which may impair patient x’s ability to wear a mask properly in all situations at all times.

No where would I state an exemption or grant my permission to go mask free.

 

[whopper]

The risks of putting on a mask are so miniscule I don't see why anyone is having a problem with them aside that they're inconvenient and you smell your own bad coffee breath.

Can I see perhaps a PTSD or OCD thing with it? Yes but I haven't seen it happen yet. I am, however, seeing a lot of idiots claiming they know more than top medical experts and say some BS like the wire in the mask is a transmitter for the Jews or some other BS nonsense.

 

[Stagg737]

The farthest I would consider going is something like: Patient X has a diagnosis of X which may impair patient x’s ability to wear a mask properly in all situations at all times.

No where would I state an exemption or grant my permission to go mask free.

Are we actually exempting people with these letters though? If we're saying it's a medical necessity that X patient doesn't wear a mask, then I agree with you that they're inappropriate in nearly all cases. If we're simply writing a letter saying "Patient X has condition Y which may lead to significant symptoms q, r, and s if they are mandated to wear a mask", then the onus is placed on the patient or whoever else decides that they can legally ignore the mandate. Especially if the letter included something about educating the patient on the significant risks of not wearing a mask during COVID.

 

[Mass Effect]

I practice in a state with a statewide mask mandate. The state allows for exemptions for medical condutions but gives no further guidance on what medical or psychiatric conditions should qualify a person for an exemption. I had a patient ask for a letter to their employer excusing them from wearing a mask at work due to anxiety. Has anyone encountered this during the pandemic? How do you handle it? Are their particular diagnoses or situations in which you would write such a letter? I feel like there should be a high bar for giving a patient license to ignore a public health order during a pandemic, especially in their workplace, but I'm curious to hear people's thoughts.

If they think the mask makes them anxious, just wait til they're admitted to the ICU with a O2 in the 80s.

I think it's malpractice to grant such a request.

 

[Mass Effect]

I was looking at how some other countries are approaching this. It looks like in the UK people who feel that they have a conditon that exempts them from masking up can register with the gov and "self certify" that they have a condition that exempts them. They can get receive a card that they can carry around to prevent getting fined. I think there are a host of problems with that system and obviously there is a high potential for abuse but at least it removes the doctors from the equation. Any liability would have to be borne by the patient if they misrepresented their condition or lied to get an exeption.

And what about the lives of everyone else? Wearing the mask isn't only for your safety. It's also so you don't spread your COVID germs to the rest of society. I'm pretty heartless on this issue. No exemptions.

 

[Mass Effect]

Are we actually exempting people with these letters though? If we're saying it's a medical necessity that X patient doesn't wear a mask, then I agree with you that they're inappropriate in nearly all cases. If we're simply writing a letter saying "Patient X has condition Y which may lead to significant symptoms q, r, and s if they are mandated to wear a mask", then the onus is placed on the patient or whoever else decides that they can legally ignore the mandate. Especially if the letter included something about educating the patient on the significant risks of not wearing a mask during COVID.

But the bottom line is someone going into the grocery store with such a letter will not be made to wear a mask because a doctor said this or that. The grocery store clerk is not going to play semantics to see what you really meant. The patient doesn't wear a mask and ends up infecting others. Lawsuit or not, you're putting others at risk by writing such a letter for any reason.

 

[Stagg737]

But the bottom line is someone going into the grocery store with such a letter will not be made to wear a mask because a doctor said this or that. The grocery store clerk is not going to play semantics to see what you really meant. The patient doesn't wear a mask and ends up infecting others. Lawsuit or not, you're putting others at risk by writing such a letter for any reason.

I disagree, this is like saying there's no difference between a service dog and an ESA. You can even write at the top of the letter in bold "This is not an exemption". If the clerk chooses not to read it, that's not on you, it's on them and the patient. One could simply choose not to write the letters at all, but ultimately the patient is going to do what they want and they are responsible for their own actions.

 

[Mass Effect]

I disagree, this is like saying there's no difference between a service dog and an ESA. You can even write at the top of the letter in bold "This is not an exemption". If the clerk chooses not to read it, that's not on you, it's on them and the patient. One could simply choose not to write the letters at all, but ultimately the patient is going to do what they want and they are responsible for their own actions.

Exempting for masks is very much like an ESA to me. One could easily write "Charlie is anxious and a dog would make it better" the same way they'd write "Charlie is anxious and not wearing a mask would make it better." You're saying it's on the patient and yes, you're right, but I'm not talking about liability or legal culpability. I'm saying that as a physician, I am not going to write anything that's not in favor of everyone wearing a mask because as a physician, I know what the evidence shows. Any letter I write for a patient will leave no doubt that the patient should wear a mask.

 

[hamstergang]

You can even write at the top of the letter in bold "This is not an exemption". If the clerk chooses not to read it, that's not on you, it's on them and the patient.

I don't know that playing naive holds up legally or ethically. If you write this letter, you know what it will get used for. Hopefully someone with more of a legal/forensics background can weigh in, but I am under the impression that we are responsible for foreseeable consequences of our actions.

Personally, I don't see how any doctor can support a mask exemption during such a pandemic. Instead, pushing for other accommodations to compensate for the inability to sustain wearing a mask makes much more sense and keeps everyone safer.

 

[calvnandhobbs68]

My area is a relative hot spot. Masks in my state are required for >10 years old in places of business. Public schooling can be virtual. There are mask equivalents like face shields, hats with shields, etc. Mask material is not regulated. Grocery stores have curbside.

With the many accommodations in the midst of a pandemic, I fail to see why child psychiatrists should determine the risk/benefit analysis of a mask with a deadly virus.

While I understand that masks are more difficult for those with ASD/ID/DD, I’m not their pediatrician, infectious disease doc, etc to allow this person to place themselves and their caretaker at greater risk of death.

Hypothetical case: 27y/o ID patient is primarily cared for by 57y/o married parent. Patient gets your permission to be exempt from mask mandate. Patient and primary caregiver get Covid and caregiver dies. Primary caregiver is no longer and spouse is overwhelmed. End result is a much worse outcome for the ID patient and your odds of a lawsuit are very high.

The farthest I would consider going is something like: Patient X has a diagnosis of X which may impair patient x’s ability to wear a mask properly in all situations at all times.

No where would I state an exemption or grant my permission to go mask free.

Okay I don't agree with your "odds of a lawsuit" are high thing. At least not a successful lawsuit. Psychiatrists are one of the least sued specialities and yet one of the most worried about lawsuits I've ever seen....

This is similar to informed consent. These patients typically have legal guardians or are minors. Part of the discussion that I would document in my note is that not wearing a mask MAY increase the risk of contracting COVID (that's honestly debatable) and more likely increases the risk of the patient infecting others if he/she becomes infected with COVID and so could more easily infect those around him/her. This would also be stated in the letter. Also, I agree with the above, this isn't an exemption in the sense that "person A is not allowed to wear a mask". So yes, it is the caregivers choice about whether to try to put a mask on, just like it's their choice whether to give the Abilify or not. If they don't give the Abilify, there's risks. If they do give the Abilify, there's risks. I'm just allowing them to actually make the choice in this situation rather than it being a huge battle every time they have to take the patient somewhere due to trying to force the patient to wear a mask.

It's not at all clear that face shields are equivalent to masking either although again I would encourage trialing this and document that as such.

 

[TexasPhysician]

Okay I don't agree with your "odds of a lawsuit" are high thing. At least not a successful lawsuit. Psychiatrists are one of the least sued specialities and yet one of the most worried about lawsuits I've ever seen....

This is similar to informed consent. These patients typically have legal guardians or are minors. Part of the discussion that I would document in my note is that not wearing a mask MAY increase the risk of contracting COVID (that's honestly debatable) and more likely increases the risk of the patient infecting others if he/she becomes infected with COVID and so could more easily infect those around him/her. This would also be stated in the letter. Also, I agree with the above, this isn't an exemption in the sense that "person A is not allowed to wear a mask". So yes, it is the caregivers choice about whether to try to put a mask on, just like it's their choice whether to give the Abilify or not. If they don't give the Abilify, there's risks. If they do give the Abilify, there's risks. I'm just allowing them to actually make the choice in this situation rather than it being a huge battle every time they have to take the patient somewhere due to trying to force the patient to wear a mask.

It's not at all clear that face shields are equivalent to masking either although again I would encourage trialing this and document that as such.

Why are we one of the lower risk specialties for lawsuits? That’s more rhetorical, but the answer is definitely not by commenting on infectious disease issues.

With Abilify, I make the recommendation for it. If patients decline, that is their right. If they accept, the odds of them killing a family member doesn’t escalate as far as research has shown. If anything, it reduces the risk, and I meet standard of care. Right now, the general public accepts that masks play a role in reducing COVID spread and death. Covid has a relatively known mortality rate. Therefore masks reduce risks to family and themselves.

Face shields = masks is not an argument that I know any of the science behind. I’m merely passing along a comment made by my medical board president.

 

[Mass Effect]

This is similar to informed consent. These patients typically have legal guardians or are minors. Part of the discussion that I would document in my note is that not wearing a mask MAY increase the risk of contracting COVID (that's honestly debatable)

How is that "debatable"? There's an established link that wearing masks helps to protect the wearer and others from transmission.

and more likely increases the risk of the patient infecting others if he/she becomes infected with COVID and so could more easily infect those around him/her. This would also be stated in the letter. Also, I agree with the above, this isn't an exemption in the sense that "person A is not allowed to wear a mask". So yes, it is the caregivers choice about whether to try to put a mask on, just like it's their choice whether to give the Abilify or not. If they don't give the Abilify, there's risks. If they do give the Abilify, there's risks. I'm just allowing them to actually make the choice in this situation rather than it being a huge battle every time they have to take the patient somewhere due to trying to force the patient to wear a mask

During a state mandate, as is the case in the OP, there should not be a choice and your helping your patient circumvent the mandate because of a "huge battle every time" they have to take it is irresponsible in my view.

And again I don't even care about court. My argument is not a legal one. Any physician handing out these letters, regardless of whatever they put in the chart, is doing a disservice to their patient, their patient's caregivers, and the rest of the public.

 

[Merovinge]

My area is a relative hot spot. Masks in my state are required for >10 years old in places of business. Public schooling can be virtual. There are mask equivalents like face shields, hats with shields, etc. Mask material is not regulated. Grocery stores have curbside.

With the many accommodations in the midst of a pandemic, I fail to see why child psychiatrists should determine the risk/benefit analysis of a mask with a deadly virus.

While I understand that masks are more difficult for those with ASD/ID/DD, I’m not their pediatrician, infectious disease doc, etc to allow this person to place themselves and their caretaker at greater risk of death.

Hypothetical case: 27y/o ID patient is primarily cared for by 57y/o married parent. Patient gets your permission to be exempt from mask mandate. Patient and primary caregiver get Covid and caregiver dies. Primary caregiver is no longer and spouse is overwhelmed. End result is a much worse outcome for the ID patient and your odds of a lawsuit are very high.

The farthest I would consider going is something like: Patient X has a diagnosis of X which may impair patient x’s ability to wear a mask properly in all situations at all times.

No where would I state an exemption or grant my permission to go mask free.

My letters (written two to date), exactly state that patient carries a diagnosis of X which may limit his/her ability to comply with proper mask use at all times. Nothing more or less. I am not making a risks/benefit analysis or legally indicating anything other than the reality that individuals with ASD/ID/sensory processing disorders have a very real disorder than can impair their ability to wear a mask properly at all times. The ability to discern if their mental health disorder impacts their ability to mask properly at all times is squarely on their mental health provider; punting to peds or ID is simply punting, clearly those specialties are less able to determine if the mental health disorder impacts the patient's ability to do this.

I am very aware of legal liabilities in general and also the abuse of MD notes for things like emotional support animals. This is NOT like that, these are among the most vulnerable population on Earth who have very real struggles because of COVID. I can't begin to estimate what infinitesimal proportion of mask non-adherence is related to IQ <60, severe ASD/sensory disorders but the number is real real low.

 

[TexasPhysician]

My letters (written two to date), exactly state that patient carries a diagnosis of X which may limit his/her ability to comply with proper mask use at all times. Nothing more or less. I am not making a risks/benefit analysis or legally indicating anything other than the reality that individuals with ASD/ID/sensory processing disorders have a very real disorder than can impair their ability to wear a mask properly at all times. The ability to discern if their mental health disorder impacts their ability to mask properly at all times is squarely on their mental health provider; punting to peds or ID is simply punting, clearly those specialties are less able to determine if the mental health disorder impacts the patient's ability to do this.

I am very aware of legal liabilities in general and also the abuse of MD notes for things like emotional support animals. This is NOT like that, these are among the most vulnerable population on Earth who have very real struggles because of COVID. I can't begin to estimate what infinitesimal proportion of mask non-adherence is related to IQ <60, severe ASD/sensory disorders but the number is real real low.

It seems we have the exact same view on this. The OP is discussing exemption letters, and I’ve had patients request that the letter specifically state “mask exemption” on it. That’s what many people are seeking. I’m advocating against that.

If the school or other entity wants something to avoid fines that states the diagnosis and how that may effect the patient’s ability to maintain 100% compliance, I’m not opposed. That is merely recognizing a reality, not permitting a lack of safety.

 

[calvnandhobbs68]

How is that "debatable"? There's an established link that wearing masks helps to protect the wearer and others from transmission.



During a state mandate, as is the case in the OP, there should not be a choice and your helping your patient circumvent the mandate because of a "huge battle every time" they have to take it is irresponsible in my view.

And again I don't even care about court. My argument is not a legal one. Any physician handing out these letters, regardless of whatever they put in the chart, is doing a disservice to their patient, their patient's caregivers, and the rest of the public.

Where's the established link that wearing regular surgical/cloth masks significantly protects the wearer from transmission? There's decent evidence normal masks help prevent transmission from the person wearing the mask to others by catching the large droplets before they have a chance to disperse in the air. Hook me up with the papers showing that wearing a regular old surgical or cloth mask significantly protects the wearer from infection. The possible best evidence showed that having a surgical mask material partition between hamsters in a cage decreased infection rates...which of course doesn't account for the fact that air follows the path of least resistance without a good seal. Which is right around the gaps of the mask.

That's not to say that I disagree with universal masking...but it'd be quite difficult to prove liability that providing a note which may then be used to allow a person to not wear a mask would somehow make you liable for that person getting infected.

This is NOT like that, these are among the most vulnerable population on Earth who have very real struggles because of COVID. I can't begin to estimate what infinitesimal proportion of mask non-adherence is related to IQ <60, severe ASD/sensory disorders but the number is real real low.

Agree. I think the downplaying of the "huge battle every time" issue is pretty callous considering a huge battle with this patient population can result in someone getting seriously injured or the patient refusing to come back home with the caretaker or the patient eloping blocks over to the nearest restaurant and having to get picked up by police to come back. This is truly being done in the best interest of the patient and caregivers and again, it's up to the caregiver/group home/etc if they want to utilize this. Is there a risk with not wearing a mask? Sure. Is there a risk to the caregiver attempting to force a 200lb significantly intellectually disabled person to put something on their face? Sure.

 

[Mass Effect]

Where's the established link that wearing regular surgical/cloth masks significantly protects the wearer from transmission? There's decent evidence normal masks help prevent transmission from the person wearing the mask to others by catching the large droplets before they have a chance to disperse in the air. Hook me up with the papers showing that wearing a regular old surgical or cloth mask significantly protects the wearer from infection. The possible best evidence showed that having a surgical mask material partition between hamsters in a cage decreased infection rates...which of course doesn't account for the fact that air follows the path of least resistance without a good seal. Which is right around the gaps of the mask.

That's not to say that I disagree with universal masking...but it'd be quite difficult to prove liability that providing a note which may then be used to allow a person to not wear a mask would somehow make you liable for that person getting infected

Evolving.

UC San Francisco Study Suggests Masks Do Protect Wearer From Contracting Coronavirus

A new study from the University of California San Francisco suggests that masks do protect the wearer from contracting COVID-19.

losangeles.cbslocal.com

Face Masks Reduce Wearer's COVID Infection Risk by 65%

'People who say 'I don't believe masks work' are ignoring scientific evidence,' Blumberg said. 'It's not a belief system. It's like saying, 'I don't believe in gravity.'

www.medscape.com

Masks Do More Than Protect Others During COVID-19: Reducing the Inoculum of SARS-CoV-2 to Protect the Wearer - Journal of General Internal Medicine

Although the benefit of population-level public facial masking to protect others during the COVID-19 pandemic has received a great deal of attention, we discuss for one of the first times the hypothesis that universal masking reduces the “inoculum” or dose of the virus for the mask-wearer...

link.springer.com

Agree. I think the downplaying of the "huge battle every time" issue is pretty callous considering a huge battle with this patient population can result in someone getting seriously injured or the patient refusing to come back home with the caretaker or the patient eloping blocks over to the nearest restaurant and having to get picked up by police to come back

This same risk exists with getting this patient population in the shower or getting this patient population to take medicine or get to doctor's appointments. Yet, if the caretaker cast those things aside, we'd be talking about neglect. So why is the standard different for masks? Someone's mental impairment being the reason they cannot protect themselves doesn't excuse exempting them from protecting themselves - and protecting others, including said caretaker.

 

[calvnandhobbs68]

Evolving.

UC San Francisco Study Suggests Masks Do Protect Wearer From Contracting Coronavirus

A new study from the University of California San Francisco suggests that masks do protect the wearer from contracting COVID-19.

losangeles.cbslocal.com

Face Masks Reduce Wearer's COVID Infection Risk by 65%

'People who say 'I don't believe masks work' are ignoring scientific evidence,' Blumberg said. 'It's not a belief system. It's like saying, 'I don't believe in gravity.'

www.medscape.com

Masks Do More Than Protect Others During COVID-19: Reducing the Inoculum of SARS-CoV-2 to Protect the Wearer - Journal of General Internal Medicine

Although the benefit of population-level public facial masking to protect others during the COVID-19 pandemic has received a great deal of attention, we discuss for one of the first times the hypothesis that universal masking reduces the “inoculum” or dose of the virus for the mask-wearer...

link.springer.com

I've read all that. This actual meta-analysis (which is what the medscape link is actually talking about even though they don't actually cite it ) is probably the best of all of those.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext

All the other links are from Gandhi advertising her opinion piece in the Journal of General Internal medicine which basically has no actual evidence in it. The best paper cited in that is the hamster study. Again, would be pretty tough to prove that non-mask wearing was the main reason why the patient got infected (as opposed to some random asymptomatic or minimally symptomatic person they were around not wearing a mask which currently seems to be far more likely).

 

[Mass Effect]

I've read all that. This actual meta-analysis (which is what the medscape link is actually talking about even though they don't actually cite it ) is probably the best of all of those.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext

All the other links are from Gandhi advertising her opinion piece in the Journal of General Internal medicine which basically has no actual evidence in it. The best paper cited in that is the hamster study. Again, would be pretty tough to prove that non-mask wearing was the main reason why the patient got infected (as opposed to some random asymptomatic or minimally symptomatic person they were around not wearing a mask which currently seems to be far more likely).

Putting all of that aside then, what about protecting others? We're not just talking about the health of the patient. If a patient can't wear a mask, for whatever reason, that patient should not be in public places.

 

[<L>]

Borderline personality disorder, fibro, and panic disorder. Nice to see that we're doing mask exemptions for the same reasons we're doing questionable xanax Rx's.

Mask rage: ‘One man told me I shouldn't be allowed out if I can't wear one’

With face coverings compulsory in many settings, people unable to comply for health reasons are being challenged and abused

www.theguardian.com

 

[Mass Effect]

Borderline personality disorder, fibro, and panic disorder. Nice to see that we're doing mask mandates for the same reasons we're doing questionable xanax Rx's.

Mask rage: ‘One man told me I shouldn't be allowed out if I can't wear one’

With face coverings compulsory in many settings, people unable to comply for health reasons are being challenged and abused

www.theguardian.com

" The abuse has made Feeley, who suffers from fibromyalgia, borderline personality disorder and panic attacks, feel “extraordinarily angry, anxious and upset”. He is unable to wear a face covering due to his medical conditions, and legally he is exempt "

Really now, borderline personality disorder and fibromyalgia makes you unable to wear a face covering?

 

[deleted480308]

" The abuse has made Feeley, who suffers from fibromyalgia, borderline personality disorder and panic attacks, feel “extraordinarily angry, anxious and upset”. He is unable to wear a face covering due to his medical conditions, and legally he is exempt "

Really now, borderline personality disorder and fibromyalgia makes you unable to wear a face covering?

“Hey dude, wear a mask” is abuse now?

 

[Fan_of_Meehl]

“Hey dude, wear a mask” is abuse now?

It's torture, even...like we do to language these days...until it has no meaning anymore. Just as astute clinicians like Richard McNally cautioned against the ongoing 'bracket creep' in reference to the endless broadening of what qualified as a 'traumatic stressor' sufficient to satisfy Criterion A for PTSD, we have to be wary of the mindless lowering of the threshold of what constitutes 'abuse' or we won't even be able to meaningfully communicate anymore. It is not uncommon for veterans to get upset if I determine that their feelings of being socially ostracized (or their commander 'playing favorites') during deployment do not constitute 'traumatic stressors' sufficient to qualify for a PTSD diagnosis. I mean, who am I to say that it wasn't 'traumatic' for them?

 

[Stagg737]

I don't know that playing naive holds up legally or ethically. If you write this letter, you know what it will get used for. Hopefully someone with more of a legal/forensics background can weigh in, but I am under the impression that we are responsible for foreseeable consequences of our actions.

Personally, I don't see how any doctor can support a mask exemption during such a pandemic. Instead, pushing for other accommodations to compensate for the inability to sustain wearing a mask makes much more sense and keeps everyone safer.

It's not playing naive, it's making a clear statement that it's not an exemption, but explaining the underlying reason why wearing a mask may cause problems for the individual. There's not really any legal leeway in the situation I described. And you wouldn't be responsible because you're not writing an exemption.

And again I don't even care about court. My argument is not a legal one. Any physician handing out these letters, regardless of whatever they put in the chart, is doing a disservice to their patient, their patient's caregivers, and the rest of the public.

The bolded brings up an interesting point that was just argued in @whopper 's recent thread here:

Hypothetical Scenario-what would you tell this patient?

Say you got a patient with a very close older relative who directly knew one of the most identifiable people in world history? This older relative has several pieces of property that should be in a museum. E.g. pictures of this historical figure, notes, personal items owned by this person. And...

forums.studentdoctor.net

Pretty much everyone in that thread agreed that as physicians we have an obligation, first and foremost, to our patients and that public interests take a back seat. Yes, a pandemic is an extreme situation and different from that thread, but at what point does public health outweigh the needs (or even rights) of our patients? If a patient had a medical condition which prohibited them from wearing a mask d/t the mask causing harm to themselves, would you still feel the same way? How much are we willing to let a pandemic affect the mental well-being of our patients and society as a whole? I've trailed off the point about exemption letters, but I think it's worth having a conversation especially in light of the ridiculous surge in mental health needs since this pandemic has started.

How is that "debatable"? There's an established link that wearing masks helps to protect the wearer and others from transmission.

I'll second Calvn, if you know of any actual studies which show solid correlations I'd love to read them. I just haven't seen anything worth writing home about yet (and doubt that we will given how hard it would be to control variables adequately to pull it off).

I've read all that. This actual meta-analysis (which is what the medscape link is actually talking about even though they don't actually cite it ) is probably the best of all of those.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext

All the other links are from Gandhi advertising her opinion piece in the Journal of General Internal medicine which basically has no actual evidence in it. The best paper cited in that is the hamster study. Again, would be pretty tough to prove that non-mask wearing was the main reason why the patient got infected (as opposed to some random asymptomatic or minimally symptomatic person they were around not wearing a mask which currently seems to be far more likely).

I'd be interested in seeing some more solid studies as well. I've read a few and they've been less than impressive in terms of making the point that makes are as necessary as current recommendations say they are. Doesn't mean I won't wear a mask or will write exemptions for my patients, but it gets tiresome hearing people make concrete statements over information which has weak evidence (and yes, I am projecting that statement to current issues beyond wearing masks).

 

[Mass Effect]

The bolded brings up an interesting point that was just argued in @whopper 's recent thread here:

Hypothetical Scenario-what would you tell this patient?

Say you got a patient with a very close older relative who directly knew one of the most identifiable people in world history? This older relative has several pieces of property that should be in a museum. E.g. pictures of this historical figure, notes, personal items owned by this person. And...

forums.studentdoctor.net

Pretty much everyone in that thread agreed that as physicians we have an obligation, first and foremost, to our patients and that public interests take a back seat

You can't compare the two scenarios when one scenario is literally a matter of life and death.

Yes, a pandemic is an extreme situation and different from that thread, but at what point does public health outweigh the needs (or even rights) of our patients?

I get worked up when people talk about rights in the same breath that they talk about masks because I know for a fact that if your patient wanted you to write a letter allowing him to smoke on a plane, you wouldn't do it. If your patient wanted a letter allowing him to drink alcohol and drive, you wouldn't do it. Hell, if your patient wanted a letter excusing him from wearing a seat belt you wouldn't do it. Yet somehow when discussing masks, it becomes a question of rights.

If a patient had a medical condition which prohibited them from wearing a mask d/t the mask causing harm to themselves, would you still feel the same way?

If someone had a legit medical condition that prohibited them from wearing masks, I'd say they should stay away from public and/or crowded places. That patient's misfortune should not be why I bury a loved one. It's selfish to show up in public places without a mask, no matter the reason.

How much are we willing to let a pandemic affect the mental well-being of our patients and society as a whole?

As long as I know the evidence behind it and that is that the more people die, the worse the mental health of the public at large. So, I don't know, I don't think I'm the one letting the pandemic affect the mental well-being of our patients and society as a whole. I think the people letting it go on by refusing to follow the guidelines are the ones who are letting this go on.

I'd be interested in seeing some more solid studies as well. I've read a few and they've been less than impressive in terms of making the point that makes are as necessary as current recommendations say they are.

Are you saying you haven't seen evidence that masks are necessary? The evidence is literally everywhere. What the other discussion was referencing was masks protecting the wearer, not masks protecting others.

 

[Stagg737]

You can't compare the two scenarios when one scenario is literally a matter of life and death.

You say this and then you do this:

I get worked up when people talk about rights in the same breath that they talk about masks because I know for a fact that if your patient wanted you to write a letter allowing him to smoke on a plane, you wouldn't do it. If your patient wanted a letter allowing him to drink alcohol and drive, you wouldn't do it. Hell, if your patient wanted a letter excusing him from wearing a seat belt you wouldn't do it. Yet somehow when discussing masks, it becomes a question of rights.

Anyway, all of the above were questions of rights at one point and we've decided as a society that they are not acceptable. Masks are new, we'll see how society views this as things continue, but I'm guessing it won't be necessary long-term like the above.

If someone had a legit medical condition that prohibited them from wearing masks, I'd say they should stay away from public and/or crowded places. That patient's misfortune should not be why I bury a loved one. It's selfish to show up in public places without a mask, no matter the reason.

There's so much variation to this statement that I'm going to assume you mean crowded public places, more likely to be indoors. Regardless, it's still a question of rights. Should a person's refusal to vaccinate be the reason you bury a loved one? No, but unless you hold the stance of mandating vaccines you're looking at this from an emotional and not rational viewpoint.

As long as I know the evidence behind it and that is that the more people die, the worse the mental health of the public at large. So, I don't know, I don't think I'm the one letting the pandemic affect the mental well-being of our patients and society as a whole. I think the people letting it go on by refusing to follow the guidelines are the ones who are letting this go on.

And the current guidelines don't go far enough to accomplish what you're hoping. If we really want to effectively decrease and possibly stop the pandemic, we'd have to take fascist measures like China did where military police show up to the houses of those testing positive and force them to remain inside without setting foot outside the house. Sure, the more people die the more it affects mental health, no doubt. But let's not pretend that the situation we've already been through hasn't had a massive effect on society. I've heard the term "societal adjustment disorder" used more and more, and I'm apt to agree with it given the number of patient's I've seen for actual suicide attempts d/t worsening symptoms that started after orders to limit the pandemic were implemented. Not saying the alternative is better, but a cavalier or dismissive attitude on this subject isn't going to help anyone.

Are you saying you haven't seen evidence that masks are necessary? The evidence is literally everywhere. What the other discussion was referencing was masks protecting the wearer, not masks protecting others.

I'm saying the evidence isn't that strong. The evidence that is "literally everywhere" is weak and suggests that social distancing is more effective than wearing masks which have many issues that society seems to ignore (need for frequent cleaning, hand contact, filtration quality etc). I'm not saying people shouldn't be wearing masks like you're suggesting, you may be too emotionally invested in this conversation. I'm for wearing masks and would not write a mask exemption unless there were very specific (and relatively rare) circumstances such as the ones mentioned above regarding patients with severe ID. Even then I'd highly encourage the caregivers to minimize public exposure and attempt to acclimate the patient to wearing a mask. That being said, it's still worth discussing the reality and practicality of these "mandates" and what is realistic in terms of implementation.

 

[Mass Effect]

You say this and then you do this:



Anyway, all of the above were questions of rights at one point and we've decided as a society that they are not acceptable. Masks are new, we'll see how society views this as things continue, but I'm guessing it won't be necessary long-term like the above.

There's no contradiction there. These things are comparable.

There's so much variation to this statement that I'm going to assume you mean crowded public places, more likely to be indoors. Regardless, it's still a question of rights. Should a person's refusal to vaccinate be the reason you bury a loved one? No, but unless you hold the stance of mandating vaccines you're looking at this from an emotional and not rational viewpoint.

I'm in full support of systems that mandate vaccines to attend school and be around others that you're likely to infect.

And the current guidelines don't go far enough to accomplish what you're hoping. If we really want to effectively decrease and possibly stop the pandemic, we'd have to take fascist measures like China did where military police show up to the houses of those testing positive and force them to remain inside without setting foot outside the house

Again, you're not looking at the evidence. The evidence shows that states that enforced masks and closing of public places early had a significant decline in cases while states that didn't had a rise in cases. Comparing wearing a mask to fascism is pretty absurd.

Sure, the more people die the more it affects mental health, no doubt. But let's not pretend that the situation we've already been through hasn't had a massive effect on society

I never said it hasn't had a massive effect on society, but it's not like opening the country and not enforcing masks and social distancing is going to somehow be better. In fact, I'd wager, we're worsening the mental health of society by not taking this more seriously.

I've heard the term "societal adjustment disorder" used more and more, and I'm apt to agree with it given the number of patient's I've seen for actual suicide attempts d/t worsening symptoms that started after orders to limit the pandemic were implemented. Not saying the alternative is better, but a cavalier or dismissive attitude on this subject isn't going to help anyone

No one is being cavalier or dismissive. I simply disagree that it's best to let people do what they want and take our chances on the premise that it's better for everyone's mental health.

I'm saying the evidence isn't that strong. The evidence that is "literally everywhere" is weak

How is it weak?

suggests that social distancing is more effective than wearing masks which have many issues that society seems to ignore (need for frequent cleaning, hand contact, filtration quality etc). I'm not saying people shouldn't be wearing masks like you're suggesting, you may be too emotionally invested in this conversation

Is it that I'm "too emotionally invested" or irrational as you said above or is it just that I disagree with your opinion on the situation on the basis of the evidence that's already out there?

 

[Stagg737]

There's no contradiction there. These things are comparable.

Not really, I don't see how smoking on an airplane or not buckling your seatbelt is "literally a matter of life or death", and neither are likely to cause long-term or even acute harm to others. The drunk driving is fair, but again this is something that's been a problem since cars have existed and something which we've agreed as a society is unacceptable, choosing not to wear masks is not.

I'm in full support of systems that mandate vaccines to attend school and be around others that you're likely to infect.

That wasn't the question, the question was should vaccines be mandated. I'll go farther and ask should one be allowed to go out in public if not vaccinated? Forget about schools and being around the vulnerable, that's not what was being implied. Though if your answer is yes, we'll have to agree to disagree.

Again, you're not looking at the evidence. The evidence shows that states that enforced masks and closing of public places early had a significant decline in cases while states that didn't had a rise in cases. Comparing wearing a mask to fascism is pretty absurd.

And again, this does nothing to control for other public health variables or the types of masks being used. You're also twisting my words. I never said wearing a mask was fascism, that's absurd. I said that if we wanted to truly eliminate/contain the virus before a large percent of the population in the US was infected we'd have to take extreme measures which could be considered fascist as I described before.

No one is being cavalier or dismissive. I simply disagree that it's best to let people do what they want and take our chances on the premise that it's better for everyone's mental health.

That's fair, given the direction society and our political system has been heading for the past several years I just wonder how far things can go and if they could be stopped if they ever went too far.

How is it weak?

Have you read any of the actual journal articles and meta-analyses that have come out or are you just referencing sources like what you posted earlier? Because there is a significant difference in how dramatically this is being reported by the media and the actual data and analysis which are suggesting that non-surgical masks may provide some benefit, but pale in comparison to use of medical-grade masks and social distancing (another significant confounding factor).

Is it that I'm "too emotionally invested" or irrational as you said above or is it just that I disagree with your opinion on the situation on the basis of the evidence that's already out there?

I never said you were irrational and disagreement is fine. Some of your statements just come across as dramatic and seem more in line with the emotional arguments/stories of the media as opposed to the actual data.

 

[SourceOfDenial]

Curious—who here actually cares/cared for hospitalized pts with Covid?

 

[Stagg737]

Curious—who here actually cares/cared for hospitalized pts with Covid?

 

[WisNeuro]

Curious—who here actually cares/cared for hospitalized pts with Covid?

We will occasionally get called in to do or consult on decision making capacity on the COVID units.