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Making Customers, Clients, Patients & Diners Wear Face Masks

First, they said don’t wear masks.  Then they said it was OK to wear masks.  And now they’re telling us we must wear masks.  

In what felt like a matter of days, mask-wearing went from horribly selfish to ethically and in many cases legally obligatory.

For many of our readers, there’s now a new problem to solve: how do you compel a customer, client, patient or diner to wear a face mask – and what do you do when they outright refuse?

Once again, we turn to Dr. Peter Sandman, perhaps the country’s preeminent expert when it comes to “risk communications.” Sandman was one of the authors of the bible of our industry, “Crisis Emergency & Risk Communication,” the 250 page guide published by the CDC (“Be First. Be Right. Be Credible.) that many top political officials continue to ignore.  Here are Dr. Sandman’s observations and suggestions:

So now the tables have turned. It’s no longer the people wearing masks who are being excoriated for being selfish and foolish. It’s the people not wearing masks.

That’s a huge improvement, in my judgment. The case for making people wear masks to try to reduce transmission of COVID-19 is way stronger than the case for forbidding them from doing so. Is the case strong enough to justify coercion? That’s a tougher call. It is plausible that my mask reduces your risk and your mask reduces mine, since either of us might be unknowingly infected. But the actual scientific evidence for this plausible risk reduction is pretty thin.

EDITOR’S NOTE:  What Sandman writes below is specifically aimed at patients in doctor’s offices and hospital waiting rooms.  The advice, however, is 100% applicable to restaurants, retail stores, offices and virtually every other place of business.

Still, if required mask-wearing is justifiable anywhere, it is justifiable in medical settings. People in a doctor’s office or hospital waiting room are likelier to be infected with COVID-19 than people elsewhere. They are also likelier to have fragile immune systems as a result of other medical conditions, and thus they are more at risk if they catch COVID-19. And protecting the health of healthcare providers is right at the top of COVID-19 priorities.

Not surprisingly and not unwisely, most hospitals, clinics, and individual doctors’ offices now require patients to wear masks.

This is the context for a risk communication inquiry I received a few days ago from a state health department official I often work with. It was succinctly framed: “Defiant patients refusing to wear a mask. How should solo physicians handle this?”

The pathway of the inquiry is worth noting. Several doctors in a group practice raised the issue with the practice manager. She took it to the county health department, which recommended asking the state medical board, which recommended the state health department. So the practice manager posted it on the state health department’s website. It bounced around the department for a while, and eventually got referred to the official who sent it to me.

What follows is the numbered list of points I sent back, somewhat revised after input from Dr. Jody Lenard and the state official I’d sent it to, and with changes to preserve her anonymity. As I wrote to her in my cover note, “The more useful reactions, I suspect, are toward the end of the list, starting with #6; I felt a need to clear away some underbrush first.”

number 1
The health department should prioritize healthcare worker safety over everything else – both safety from violence and safety from infection. Stand with your peeps. Say so explicitly – and explain why: If healthcare personnel are endangered, everybody’s healthcare is endangered. COVID-19 already poses that risk more vividly than any domestic disease threat in recent history.
number 2
Violence comes first. A week ago a security guard at a Walmart in Flint, Michigan was shot and killed after a dispute over the store’s mask policy. There have been other incidents around the country, and there will be more.

As a risk communication consultant, I have always told clients that safety trumps outrage management. If you are threatened, call the cops. If you feel threatened, call the cops. If one of your staff or one of your patients feels threatened, call the cops. If you think maybe you should call the cops, call the cops.

And if you can’t call the cops, or while you’re waiting for the cops to arrive, give in if you think you should: A patient who’s violently out-of-control is a much more imminent threat than a patient who isn’t wearing a mask.

number 3
I don’t know what current state law says about the obligation to wear a mask, or what various county and local ordinances say. It’s a moving target. If patients are legally required to wear a mask, the doctor’s office should do its best to enforce that requirement … but not at the risk of violence. If the law says the patient has to wear a mask and the patient refuses, I wouldn’t risk an escalation by insisting. I would politely ask the patient to wear a mask. I’d ask several times, still politely. If the patient keeps refusing but isn’t threatening, I would politely ask the patient to leave. If the patient won’t leave and won’t put on a mask, I would politely call the cops, even if the patient is not threatening violence.

But what if your local cops say they are not enforcing this law? Or if it isn’t actually a law where you are? If the cops don’t consider the mask requirement worth enforcing, there’s not much reason to call them, absent feeling threatened. I would handle an unenforced law like an in-house policy. It’s your call whether to treat a recalcitrant patient without a mask or make the patient choose between putting on a mask and leaving your office without getting treated. If mask-or-get-out is your policy, then implement it if you can do so safely. If the patient won’t leave, call the cops if you can do that safely. If that feels scary too, back off. Enforcing your mask policy isn’t worth risking deadly violence.

number 4
If there is no legal requirement for the patient to wear a mask, then there may be a legal question on the other side. Are there any circumstances under which a doctor is not entitled to require patients to wear a mask and refuse to treat patients who won’t comply? The answer may vary depending on the situation:

  • When a prospective patient is asking you to become that patient’s doctor;
  • When you are that patient’s doctor already and the patient is seeking routine care; and
  • When the patient needs urgent care.

Before the doctor considers how s/he wants to handle these three situations, s/he should first consider whether there are any strictures imposed by law.

Also worth considering is whether medical institutions to which the doctor owes allegiance have instituted any policies that apply. Policies urging doctors to urge patients to wear masks are more or less universal. Policies vis-à-vis what doctors should do when patients refuse, on the other hand, are comparatively scarce. And the ones I’ve found are comparatively vague. Here’s one link is to a PDF file, for example, from the Texas Medical Board. It says patients have to wear masks when they’re closer than six feet away from a medical provider or another patient. Asked whether doctors can refuse to treat patients who refuse to wear masks, it says “The decision to treat/see any patient is at the discretion of the physician/practice” – which to me implies that it’s your call whether to treat or not treat an unmasked patient. On the other hand, in answer to a different question the same document says that “If the physician chooses to deliver care and the patient cannot wear a mask, practitioners should document the circumstances surrounding the decision to render care to a patient who is not wearing a mask” – which pretty much implies that you shouldn’t treat an unmasked patient without a convincing rationale.

number 5
Doctors should consider the actual hazard posed by an unmasked patient. This obviously depends on how much SARS-CoV-2 is currently circulating in the area; whether the unmasked patient is symptomatic (e.g. coughing or sneezing); whether there are other patients who cannot be separated from the unmasked patient; what procedures need to be performed on the patient; etc. Protecting staff and other patients from the added risk of an unmasked patient is the paramount reason for a mask policy. The magnitude of that added risk varies with the situation.

Doctors are entitled to have a mask policy that doesn’t vary with these factors. Even under conditions where you think the risk of infection is low, an unmasked patient can be a serious source of anxiety to staff and other patients. But it makes sense to think about the extent of the hazard when considering how rigidly and how aggressively to enforce the policy in a particular situation.

number 6
Doctors should make sure the patient knows about the mask policy in advance. Yes, anyone who’s paying the least attention should know by now that medical encounters usually require masks. (Even back in the old days a few months ago when officials were fervently anti-mask, they said masks made sense for symptomatic people going to the doctor.) But a reminder is still helpful – especially in areas where most venues are merely recommending masks while you’re flat-out requiring them. If it’s your policy to provide masks to patients who don’t bring their own, say that too.

Better yet, don’t just tell the patient your policy. Get the patient to repeat it back to you. This can be a standard part of the protocol for confirming appointments by phone or text: “I understand that I will be required to wear a mask.” It’s not just that people who have repeated the words can’t later claim they didn’t know. Repeating the words is a behavioral commitment that will help patients rein in their inclinations to resist. Alternatively, refusing to repeat the words will signal that you have a problem and a choice: continue the discussion, cancel the appointment, or make an exception.

For suggestions #7 thru #11, please click here.


Founded in 1989, Hennes Communications is one of the few firms in North America focused exclusively on crisis management and communications, serving manufacturers, schools, hospitals and adult care communities, government agencies, for-profits and non-profits “that are on trial in the Court of Public Opinion.”  Recently, the Ohio School Boards Association entered into a strategic partnership with Hennes Communications to provide crisis management and communications services to public school systems throughout the State of Ohio facing sudden challenges to their organizations’ reputations and operations.  For more information:, 216-321-7774.

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