To say the COVID-19 pandemic has wrought drastic changes on the way we practice medicine is a galling understatement. Unfortunately one of the stressors on many outpatient physicians since March of this year has been the rash of patient requests for letters of medical necessity to be out of work, or to go back to work after their possible COVID-19 illness, or exposure. These requests run the gamut from the complex and nuanced, to the ridiculous. To stem the flow of this veritable deluge of requests our organization has drafted a form letter from The Clinicians to The Employers, advising them to adhere to the CDC recommendations (which are included in the letter), and generally to please not request letters of medical necessity from clinicians, who are ideally spending their work hours treating actual sick people as opposed to writing letters. It has succeeded in covering a mild to moderate percentage of these requests.
Recently a patient requested a letter exempting her from masking at her job, in which she works with the public, for psychological reasons. My heart went out to her as I explained my rationale for needing to adhere to infectious protocols during a deadly global pandemic, to which she responded by firing herself from my patient panel. Her request was brought to the next doctor she employed to provide her care (down the hall, within my practice), who heard her plea and held the line. By the end of the consequent ordeal that this caused, our office manager, medical director and the director of primary care became involved in the question of whether it was legal to decline to provide medical exemption from wearing a mask while working in a public area, directly with the public, during a pandemic. (It is.)
Later while out running an essential errand at a different, large regional chain store I observed most of the employees wearing face shields and masks, and multiple of the employees wearing face shields without masks. Referencing the COVID-19 guidelines for employee and patron safety of several national and regional chain stores I noted that guidelines range from requiring all employees to wear either masks OR face shields, or both if they prefer, while some require just masks. Even others accept “personal face coverings,” which according to news sources have in one publicized instance unfortunately included a confederate flag. Summarizing our data that a face shield generally protects from incoming droplets while masking generally protects from outgoing droplets why do employees working with the public get to choose essentially whether to infect or be infected (likely based largely on physical comfort)? Add to that the strong effect of social pressure and the knowledge that if one clinician exempts an employee from masking, other employees are likely to seek the same and in some cases succeed, it becomes easy to see how containing this virus, in a place where personal liberty is prized above all else, even when it comes to endangering others, can undermine an entire public health initiative. Add in the projected numbers of Americans who report they would not accept a COVID-19 vaccine when one becomes available. Then add to that the breaking news of the US’s withdrawal from the WHO (and therefore our $400 million/year funding, which currently fuels COVID-19 clinical research and vaccine development), it’s difficult to find optimism. Our distinctive American spirit, which has at times been the world’s beacon of dynamism, creativity and progressiveness, now contorted by ignorance and selfish self-pursuits, unable to mobilize into a coherent vision, message or action, spearheaded by a uniquely anti-science, pro-capitalist and individualist (I won’t wax further right now on xenophobic and racist) government, poises us perfectly to continue on our trajectory toward a uniquely impressive failure, measurable directly by loss of human life.