Date: May 18th, 2020
I was asked to participate in a debate regarding the issue of Masks4All in Canada by the people involved in the COVID Information for Canadian Physicians Facebook group. This is a private group ~22,000 physicians, residents, students and nurse practitioners from around the world.
Dr. Joe Vipond
I was reluctant to participate but was convinced after having a good conversation with the organizers and Dr. Vipond. They assured me it would be respectful, focus on the evidence and be an educational experience for the audience. These are stressful times and we all want the best recommendation for patients, based on the best evidence to ensure community well-being.
Arguing for the affirmative position was Dr. Joe Vipond. He is an emergency physician at the Rockyview General Hospital and a clinical assistant professor at the University of Calgary. He has generously made available his notes from the debate that include links to more information.
I argued against the resolution. This does not mean I am against wearing a cloth mask in public. Those who know my not so secret identity (BatDoc) know that I am often seen in public wearing a mask. This is not the type of mask Dr. Vipond and I were debating.
We were not talking about wearing medical masks, surgical masks, N95 masks or respirators by healthcare providers on the front lines of COVID19. The debate also did not include symptomatic people or those caring for high-risk people. We were only debating the issue of universal cloth Masks4All in public.
To be very clear, I am not anti-mask wearing in public. My position is "it all depends" as taught by my evidence-based medicine (EBM) mentor Dr. Andrew Worster from BEEM. I am just not in favour of a mandatory universal Masks4All in public in Canada.
You can watch the Mask4All debate on YouTube.
Resolution: Be it resolved that a mandatory universal mask for all to prevent transmission of COVID19 be recommended for Canadians.
Dr. Kashif Pirzada
We were each given four minutes for an opening statement, three minutes for a rebuttal, four more minutes for a second affirmative statement and finished with three minutes for another rebuttal and closing statement.
We had two moderators for this debate. Dr. Kashif Pirzada is an emergency physician in Toronto with an interest in startups and innovation. He is also a co-founder of Conquer-Covid19, a charity that sources personal protection equipment for frontline health workers.
Dr. Jennifer Kwan
Dr. Jennifer Kwan is a family physician in Burlington, Ontario. She is known for COVID19 data visualizations on Twitter (@jkwan_md) along with the HowsMyFlattening team, and is an advocate for #Masks4Canada and personal protection equipment donations with Halton Regional Chinese Canadian Association.
I am not against wearing a cloth mask in public. My position is that I am not convinced that a mandatory Masks4All in public by people that are practicing physical distancing will prevent transmission of clinical disease (COVID19). This is an important distinction.
Dr. Samir Grover
Questions on the Facebook feed were moderated by Dr. Samir Grover. He is an associate professor and program director for gastroenterology at the University of Toronto. Kashif and Samir have a podcast about COVID-19 called "The Medicine Club" which can be accessed on Twitter @TheMedClubTO
It is important in any discussion to be clear on the terms being used.
Mandatory: Required by a law or rule : OBLIGATORY.
Universal: Including or covering all or a whole collectively or distributivity without limit or exception.
Public: All public places (not to private places)
Clinical Disease: There is a difference between a DOO (Disease Oriented Outcome- detection of COVID19 RNA) and a POO (Patient-Oriented Outcome - clinical disease). As a clinician, I am more interested in POOs and less interested in DOOs.
Epistemology: The study or a theory of the nature and grounds of knowledge especially with reference to its limits and validity
I want to accept positions for good reasons not because it is someone’s opinion. Just because someone is a gifted clinician and an excellent advocate for the environment does not mean they are an expert in clinical epidemiology, biostatistics and critical appraisal. This brings up the possibility of a Dunning-Kruger Effect.
Here is a link to a great video made by Dr. Rohin Francis (@MedLifeCrisis). It is a satirical ad for Dunning-Kruger Alcohol and uses humour as a COVID19 coping strategy.
“The Dunning-Kruger effect is a cognitive bias in which people wrongly overestimate their knowledge or ability in a specific area. This tends to occur because a lack of self-awareness prevents them from accurately assessing their skills.”
My credentials included 37 years of medical research, Senior Editor of Academic Emergency Medicine (AEM), advance training in clinical epidemiology, biostatistics and critical appraisal. I teach these skills and cognitive bias and logical fallacies to MSc and PhD students in the Department of Epidemiology. I have published dozens of critical appraisals which are considered a higher level of evidence than a randomized control trial on the EBM pyramid of evidence. Basically, I am an uber nerd.
This does NOT make my position of the evidence on cloth Masks4All correct or an argument from authority. The information is presented as evidence of my expertise and to support my claim that this is my lane.
In the scientific method we start with the null hypothesis. The null would be that there is no statistical difference between universal/mandatory cloth masks4all and not wearing a cloth mask in public. The burden of proof is on those making the claim that cloth masks4all in public is superior in preventing transmission of clinical disease (POO) in those physically distancing. Without sufficient evidence we should not accept the claim. Therefore, we should accept the null hypothesis of no superiority.
Everyone will have a different level of evidence required to accept a claim. I want patients to get the best recommendation, based on the best evidence. Without evidence people are providing an opinion. Christopher Hitchens famously said "that which can be asserted without evidence, can be dismissed without evidence." (Hitchens’ Razor)
Peltzman Effect: Risk Compensation and Risk Homeostasis
Prof Sam Peltzman
Sam Peltzman was a professor who wrote a paper in 1975 about seatbelt regulations (The Effects of Automobile Safety Regulation, J Political Economy 1975).
Professor Peltzman argued that the benefits of seatbelt would be offset by more pedestrian deaths and more nonfatal accidents because of “driving intensity”. This was driving faster and more recklessly with the security of the safety belt. His hypothesis was proven to be wrong and seatbelts were a net benefit but it did open a field of risk compensation.
Bill Booth
There are examples where an intervention did have a positive outcome (seat belts in cars and helmets when cycling) but there are other examples where the theoretical benefits did not materialize in the real world. This includes parachute equipment advancements to prevent morbidity and mortality from jumping out of a plane. Bill Booth was a person who designed safety equipment for parachutes. They should have decreased morbidity and mortality of jumping out of plane. The data showed it did not. There was risk compensation and it did not have the impact he hoped (Booth’s Second Law).
"The safer skydiving gear becomes, the more chances skydivers will take, in order to keep the fatality rate constant."
Condoms
Another example is condoms to prevent HIV virus transmission during that pandemic. The no glove, no love was thought to be a “no brainer”. It was widely felt that condoms could help prevent the spread of the HIV epidemic. However, the impact of condoms alone was mitigated during a global pandemic due to risk compensation/homeostasis. There are a significant portion of people who dislike using condoms, use is often irregular, and condoms seem to give a sense of security. This can lead to disinhibition, in which people may engage in risky sex with condoms (Shelton JD. Ten myths and one truth about generalized HIV epidemics, Lancet 2006).
Risk compensation/homeostasis (Peltzman Effect) can also be seen in the unintended behavioral responses by patients and physicians to health care interventions. This may explain why certain health care interventions that seem logical and foolproof fail to demonstrate real-world benefits (Prasad and Jena Healthc Amst 2014).
EHR and Burnout
Electronic Health Records (EHRs) is just one newer example of the risk compensation hypothesis. One of the claimed benefits of introducing EHRs was to decrease medication errors. While they did demonstrate fewer of these errors they increased other errors. It is also unclear if the type of medication errors that were reduced had an important POO.
EHRs also have been shown to negatively impact emergency department efficiency. They have been blamed for contributing to physician burnout. Burnout is associated with worse patient care.
Gray A et al. The impact of computerized provider order entry on emergency department flow. CJEM 2016.
Shanafelt et al Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613
West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006; 296(9):1071-1078.
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6): 995-1000.
Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care.
