Your winter COVID bubble: How can you decide who's in, who's out?

As an infectious disease specialist at the Mayo Clinic, Dr. Jack O'Horo is an expert on how to safely create a "COVID bubble" — a small, restricted group of people who visit each other's homes mask-free and spend time together without keeping a 6-foot distance.

When he formed his bubble, the Rochester doctor's closest friends didn't make the cut, but three of his son's playdates did.

He made the selections "partly because it [the bubble] has to stay manageable, and partly because there's not that many people who are excited about having a kid whose dad is an infectious disease doc in their bubbles," he said.

As a pandemic winter approaches, many of us are reassessing our bubbles, trying to solidify the pods the kids will be tackling distance learning with and figuring out how to navigate indoor gatherings as safely as possible. But as we close ranks, create smaller social circles or break away from former bubbles, we might find ourselves facing difficult family dynamics, hard feelings and tough conversations.

O'Horo said he took a practical approach to creating his bubble, figuring it's easier for adults to stay connected online or by phone than it is for little kids who want to play together.

"It's not necessarily a value judgment if you're outside of the bubble," he said.

Even so, it can be tough to be on the outside looking in.

Forming bubbles has already become a contentious subject in the family therapy practice of William Doherty, a family social science professor at the University of Minnesota.

"Families have been around a very long time, but this is new territory," he said.

From a safety perspective, it's important for members of any bubble to have straightforward conversations about what expectations are. That helps members trust one another and hold one another accountable.

But that's not always easy in a family group.

"You want to be able to trust these individuals to think of the good of the bubble first," said O'Horo. "In the sense that they will protect your community by doing consistent masking and hand-washing behaviors and would tell you if they start to feel sick."

That can prevent any further exposures and lead to an earlier diagnosis, O'Horo said.

During this time, "normal" social rules don't necessarily apply.

"Canceling plans at the last minute has to be a little bit more acceptable in 2020 than it otherwise might have been," O'Horo said. "It's about everybody's safety."

Being clear and honest can also help when one member of the bubble isn't following the agreed-upon rules, said Doherty.

"When you've got vulnerable family members or people with chronic illnesses, the elderly, the breaking of the bubble can be life-threatening," he said. "A family member may have to say to somebody, 'You can't be in the bubble anymore.' That can make us feel quite rejected."

Doherty also has been coaching folks through what happens when one member of the bubble decides to leave on their own. Some leave in order to spend time with colleagues at the office, others to start traveling again or to send their kids to in-person classes.

"If that means the grandparents are not going to see their grandchildren, except from across the street, then they can have really hurt feelings about that," he said. "When I coach people on this, I suggest you be really open about a couple things: what you're doing, why you're doing it, and then your regret about the side effects."

It's tempting to feel guilty and defensive and clam up instead of sharing how bad you feel, he said. But being open can help the situation.

"Say it was an agonizing decision," he said. "That kind of vulnerability, it may seem obvious as a bit of advice, but I can tell you that it's hard to do when you're feeling guilty and criticized."

Everyone is making their own choices about how to create some sort of life balance right now. Whether you're on the inside of the bubble looking out, or on the outside looking in, try not to take things personally, Doherty counseled.

"We are in an ongoing, slow-rolling national crisis here. The enemy, if you will, is COVID, the pandemic," he said. "The enemy is not in the family. We're all trying to cope as best we can with a situation that is not normal."

Bubbling up

What it is: A small group of people from different households who socialize closely only with each other to lower the risk of COVID-19 infection.

How to set one up: As a group, set clear guidelines. As a basic rule, members should commit to consistently wearing a mask when interacting outside of the bubble indoors and in crowded conditions outdoors. Members need to agree to speak up right away if they feel sick.

How to size your bubble: Some countries have specific guidelines for social bubbles, but the CDC hasn't made a recommendation. The size of a bubble should depend on members' health risks, their level of social activity outside of the bubble and what's practical.

"My rule of thumb is you should be able to draw a map around it and have some idea of who your first-order exposures are," said infectious disease specialist Dr. Jack O'Horo. "If you're starting to lose track of that, that's a good indication the bubble's too hard for you to manage, and too big for you to manage."