“Place the oxygen mask over your own face before assisting others.”
Common-sense emergency management calls for securing the safety of those persons who secure the safety of others, whether in an airplane or in a pandemic. Prioritization of SARS-CoV-2 vaccination should be no different, protecting those frontline health care workers who are most at risk so they can continue caring for the sickest patients.
“First in the room, back of the line,” chanted the droves of Stanford Medicine physicians-in-training, streaming through the hospital in protest last week after learning that a meager seven of their 1,300 colleagues would be included in the first wave of 5,000 workers vaccinated at the hospital.
One particularly a propos placard read, “I saw 16 COVID patients in the last 24 hours, more than double the amount of residents getting the vaccine.”
With non-frontline providers who had been working from home receiving vaccines before the resident physicians who had just been asked to volunteer in the intensive care unit, Stanford Medicine responded that an error in its vaccine distribution algorithm had deprioritized certain frontline workers and residents, including those providing bedside care for patients with COVID-19. An open letter to the Stanford Medicine administration made it clear that physicians-in-training as a group had been overlooked in the distribution planning process.
Not only had those residents been deprioritized from vaccination — they had been ignored entirely, a psychological blow to the frontline health care workers who have become sick and have even died from COVID-19, and whose mental health continues to suffer during the pandemic.
The vaccination blunder reflects what can happen when a sanity check is missing from an algorithm’s application, and to its credit, Stanford Medicine apologized and is seeking to rectify the ghastly error. But could it have been avoided by involving in the planning and rollout processes the actual health care workers who have been placed in jeopardy during the pandemic? Perhaps prevention is best accomplished not by top-down measures, but by bottom-up ones.
It has been long recognized that health care personnel, defined by the Centers for Diseases Control (CDC) as all persons serving in health care settings, are at risk of being exposed to clinically significant inoculas of SARS-CoV-2. As such, the CDC’s Advisory Committee on Immunization Practices (ACIP) summary statement, published prior to the first COVID-19 vaccine Emergency Use Authorization, established a common-sense framework for the initial phase 1A of vaccination: to vaccinate all healthcare personnel, including support and environmental services, nursing staff and clinical staff whose duties require proximity to patients with COVID-19, so as to “preserve capacity to care for patients with COVID-19 or other illnesses.”
This was academic medicine’s first instinct, too. Early journal articles predating the ACIP’s official recommendations, including the National Academy of Medicine’s guidelines, prioritized vaccinations to in-person health care workers and staff to prevent direct harm to workers and indirect harm due to spread of COVID-19 in health care facilities. By vaccinating the respiratory therapist, resident physician and ICU nurse who spend night after night resuscitating our sickest patients with intubations, central lines and chest compressions, and the mission-critical support staff who enable this care, we provide more societal good than vaccinating the health care workers who can see their patients through telemedicine from home.
Remarkably, vetted national guidelines still fail to be upheld, and vaccinations of frontline health care workers have not been a universal priority. Why might this be the case?
Ultimately, the answer is institutional discretion. Tracing the path from vaccine manufacture to administration is informative. Public health authorities built frameworks largely aligned with the ACIP’s official recommendations. Within our own jurisdiction, for example, the Illinois Department for Public Health (IDPH) and Chicago Department of Public Health (CDPH) released common-sense and non-binding guidance: Within phase 1A of vaccination, first priority is vaccination of health care workers routinely caring for patients with COVID-19 or engaging in high-risk clinical activities, with second priority to workers who may care for patients with COVID-19. The IDPH guidelines are unambiguous: “Access to vaccine when scarce should not be defined by professional title, but rather by an individual’s actual risk of exposure to COVID-19.”
After distributing the vaccines, regulators have left individual institutions to their own devices. Institutions’ choices surrounding vaccine distribution then become a reflection of their values, and the extent to which they deviate from the recommendations of public health authorities are an approximation of these institutions’ perceived level of accountability to society. Further, the processes by which they arrive at those choices and the transparency with which they do — independent of what they choose — are proxies for the respect they have for their employees’ intelligence and input.
Prioritizing vaccination to those at “risk of severe disease” rather than “risk of workplace transmission” acts in opposition to guidance issued by the IDPH which recommend an exposure risk prioritization schema for vaccination. Further, those who are disadvantaged by a policy of “risk of severe disease” before “risk of workplace transmission” are the health care workers who have provided direct care for patients from the pandemic’s onset. In academic systems, these are often the workers with the lowest likelihood of having influence within their institution, including trainee physicians that frequently lack a representing union to advocate for their best interests.
More seriously troubling than this is the lack of transparency in institutional allocation processes. At their best, algorithms with transparent design and careful deliberations involving stakeholders afford an opportunity for health care institutions — with their own diverse structures, goals and sets of beliefs — to set an example for how society’s other organizations ought to behave in a crisis. But at their worst and when done without transparency, algorithms are merely “garbage in, garbage out” — such as what happened at Stanford Medicine — and the invocation of “Committees” and “Ethics Departments” to set vaccination guidelines can bring to their employees’ minds notions of conspiracy and kleptocracy.
We believe that medicine’s reflex is still to do the right thing, and the servant leadership that called many of us to medicine in the first place is alive and well, including the Department of Medicine at Stanford.
Rather than providing quick answers, thoughtful leadership during the COVID-19 pandemic has more often been shown by those who publicly ask good questions, including of themselves. Thoughtful leadership is also shown by seeking to reassure others by disclosing what they do not know. To those of us in medicine that means, famously, taking one’s own pulse as the first step in a cardiac arrest.
Reaching back to the airplane oxygen mask metaphor, the critical question to be asked by leadership is not, “Where is my mask?” — it is, “Who is on the plane?” The folks who have been on the frontlines directly caring for patients with COVID-19 from the beginning have been on the plane in a way that many of us have not.
In the increasingly balkanized world of health care, leaders know that they occasionally need help in answering these challenging questions, from vaccine prioritization to hazard pay to volunteers needed for the next wave of COVID-19 cases. Effective and compassionate leaders seek that help by bringing those on the front lines into the fold, by giving health care workers, particularly those trainees who have been historically disenfranchised, a say in their working conditions.
Crafting policies with which 100% of employees will be happy is a fool’s errand. But an institution’s greater error is in not approaching a crisis as an opportunity to seek antifragility and become an increasingly accountable organization. In medicine, this is of critical import — nothing less than medicine’s continued self-governance and self-regulation depend on its accountability. All stakeholders in COVID-19 vaccination, from environmental staff workers to resident physicians to nurses to patients, should have a seat at the table to preserve the legitimacy and equity of a process entrusted to us by society.
Garth Strohbehn is a clinical fellow in hematology and oncology at the University of Chicago and a former resident physician in internal medicine and chief medical resident at the University of Michigan. Ajay Major is a clinical fellow in hematology and oncology at the University of Chicago and a former resident physician in internal medicine at the University of Colorado. The views and opinions expressed here are those of the authors and do not necessarily reflect those of their employers, past or present.
Contact Garth Strohbehn, M.D., M.Phil., at gstrohbehn ‘at’ uchicago.edu and Ajay Major, M.D., MBA, at ajay.major ‘at’ uchospitals.edu.
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