Incident 91: Frontline workers protest at Stanford after hospital distributed vaccine to administrators
Suggested citation format
CSET Taxonomy ClassificationsTaxonomy Details
In 2020, Stanford Medical Center residents protested the Center's distribution of only 7 of the 5,000 COVID-19 vaccines it had received to Medical Residents, who were frontline workers compared to other hospital staff less exposed to COVID-19. Stanford Medical Center employed an algorithm to determine vaccine distribution, and its weight of certain factors alongside the lack on information inputted for Medical Residents shaped the outcome of the distribution plan. The algorithm alledly prioritised age and superiority of position, regardless of physician's physical location at the Stanford Medical Center during the COVID-19 pandemic.
In 2020, Stanford Medical Center's distribution algorithm only designated 7 of 5,000 vaccines to Medical Residents, who are frontline workers regularly exposed to COVID-19.
Harm Distribution Basis
Age, Ideology, Other:Physician superiority status
Harm to physical health/safety
AI System Description
Stanford Medical Center's algorithm used a rules-based formula for calculating who would get the COVID-19 vaccine first at Stanford. It considers three categories: “employee-based variables,” which have to do with age; “job-based variables”; and guidelines from the California Department of Public Health. For each category, staff received a certain number of points, with a total possible score of 3.48. Presumably, the higher the score, the higher the person’s priority in line.
Stanford Medical Center
Sector of Deployment
Human health and social work activities
Relevant AI functions
Stanford Medical Center
Stanford Medical Center
Stanford Medical Center
names, age, location, position, job, COVID-19 tests
Update, Dec. 18, 2020: This story has been updated to add comments from Stanford Medicine.
Stanford Medicine residents who work in close contact with COVID-19 patients were left out of the first wave of staff members for the new Pfizer vaccine. In their place were higher-ranking doctors who carry a lower risk of patient transmission, according to interviews with six residents and two other staff members and e-mail communications obtained by ProPublica.
“Residents are patient-facing, we’re the ones who have been asked to intubate, yet some attendings who have been face-timing us from home are being vaccinated before us,” said Dr. Sarah Johnson, a third-year OB-GYN resident who has delivered babies from COVID-positive patients during the pandemic. “This is the final straw to say, ‘We don’t actually care about you.’”
Another resident, who asked not to be named, said a nurse who works in an operating room for elective surgeries has been notified she’ll get the vaccine in the first wave. “We test people for COVID before elective surgeries, so by definition, we will know if those patients have COVID,” he said, so to him, it didn’t make sense that that nurse would be prioritized.
“We take complete responsibility for the errors in the execution of our vaccine distribution plan,” said Lisa Kim, a Stanford Medicine spokesperson. “Our intent was to develop an ethical and equitable process for distribution of the vaccine. We apologize to our entire community, including our residents, fellows and other frontline care providers, who have performed heroically during our pandemic response. We are immediately revising our plan to better sequence the distribution of the vaccine.”
An algorithm chose who would be the first 5,000 in line. The residents said they were told they were at a disadvantage because they did not have an assigned “location” to plug into the calculation and because they are young, according to an email sent by a chief resident to his peers. Residents are the lowest-ranking doctors in a hospital. Stanford Medicine has about 1,300 across all disciplines.
Only seven made the priority vaccination list, despite the fact that this week, residents were asked to volunteer for ICU coverage in anticipation of a surge in COVID-19 cases.
Stanford Medicine didn’t respond to a request for comment on how the vaccines were allocated and whether there was a flaw in the algorithm. The tumult reflects the difficulties of ethically parceling out a limited supply of vaccine and weighing competing factors, such as age, risk of contracting the disease and comorbidities. Adding to the challenge is the angst that comes when such decisions are made without all stakeholders involved.
In a letter to Stanford leadership sent on Thursday, the chief resident council wrote, “While leadership is pointing to an error in an algorithm meant to ensure equity and justice, our understanding is this error was identified on Tuesday and a decision was made not to revise the vaccine allocation scheme before its release today.” The council asked for a timeline for vaccination of the residents and transparency regarding the algorithm.
In response to the residents’ protests, Dr. Niraj Sehgal, chief medical officer, sent an email saying, “Please know that the perceived lack of priority for residents and fellows was not the intent at all.” He added that with the anticipated authorization of Moderna’s vaccine, “we’re increasingly confident in getting everyone vaccinated, including all of you.” He signed off with “heartfelt apologies.”
Some departments appear to be trying to fix the problem on their own. Dr. Mary Hawn, chair of the department of surgery, confessed to being “disturbed and puzzled” by the vaccination roster that “included many of the medical staff list that aren’t our physicians on the front line.” She emailed her department asking people slotted for the first wave to “bring a resident that is patient facing to get the vaccine in your place” and to ask the program director for their “buddy” assignment.
She added: “Let’s get this right.”
In the months before the election, Joe Biden’s most influential voice on the issue of our age shared his views on climate migration, open borders, the threat of nationalism, and the challenge posed by China.
Stanford Health Care apologized Friday for a plan that left nearly all of its young front-line doctors out of the first round of coronavirus vaccinations. The Palo Alto, Calif., medical center promised an immediate fix that would move the physicians into the first wave of inoculations.
Stanford’s turnaround followed a raucous demonstration by some of those doctors, who demanded to know why other health-care workers — including pathologists and radiologists who do not attend to covid-19 patients — would be vaccinated before they are.
The protest at Stanford could foreshadow similar disputes nationwide as the federal government and states begin the arduous process of distributing limited supplies of the first vaccines.
James Dickerson, a 28-year-old internal medicine resident who has cared for covid-19 patients, predicted the controversy at Stanford will unfold around the country: “The devil is in the details,” he said.
The “residents” — medical school graduates who staff the hospital for several years as they learn specialties such as emergency medicine, internal medicine and family medicine — were furious when it became clear that just seven of the more than 1,300 at the medical center were in the first round for vaccinations. Also affected were “fellows,” who work in the hospital as they train further in sub-specialties, nurses and other staff.
Residents across specialties had just been asked to volunteer for extra intensive care unit work in preparation for a surge in covid-19 patients.
An email to pediatrics residents and fellows obtained by The Washington Post said that “the Stanford vaccine algorithm failed to prioritize house staff,” as the early year doctors are known collectively.
“This should not have happened — we value you and the work you do so highly,” the email stated. “We had been told that residents and fellows would be in the first wave. This should never have happened nor unfolded the way it did.”
Stanford Medicine issued a statement Friday saying it takes “complete responsibility for the errors in the execution of our vaccine distribution plan” and is “immediately” revising it.
Christine Santiago, a 29-year-old resident in internal medicine who treated covid-19 patients during night shifts in the ICU, also worries that the vaccine distribution issues at Stanford are part of a broader problem — “a harbinger of population level inequities … for our underserved communities,” as she put it in a tweet.
She told The Post that resident physicians “occupy a very unprotected space in the United States.”
“We’re not fully employees of the workforce,” said Santiago, who said she is home quarantining and waiting on a coronavirus test after using a faulty batch of N95 masks. “We fall in this vague, unclear position.”
Santiago said that some residents have been able to get a vaccine on the spot after Friday’s protests. Another resident said she appreciated the quick pledge that Stanford would rectify the situation.
But that resident, who spoke on the condition of anonymity because she believed open criticism of Stanford could harm her career, said that “residents and house staff and people who support us were left out of the development of said algorithm, with unacceptable consequences.”
Janis M. Orlowski, chief health-care officer for the Association of American Medical Colleges, which oversees medical education in the United States, said the group previously informed large academic medical centers that “they need to consider residents, fellows and medical students involved in direct patient care as essential workers” as they plan distribution of vaccines.
Residents estimated that about 100 health-care workers — doctors as well as some nurses — gathered on the Palo Alto campus Friday to protest as a first wave of vaccinations began. Carrying signs that read “transparency” and “protect the front line,” the group accused university officials of selecting orthopedists, dermatologists and even some faculty who work from home for the first wave of vaccinations, while leaving out workers who treat patients face-to-face.
Video posted by the San Francisco Chronicle showed the facility’s front lobby and staircase packed with physicians in blue medical masks chanting, “Health-care heroes, support is zero!” Shortly after, the demonstration moved outside to the front of the building.
In video shared with The Post, Associate Dean of Graduate Medical Education Laurence Katznelson told demonstrators that department chairs would ask their faculty without comorbidities to give up vaccination slots for residents and fellows. Chairs have agreed to say that all leadership will not get vaccinated until residents and fellows do, Katznelson said.
“I feel awful that this happened,” Katznelson said, adding it’s “disturbing to me that things went this way.”
“It was no one’s malicious fault, but it was a bad outcome,” he said.
Medical residents and nurses from Stanford Medical Center held a protest on Friday following the hospital choosing to vaccinate some staff members who don’t interact with coronavirus patients over other frontline workers.
Video footage from the San Francisco Chronicle showed hospital workers gathering in a common area of Stanford Medical Center with signs as they shouted chants.
“How many residents? Seven,” the workers chanted through the hospital. Seven represented the number of medical residents who have so far received a coronavirus vaccine in the hospital out of the 1,349 employed.
These frontline workers accused the hospital of prioritising administrators and physicians who don’t interact with coronavirus over them during vaccine distribution.
The demonstration was largely made up with medical residents who were excluded from the first wave of staff offered coronavirus vaccines, but they made it clear nurses and other frontline workers were also excluded.
“This is not just about the residents … we stand here to represent our nurses … we are here to back them … our respiratory therapists, our environmental services workers, food staff, everyone,” one medical resident is heard saying to the crowd.
Medical residents were asked who among the hospital’s administration made the decision to exclude some frontline workers from receiving the vaccine. These residents said they did not know who made the decision.
Several departments at Stanford Medical Center tweeted their support for the frontline workers who protested at how vaccines were being distributed.
“The Department of Urology faculty find the algorithm that led to the exclusion of residents (from all services) in the first wave of vaccinations at Stanford appalling. Our faculty have volunteered their appointments go [to] trainees on the front lines to make this right,” The Stanford Medical Center Department of Urology tweeted on Friday.
Dr Joy Wu, a physician-scientist in endocrinology at Stanford, also tweeted her support of the protest.
“The Stanford vaccine algorithm failed to prioritize housestaff,” she wrote. “We @StanfordDeptMed faculty stand with @StanfordMedRes.”
Stanford’s Department of Medicine faculty, division chiefs, and other doctors have all volunteered “to wait until all house staff have been vaccinated” unless they are “high-risk”, Dr Wu said.
Healthcare workers and people living in long-term care facilities started to receive Pfizer’s coronavirus vaccine on Monday after it received emergency use authorisation from the Food and Drug Administration (FDA).
The Centers for Disease Control and Prevention (CDC) advised for those two groups to receive the vaccine first, as healthcare workers are most at-risk to come in contact with the novel virus and high deaths rates were seen in long-term care facilities. But it was largely left up to the state and individual hospital systems to distribute the vaccine doses how they wanted once they received them.
Stanford Medical Center said in a statement to The Independent: “We take complete responsibility for the errors in the execution of our vaccine distribution plan. Our intent was to develop an ethical and equitable process for distribution of the vaccine. We apologize to our entire community, including our residents, fellows, and other frontline care providers, who have performed heroically during our pandemic response. We are immediately revising our plan to better sequence the distribution of the vaccine.”
An algorithm determining which Stanford Medicine employees would receive its 5,000 initial doses of the COVID-19 vaccine included just seven medical residents / fellows on the list, according to a December 17th letter sent from Stanford Medicine’s chief resident council. Stanford Medicine leadership has since apologized and promised to re-evaluate the plan.
“We take complete responsibility for the errors in the execution of our vaccine distribution plan,” a Stanford Medicine spokesperson said in a statement to The Verge. “Our intent was to develop an ethical and equitable process for distribution of the vaccine. We apologize to our entire community, including our residents, fellows, and other frontline care providers, who have performed heroically during our pandemic response. We are immediately revising our plan to better sequence the distribution of the vaccine.”
The initial plan led to demonstrations from medical staff in addition to the letter sent by the chief resident council.
“Stanford’s decision to de-prioritize residents and fellows is defenseless on the basis of science, reason, ethics, and equality,” the letter said. (ProPublica has hosted the full letter on DocumentCloud.) “Many of us know senior faculty who have worked from home since the pandemic began in March 2020, with no in-person patient responsibilities, who were selected for vaccination. In the meantime, we residents and fellows strap on N95 masks for the tenth month of this pandemic without a transparent and clear plan for our protection in place.”
The residents’ letter also alleges that the error in the algorithm was found on Tuesday but that leadership opted not to make changes to the plan ahead of its December 17th release.
Here’s how the algorithm reportedly worked, according to NPR:
According to an email sent by a chief resident to other residents, Stanford’s leaders explained that an algorithm was used to assign its first allotment of the vaccine. The algorithm was said to have prioritized those health care workers at highest risk for COVID infections, along with factors like age and the location or unit where they work in the hospital. Residents apparently did not have an assigned location, and along with their typically young age, they were dropped low on the priority list.
Stanford Medicine administration also sent an email to staff on December 18th apologizing for the initial plan and promising changes. “We are working quickly to address the flaws in our plan and develop a revised version,” the email said, which was obtained by ProPublica health care reporter Caroline Chen. “We are optimistic that a large shipment of vaccines will arrive next week, which will allow us to vaccinate a substantial segment of our community.”
The Food and Drug Administration has authorized two COVID-19 vaccines for use in the US. The vaccine developed by Pfizer / BioNTech was authorized on December 11th, and the one developed by Moderna was authorized on December 18th.
When resident physicians at Stanford Medical Center—many of whom work on the front lines of the covid-19 pandemic—found out that only seven out of over 1,300 of them had been prioritized for the first 5,000 doses of the covid vaccine, they were shocked. Then, when they saw who else had made the list, including administrators and doctors seeing patients remotely from home, they were angry.
During a planned photo op to celebrate the first vaccinations taking place on Friday, December 18, at least 100 residents showed up to protest. Hospital leadership apologized for not prioritizing them, and blamed the errors on “a very complex algorithm.”
“Our algorithm, that the ethicists, infectious disease experts worked on for weeks … clearly didn’t work right,” Tim Morrison, the director of the ambulatory care team, told residents at the event in a video posted online.
Many saw that as an excuse, especially since hospital leadership had been made aware of the problem on Tuesday—when only five residents made the list—and responded not by fixing the algorithm, but by adding two more residents for a total of seven.
“One of the core attractions of algorithms is that they allow the powerful to blame a black box for politically unattractive outcomes for which they would otherwise be responsible,” Roger McNamee, a prominent Silicon Valley insider turned critic, wrote on Twitter. “But people decided who would get the vaccine,” tweeted Veena Dubal, a professor of law at the University of California, Hastings, who researches technology and society. “The algorithm just carried out their will.”
But what exactly was Stanford’s “will”? We took a look at the algorithm to find out what it was meant to do.
How the algorithm works
The slide describing the algorithm came from residents who had received it from their department chair. It is not a complex machine-learning algorithm (which are often referred to as “black boxes”) but a rules-based formula for calculating who would get the vaccine first at Stanford. It considers three categories: “employee-based variables,” which have to do with age; “job-based variables”; and guidelines from the California Department of Public Health. For each category, staff received a certain number of points, with a total possible score of 3.48. Presumably, the higher the score, the higher the person’s priority in line. (Stanford Medical Center did not respond to multiple requests for comment on the algorithm over the weekend.)
The employee variables increase a person’s score linearly with age, and extra points are added to those over 65 or under 25. This gives priority to the oldest and youngest staff, which disadvantages residents and other frontline workers who are typically in the middle of the age range.
Job variables contribute the most to the overall score. The algorithm counts the prevalence of covid-19 among employees’ job roles and department in two different ways, but the difference between them is not entirely clear. Neither the residents nor two unaffiliated experts we asked to review the algorithm understood what these criteria meant, and Stanford Medical Center did not respond to a request for comment. They also consider the proportion of tests taken by job role as a percentage of the medical center’s total number of tests collected.
Many states rolled out exposure notification services after covid transmissions started surging, but health experts say new apps can still help.
What these factors do not take into account is exposure to patients with covid-19, say residents. That means the algorithm did not distinguish between those who had caught covid from patients and those who got it from community spread—including employees working remotely. And, as first reported by ProPublica, residents were told that because they rotate between departments rather than maintain a single assignment, they lost out on points associated with the departments where they worked.
The algorithm’s third category refers to the California Department of Public Health’s vaccine allocation guidelines. These focus on exposure risk as the single highest factor for vaccine prioritization. The guidelines are intended primarily for county and local governments to decide how to prioritize the vaccine, rather than how to prioritize between a hospital’s departments. But they do specifically include residents, along with the departments where they work, in the highest-priority tier.
It may be that the “CDPH range” factor gives residents a higher score, but still not high enough to counteract the other criteria.
“Why did they do it that way?”
Stanford tried to factor in a lot more variables than other medical facilities, but Jeffrey Kahn, the director of the Johns Hopkins Berkman Institute of Bioethics, says the approach was overcomplicated. “The more there are different weights for different things, it then becomes harder to understand—‘Why did they do it that way?’” he says.
Kahn, who sat on Johns Hopkins’ 20-member committee on vaccine allocation, says his university allocated vaccines based simply on job and risk of exposure to covid-19.
He says that decision was based on discussions that purposefully included different perspectives—including those of residents—and in coordination with other hospitals in Maryland. Elsewhere, the University of California San Francisco’s plan is based on a similar assessment of risk of exposure to the virus. Mass General Brigham in Boston categorizes employees into four groups based on department and job location, according to an internal email reviewed by MIT Technology Review.
“There’s so little trust around so much related to the pandemic, we cannot squander it.”
“It’s really important [for] any approach like this to be transparent and public …and not something really hard to figure out,” Kahn says. “There’s so little trust around so much related to the pandemic, we cannot squander it.”
Algorithms are commonly used in health care to rank patients by risk level in an effort to distribute care and resources more equitably. But the more variables used, the harder it is to assess whether the calculations might be flawed.
For example, in 2019, a study published in Science showed that 10 widely used algorithms for distributing care in the US ended up favoring white patients over Black ones. The problem, it turned out, was that the algorithms’ designers assumed that patients who spent more on health care were more sickly and needed more help. In reality, higher spenders are also richer, and more likely to be white. As a result, the algorithm allocated less care to Black patients with the same medical conditions as white ones.
Irene Chen, an MIT doctoral candidate who studies the use of fair algorithms in health care, suspects this is what happened at Stanford: the formula’s designers chose variables that they believed would serve as good proxies for a given staffer’s level of covid risk. But they didn’t verify that these proxies led to sensible outcomes, or respond in a meaningful way to the community’s input when the vaccine plan came to light on Tuesday last week. “It’s not a bad thing that people had thoughts about it afterward,” says Chen. “It’s that there wasn’t a mechanism to fix it.”
A canary in the coal mine?
After the protests, Stanford issued a formal apology, saying it would revise its distribution plan.
Hospital representatives did not respond to questions about who they would include in new planning processes, or whether the algorithm would continue to be used. An internal email summarizing the medical school’s response, shared with MIT Technology Review, states that neither program heads, department chairs, attending physicians, nor nursing staff were involved in the original algorithm design. Now, however, some faculty are pushing to have a bigger role, eliminating the algorithms’ results completely and instead giving division chiefs and chairs the authority to make decisions for their own teams.
Other department chairs have encouraged residents to get vaccinated first. Some have even asked faculty to bring residents with them when they get vaccinated, or delay their shots so that others could go first.
Some residents are bypassing the university health-care system entirely. Nuriel Moghavem, a neurology resident who was the first to publicize the problems at Stanford, tweeted on Friday afternoon that he had finally received his vaccine—not at Stanford, but at a public county hospital in Santa Clara County.
“I got vaccinated today to protect myself, my family, and my patients,” he tweeted. “But I only had the opportunity because my public county hospital believes that residents are critical front-line providers. Grateful.”
Did our AI mess up? Flag the unrelated incidents