 serve as the executive director of the Bucksbaum Institute for Clinical Excellence. I'm so happy that you are all able to join us now in the 10th year of the Bucksbaum Institute for this year's annual symposium. Today's symposium is the first that we've ever done on virtual. And so it's a new experience for all of us. The Bucksbaum Institute was founded in 2011 with an incredible endowment gift from Matthew and Carolyn Bucksbaum Family Foundation. The mission of the Bucksbaum Institute is, I'm quoting now from the record, to improve patient care, to strengthen the doctor-patient relationship, to enhance communication and decision making in health care, through research and education programs for medical students, junior faculty, senior faculty, and to reduce health care disparities. Since the Institute's founding, we have continually sought ways to better fulfill our mission. Currently, the Institute has appointed 446 master clinicians, senior faculty scholars, junior scholars, medical student scholars, and even undergraduate pre-medical student scholars. Additionally, the Institute has supported 30 programs, including pilot grants, an annual lecture series, and courses for the fourth-year medical students. Today, I would like very much to introduce our speaker, our lead speaker, in today's program. And our lead speaker is a dear colleague and friend of mine for years, Dr. Bernie Lowe. After nine years as President, Bernard Lowe MD is now President Emeritus of the Greenwall Foundation, a foundation whose mission is to expand bioethics knowledge in order to improve clinical biomedical research and public health decision-making policy and practice. Previously, Dr. Lowe served as professor of medicine and director of the medical ethics program at the University of California in San Francisco. A member of the National Academy of Medicine, I'm going to call it NAM, National Academy of Medicine, Dr. Lowe has chaired NAM committees on sharing clinical trial data in 2015, on conflicts of interest in medical research, education and practice, and more recently, in 2019, on evidence-based clinical practice guidelines for prescribing opioids for acute pain. Dr. Lowe serves on the board of directors of the Association for the Accreditation of Human Research Protection programs and also on the medical advisory panel of Blue Cross and Blue Shield. Dr. Lowe and his colleagues have published well over 200 peer-reviewed articles on ethical issues concerning responsible oversight of research, decision-making near the end of life, the doctor-patient relationship, and conflicts of interest. The talk that Dr. Lowe will give today is entitled Allocation and Triage in COVID-19. What I'd like to remind you about before we start hearing Dr. Lowe's lecture is that we encourage you to submit questions under the Q&A option rather than the chat option. You can make statements if you wish on chat, but the questions and answers should be submitted on Q&A. And with that introduction, it's an honor to present Dr. Bernard Lowe, Bernie. So, Mark, thank you very much for that very kind and gracious introduction. It's a real pleasure for me to be here today. I only regret that I can't be there in person to visit good friends in Chicago. I'm going to try and keep my formal remarks relatively brief, leave lots of times for questions. I know Brian Callender is going to be moderating a Q&A, and I know there's a session for informal discussion afterwards as well. So let me share my screen. So I just want to say that I don't have any conflicts of interest. So I want to thank my colleagues, particularly Doug White, now at University of Pittsburgh, with whom I've worked on the topic of allocation and triage for years and continue to work with him. Alice Chen is the Deputy Director of the California Department for Health Services. And she faces these issues every day on the ground and actually has a difficult allocation decision coming up that she would love to get your insight on. And Collette De Jong is one of these incredible residents that populate our medical centers and it's a found time to actually also do research with. I'm going to try and just talk first to cover cross-cultural and historical perspectives on triage. Secondly, present an ethical framework for crisis standards of care. And particularly to emphasize health disparities and cultural structural injustices, which COVID has really laid bare. And finally end with some comments on remaining challenges. This is a picture of Northern Italy, the town of Bergamo. It's a lovely region, wonderful place to visit. But this year in February, this region was hard hit by the COVID epidemic. Northern Italy has an excellent healthcare system unlike the south of Italy. And despite really heroic efforts, they were really overwhelmed by the number of cases. They were so overwhelmed that the morgues in the hospitals were filled. Mortuaries were overwhelmed and bodies stacked up everywhere there was space in the hospital. People in Italy said, a physician said, we are on our knees. And another said, we are one step away from collapse. And this is a picture that was widely circulated in Europe. It's actually a nurse who had been working double shifts out a day off and just collapsed at her workstation. Italy is very different culturally than the US. They're reluctant to talk about tragic choices. And it's clear that fairly elderly patients were not put on ventilators, but as one Italian ICU doctor said, it is not nice to talk about. And this is very different in the US. Many of you will know that patients with cancer in Italy are not always told their diagnosis. It's much more indirect. We're over unlike the sort of very prominent blogging and Twitter accounts that US doctors do. There are few explicit accounts of the emotional reactions of doctors and nurses. It's a society that has very high trust in physicians. The Italian professional society of critical care physicians and anesthesiologists issued guidelines several weeks after the crest of the pandemic for allocating ICU beds and ventilators. They came out and said an age limit for the ICU may ultimately need to be set. And they also said it's important to save resources, which may become extremely scarce for those who have much greater probability of survival and life expectancy. I'd like to suggest that crisis standards are important to develop and make explicit. It's extremely difficult and actually unfair for treating physicians to have to make difficult trials decisions completely on their own. And I believe that standards for crisis managed care should be in place before the crisis is. And we'll talk in America how we also fail to do that. This is a drawing of Napoleon's army after the battle of Vienna in 1806. This is not the heroic grand army, but a depiction of the extreme casualties in war at the time. Battlefield triage initially started with officers being evacuated and enrolled enlisted men being left to fend for themselves in the fields. Napoleonic triage, which was instituted after this battle, first was egalitarian. Conscripted soldiers and officers received the same priority for treatment. Priority was very clear. The goal of triage was to return soldiers to fighting. And priority was to the most severely wounded, but who were treatable. They were the ones who got ambulance evacuation, which is another innovation of Napoleon's army. Those who were too sick to help to benefit from assistance received lower priority. And those who would do well without assistance were on their own. Let's skip forward 200 years. On August 29, 2005, Hurricane Katrina hit New Orleans head off. It devastated the town, which as you know is under sea level. Streets were flooded. Transportation was cut off. And relief efforts were non-existent or extremely chaotic. And people really had to fend for themselves. These people are trying to evacuate little children. On their own. The water sometimes got much deeper. And here are people struggling in high currents. In New Orleans parish alone, almost 700 people died. Mostly by drowning. And African Americans were had a much significantly higher death rate than others during Katrina. Hospitals also suffered. This is a hospital that was completely cut off. From the rest of the world. Electricity. Water. Telephones were shut off. Cell phones couldn't be recharged medical equipment. They were no longer operated with electricity. And the staff were really on their own for several days. Hurricane Katrina. I thought. Really struck home to America that. You cannot develop or implement standards of crisis during a crisis. For the first time. When the crisis standards of care are needed. Is too late to work them out. In the wake of Katrina. The federal government put out a call for states to do preparedness. Preparedness. Including. Developing crisis standards of care. And implementing plans for. Serious crises. Sorry. Keeping our own button. Many states did not complete preparedness planning. And of the ones who did. There were really serious problems that we'll talk about a little bit later. As of March 2020. If you look state by state at crisis standards of care. 17 states had publicly developed available policies. And 17 said they were in the process of developing. Now what are crisis standards of care. We're talking about situations where the need for medical care. Greatly exceeds the supply. And therefore. Not all who might benefit from ICU care and ventilator support. And I might parent. Thank you. And want to. Receive it. Can receive it because of the shortage. Now crisis standards of care. Should be approved state policies. Or municipal policies activated. By formal declaration of public health emergency. By the governor. Standards need to be operational and actionable. They're actually step by step things for physicians, nurses, first responders to do. Now crisis standards of care. Presuppose. Other things have been tried and proved unsuccessful. There have been attempts to increase the supply. And decrease the demand for ICU services. People have tried to provide equivalent care. With fewer resources. And COVID I think was remarkable has been remarkable. For inspiring creativity and improvisations. And it's not only by front line healthcare workers. But by researchers. Tinkerers and inventors. We learned, for example. That you could avoid the need for ventilator. By prone positioning, putting a patient on the ballot. And people with COVID could tolerate. A much lower P02. Than the level at which people are traditionally intubated. And the official. News is that the need for triage was averted in the U.S. But during the first surge. Many municipalities and cities came on the razor's edge. For needing to, to triage. Now, how can we improve current policies? First, I think we need to say that. The need for developing crisis standards of care. Should be iterative. And we should view it as a. A policy that needs continuous. Improvement. And I would include articles that I and my colleagues have written. Certainly if we look back even several months. There are things we would have said differently and advocated different. But among the things I think that. Needed need more attention are first. How to address the structural injustices that cause. The health disparities that. COVID has, has, has revealed. As you know. Blacks Latinx people, Native Americans. Have much higher caseloads. And much higher rates of death. But secondly, it's important to avoid discrimination. Against multiple categories of vulnerable people. So I'm going to switch now to. Talking, suggesting an ethical framework for. I see you beds and then. First, there are multiple ethical principles at stake. That seem to make moral sense in crisis standards of care. And I think that's one of the things that we need to look at. And I think that's one of the things that I listed for. First, reducing mortality benefits. Community as a whole. On the whole, I think most of us would rather see fewer deaths. In the ICU from COVID. Fewer inpatient deaths. Then more deaths. Secondly, there needs to be fair allocation among those in need. And then there needs to be fair process. Fair procedures as well as substantive fairness. It makes a difference that people think. Can trust. That the decision making process was fair. And for we should respect patients as persons as much as possible. During the emergency crisis. I'm not going to say very much about for. I'll spend my time today on one through three. So one. Reduce mortality. First, we strongly advocate a scoring system. Rather than. Blanket exclusions by category. And that's because a scoring system is flexible. It can adapt to changes in both supply and demand. Categorical exclusions are inflexible. You say this group of patients. Won't get a ventilator. We really mean that. Even if. The supply and larges or the. Demand decreases. The pandemic is dynamic. And. Things wax and wane sometimes very quickly in different regions. And unfortunately, I think there are many. Public health. Specialists. Who are concerned. There will be a second wave. In the fall. Coinciding with. The influenza season. Secondly, when we talk about reducing mortality, it's important to be precise. And to specify the outcome, what do we mean? Do we mean just survival to hospital discharge? Or do we also mean near term survival? Now, in our original JAMA article, we use the term short-term survival. And. Talking to, to many people. We would agree that near term survival is a much better term. So. Why do we, why do we believe that near term survival is important? Oh, first, let me. Let's talk a minute about. What we use to. Put people in different levels of products. Pergnostication. Pergnosticated. In patient retail. The sequential. Organ failure assessment score, the sofa score predicts in patient possible mortality. It's based on six routinely gathered. Measurements parameters that. Are quite. A standard in clinical care. I won't read through them all. They're six different organ systems. You get zero to. To four points for each. And then you add up the total score. Total score of over 11 or 12 is a bad. Very bad. And higher scores are worse. So we. Believe that. There should be some adjustments in the sofa score. To give a lower priority to patients who are expected to die. Within a year. From an end stage condition. Even if they survived the acute hospitalization. And received appropriate condition. Appropriate treatment for the end stage condition. So how do you make the adjustment? Which patients get an adjustment. And how large an adjustment. Looks like I left off a slide, which I need to just. Walk you through. So, so why don't we say that near term prognosis. Matters. So consider. Two patients. One. Previously healthy. Youngish man. Which patients get an adjustment. And how large an adjustment. For the end stage condition. Previously healthy. Youngish man of say 45, 46. Who develops. Of COVID with multi-system. Failure. Acute renal failure. Ventilatory failure. Hypotension. Multiple. Quite a lot of things. He has a. Let's say his sofa score is. 1213 14. But if he survives. He's likely to do well. COVID can have a lot of chronic sequela. But. He, there's nothing. He has no other end stage condition. Consider the other hand. A patient who. Is older. Say in his 70s. And just has. One. Organ system. As long. But he also has. Inoperable pancreatic cancer. And he was unable. To tolerate chemotherapy. Or radiotherapy. He will most likely. Have a better prognosis from COVID. But if he survives, he goes back to having. His inoperable cancer. And no. Available treatments to him to try and. Change the course of illness. So if we all relied on the sofa score. Inoperable cancer would get priority. Over the younger person who if he survived. Would have. An expectation of multiple years of life. So that's why we believe an adjustment is. Appropriate. So. I'd also like to say that. We feel that exclusion of categories of patients who are felt. Is a bad idea. Ignores that the supply of ventilators can change. In the matter of days. And if you look at the policies of states that have these. They often. Are. Very vaguely written and hard to operational. So a very common one is metastatic cancer. With a poor prognosis. Well, what exactly does that mean? Who is in and who is out. People with metastatic breast cancer have a poor prognosis. But there are many treatments. That are failed. Can palliate life. And similarly with. Increasingly now. With metastatic. Carcinoma. The colon. Within. Given category. There's tremendous individual patient variation. And. Assigning people by categories. Deprived them of an individual assessment. Of how they're likely to do. And finally, the list that's included in state policies. Is usually about 10. And. At most and other groups with assembly poor prognosis. Are not listed. So it's unfair. In what groups are not considered. I'm sorry. I keep. Hitting. A wave in front of my track pad. It jumps. Another thing that's important to clarify is there are people who. Are at home on chronic families. For example. Patients with. With ALS. And they should get to keep their ventilators when they're admitted to the hospital. We also feel that some things that appear to be fair. Allocation policies actually. So first come first served. And a random lottery. And then there's a list of. Some things that appear to be fair. Allocation policies actually. So first come first served. And a random lottery. Would lead to more in hospital debts. Because you could end up assigning. A ventilator in a bed. To someone who is. Has so many. Organ systems. Family. That they're in hospital prognosis is poor. Even with a family. They're also problems with first come first served. They have to do with. Barriers to access to care. And I'll talk about that more a little bit later on. So I want you to just look at the first two lines. So this is how we tried to operationalize. Well. First row is the prognosis for survival. Using sofa score. By quartiles. We suggested. We also suggested. More quartiles and a point. For the ascending severity of illness. So more points. Gives you a lower priority. We also. Suggest a correction. For near term prognosis. Due to an end stage medical condition. For which treatment will not. Pro long life. So. So. So. So. My side is. Death within one year is expected. And we said. They should have four points. I'll get to the next two lines after I go through the. Well. Fairness considerations. So. So another aspect of our recommendation is that. You know, I think that a ventilator should be a timely bid trial. With regular reassessment. Patients who are admitted. And then deteriorate. Sharply. Over a period of days. As opposed to having an expected course. And we know. Patients with COVID. Ventilatory failure often needs long-term ventilation. So if they continue to get worse despite maximal treatment. Should they. Have their. Assignment to a ventilated bed reassess. We believe that's. Important if we want to. Maximize the number. In patient lives. And a policy should be based on the best available evidence. And modified when good evidence becomes available. I think we're still looking for. Very good studies on rigorously done studies on. Validating the self a score in COVID. And other studies on how the allocation policy actually works. On the ground. So let me now shift to my second cartoon. Which is fair allocation among those in need. I think we should start by saying that in historical epidemics going back to the plague color. There's has always been a disproportionate. The bad impact on the poor and on minorities. And there also has been discrimination in public health policies. Including in the U.S. So that's the background. And I think we're seeing this today with COVID. Well. The first point about fair allocation is there should be no exclusions by. Categories that should be protected. There should be no exclusions. Age, disability, religion, race, color. National origin, gender, sexual orientation. Some of these are actually protected by. By law and interpreted to be constitutionally protected. But then there are others that I think are ethically. Appropriate categories for protection. And I think that the quality of life. As quality of life perceived by others, whether it's family. Doctors or nurses. Should be excluded because we know. That people living with a disability. Consistently rate their own quality of life higher than others. First come first serve is not fair allocation. And then there are other categories to access to care. People who don't have insurance. Where. They live in a neighborhood where. There just aren't that many hospitals and the hospitals that are there. Are safety net hospitals that are underfunded. Under resourced. And easily overwhelmed. I think it's important to consider the social determinants of health disparities. I know that a number of you in Chicago or work at. Health disparities. Ethically, I think at a minimum, we would not want to worsen existing disparities. But we would go beyond that and argue that we should ameliorate disparities. In the context of ventilators and ICU beds. What do we mean by that? And as background in COVID. There are structural injustices in the US that cause a really market health disparities. I mentioned the disproportionate number of. Cases in the counties. Minority groups, people of color. There are multiple pathways by that for that. And I think some of you in Chicago are actually researching those. Those mechanisms. We recommend. Adjusting the. Scores based on medical prognosis. To give higher priority to people who live in a high area. An area with a high ADI area deprivation index. Oops. So the ADI. Measures social economic. A disadvantage. In the unit of a census block, which is about 1500 people. Within that census block, it computes a score based on education, employment, housing quality and poverty within their. So I think you can describe. Individual score based on the neighborhood they live in. We also think that some share priority should be given. To some essential workers. Now. Not all essential workers, but those who are unable to socially distance. Frequent face to face contact with other people. And frequent covert exposures. Often. Doctors are quite successful advocating priority for doctors. But really. It's a category far greater than doctors and nurses. I think we should include nursing home aids. Home health worker. Home health workers. Police first responders, bus drivers, meat plant workers. All who. Have met these categories of having to work where they can't socially distance. And have face to face contacts. Part of this I think is reciprocity. These are people who put themselves. Knowingly at risk. In, in their work in order to help others. And if you come to the. Talk tomorrow. Second day of seminar. That's going to be the topic of my talk. There's also an instrumental value. We know COVID is going to be. Recurrent in wages, waves and surges. And we would hope that these people will be able to return to work in, in later searches. So we. Would add on two more rows. One for people living in a high. Area. We would subtract a point if the ADI is eight, nine, or 10 on the 10 point scale. We will also subtract one point for an essential worker in a high risk cooperation. Now, many people. Who are essential workers. Also live in the area of the high ADI. And they would get two points off. And again, I think it's open to discussion. But this is the framework that we would like to propose. The ADI, by the way, can be calculated. They were. It can be calculated electronically based on the patient's address. And there's an app from the University of Wisconsin. Who does it that does that. So tie breakers, there are. There's a high likely that people will end up with identical priority scores. How, how should you break the time? We would advocate. If one patient is significantly younger. And that has to be operationalized. That patient should get priority. But if they're identical priorities, scores and similar age, then random allocation is, is fair. I'll say, oh, that's all well and good. But rather than triaging patients, why don't we reallocate ventilators. To different hospitals. So the idea is you could transfer ventilators. From hospital to hospitals with shortages of ventilators. From hospitals that have an excess. And that was hard to work out in advance. Now I think in the app for the first wave has subsided. There are cooperative arrangements among hospitals, even in different states to ship ventilators to where they're needed. Again, to me, that is. It illustrates the importance of having these problems, these policies worked out in advance. And more than just paper policies. What we learned from preparedness exercises. Is the people in different roles need to know who each other are. And to talk with each other. So the director in one state. Needs to talk to needs to know who the directors are. In other states and regions. Another recommendation is within a region within the city. To transfer patients. From hospitals that are overwhelmed. To hospitals with open ICU beds and ventilators. New York City actually had a formal. Policy to this effect that put it in place. During their first surge. But the policy did not work in practice. Well. Hospital transfer phones basically are one way phones. They're from well-resourced hospitals. To safety net hospitals to transfer patients who are. Uninsured or under insured. People in safety net hospitals in New York City. Said, oh, there's a hospital in a different barrel. Who has open beds. Let's transfer some of our patients. The phones weren't answered. So I also want to talk about a fair process. For triage decisions. This has many components. First. The policy needs to be transparent. It needs to be openly accessible. And. When I first started. Doing this earlier this year. It was really hard to get some state policies. You. You had to do multiple searches and they were sort of hidden. So. The process for how the policy was arrived at. Also needs to be transparent. And the policy by which. Decisions are actually made at. Hospital level. Need to be transparent. We strongly advocated having a triage committee or officer. Make these really hard decisions. As to who has priority. And so. The individual digital physician. The individual physician we think needs to focus on the well-being. Of her patient. And not be concerned about. How other patients might be affected. There needs to be an appeals process. We thought it really should be for errors in. Calculating triage scores. And it needs to be quality improvement to be. Profine improve the process. And if necessary. To change the policy. So let me pivot towards the end here on. Remaining challenges. So. One challenge is forming public policy. I'm old fashioned. I still believe in evidence based policy. It doesn't work. So it's important, I think, to assess the outcomes of policies. As rigor sees as possible. With real world evidence. I think we have to pay attention to how the policies implemented on the ground. Is it something that works at the level of. The ICU and hospital. I think there's a. I think there should be a feedback loop. Where policies are. Refined and altered. Based on evidence of. Outcomes. This whole feedback loop. Evidence based policies. That are used or. Proposed. And model them on. Actual data sets with. COVID to see what the impacts are. Particularly the unintended impacts. And then I think there should be a feedback loop. Where policies are. Refined and altered. And then there should be a feedback loop. Evidence based policies. Very. Precarious at this point in our history. I think another big remaining challenge is forming public policy. One thing that we've learned is that. There has not been sufficient. Public engagement and feedback. And I think it's important that we engage in. Many different communities with very different points of view. I think it's particularly. Important that we. Engage and hear from disadvantaged communities who are now. Doing worse than the pandemic. And I think there needs to be a board. To include more representatives from groups that. Could be harmed by. Policies that don't pay much enough attention. To fairness. Finally, we need to rebuild public trust, which is really. Low in this country, but also around the world. We have not had consistent. Evidence based. Evidence based. Segmented messages. Messaging that engages the values of audiences that you before. If you look at statements by state and federal leaders. They're. Distraught often inconsistent. And often not evidence based. But I think it's really important. I think it's recommended if you talk to people in advertising, they said, well, You don't have a homogenous target audience. You need to think of what are the different segments and how do you reach them? How do you engage them? We're now beginning to try and do that. With allocation of vaccines. It's really hard and remains to be seen if we're going to be able to identify credible spokespeople for different audiences. So community leaders, leaders of community based organizations that people trust. In the community. Religious leaders who can speak to their communities. And we've seen. Well, let me just. Say that. And sports starts people who have a lot of fans and followers. I personally think that. The NBA has done some really nice public service messages about. Social distancing and wearing mask. And actually demonstrated. That they can do that. So let me end with formal remarks with. Three odd standards of care. Under crisis standards of care should be first. Developed in advance. Second, take into account health disparities and structural injustices. And third, engage publics. Meaningfully. Well, so let me stop there. And thank you. And turn off my screen. So Brian. Dr. I'll turn it over to you for, for Qs and eights. Great. Wonderful. Thank you very much for. That sort of opening lecture on the sort of sub theme of resource allocation that's going to be throughout this lecture series throughout the year. I thought it gave us sort of great historical perspective as well as a general framework on how we should think about resource allocation. So thank you very much. Thank you very much. Thank you very much. Thank you very much. And we'll jump over to the Q and a. So anybody who has questions, we will try to address whichever questions you have through the Q and a. And so I'm going to sort of start with the first question. By will Parker, one of our poem critical care attendings here. And he asks. In your annals of internal medicine paper in 2009. What are some of the categories are identified for near term prognosis. Such as major. A two point. Deprioritization in the PA system. It appears you have dropped this from your current framework. Why? Well, first of all, thank you for the question. So in 2008, we actually thought there should be. Several levels of. Outcomes considered beyond the hospital survival. So one was a near term outcome. And we also thought that a longer term outcome. Several years up to five years should be considered. We now believe that. The five year prognosis correction. That should be dropped. That it's, it's a lot. There's a lot more. Uncertainty in how accurate those predictions are. And probably a lot of variability as well. So we, we retain a near term option, which we now define as. Having an end stage disease. For which death is expected within a year. Again, we're not great prognosticators as physicians. But I think it's an intuition that that's worth pointing out. Keeping. Great. And actually the next two questions. Relate to sort of the, I think the near term prognosis. And so. The first would be statistically what percent of those predicted to survive only one year. And then the second would be, I think that would live only one year, not more. So I think I hear you get to the sort of prognosis, prognosis and statistics of that. And then we'll park our gas a related question. That what is your formal ethical justification. For a four point penalty for death within one year. Great questions. So I think I would say that there needs to be. Accurate. Doctors estimates of patients. Likely to die within a year because they have an end stage disease. How accurate is that? Some years ago, we did. Studies with. This was gosh, the eighties. When the ventilators were scarce during the eight. It depends on the organ system. And so, for example, we know that. The model we often have in mind is metastatic cancer, which is sort of. Monotonically downhill. But there are other diseases that have exacerbations and. Missions, if you will. CHF. CLPD. So I think we need to. Look at how. Accurate prognostic predictions are. Now the question of how. Much weight you give to a factor. That's a terrific question. And I think one could easily make an argument. It should be two points rather than one point. I think. Data might help here. But I think, and I would certainly be comfortable with someone. You know, I think we think it's forced too many. That's our state's going to cut it cut it back. Let me just say that I think different regions. Through a deliberative process will come up with different. Final scores. Maryland did a. Deliberative democracy exercise. Where they prioritized. Or they gave some priority. To some. Something that's been termed. Ability to. Chance to lead to live a full lifespan. Overall stages of life. No. That's really discriminating against the elderly. So I'm perfectly open. I don't have a. Ethically defensible argument other than to say it should be. None zero. I think two could be fine. Three. Next question then is. Sort of addressing the issue of essential workers. Where do government officials, both sort of nationally and locally fit in. As essential workers. Yeah, well. So it's actually a very interesting report that. Brookings, from the Brookings Institute put out about who are essential workers. So if I can take a couple of minutes, I'm going to be right back to you. I'll just give you a little bit of a rundown. First, essential workers. There's a list of federal guidelines, but it's states and sometimes counties that have formal designations. And it turns out a third to 40% of all American workers are considered essential. So I wanted to narrow it down to essential workers who can't work remotely. Mark SIGGLE and I were talking about. patients via telemedicine. So to the extent that we're able to do that, I like to think I'm essentially fulfilling important role, but to the extent I can do that remotely, I shouldn't qualify. So it's people who can't work remotely. And then also I think in terms of the question of politicians, politicians can't they work via Zoom? Sure, it's not quite the same. You can't go in and put your arm around your colleague and say, now look, you can't be serious about opposing this measure. What can I trade you for? Maybe you can't do that. But I think you need to say, can you adapt your work to socially distance or wear masks? You know, if you want to meet in person, put on a mask and stay six feet apart. So I think I would not want to accept the moral hazard where someone says, well, I'm too important to wear a mask or socially distance, but I should get priority. I think that just doesn't seem right. Let me stop there before I go. Okay. The next question then is, when we talk about ventilator shortages, I also think about staffing to care for vented patients. And this doesn't seem to be frequently explicitly discussed. So to what extent is staffing a limiting factor? And if staffing is a limiting factor, how does that impact ventilator sharing? Great question. It's a hugely important factor, and it can be a limiting factor. Again, those of you who are in pulmonary critical care can correct me, but my impression is that pulmonary critical care physicians and nurses, respiratory therapists, have really been extraordinary figuring out how to increase staffing. And I don't mean just, you know, work longer shifts and take fewer days off. You can't work more than seven days a week. But many people who are not primarily involved in managing ventilators day to day were retrained to learn how to do that. I think in addition, people got really good at having almost pyramidal systems of care where the ICU physician stepped into a consultant role to the frontline people managing the ventilators. Nurses similarly, they retrained themselves. And then I think we have to recognize that there are some healthcare workers who really view what they do as a mission. And they went to volunteer at hospitals in understaffed areas to sort of designate their, to disseminate their expertise. I think the other thing that, again, the ICU folks, critical care folks can correct me, but my impression is that ICU doctors learned a lot and they shared their knowledge with each other over informal social media networks and email chains. And people learned how to get better at doing this because a lot of things that were considered standard care turned out to be unnecessary. We got really good at learning who didn't need to be ventilated but still could do well with a PO2 that seemed ridiculous. And there was sort of an, in addition to that question, is that, you know, recognizing that agency or travel nurses and healthcare workers are costly resources, does this play into further disadvantage in safety net hospitals and the populations they serve? And I think this sort of came up when states were sort of bidding against each other for various resources. So how does this sort of come into play? Yeah, so I would separate out material resources from human resources. So again, for the human resources, I really tip my hat to healthcare workers who volunteer to go to the worst places. And there's a contingent from San Francisco who went to the safety net hospitals to work in New York City for several weeks. I think you're absolutely right when it gets into how do I get whatever it is, more masks, more ventilators, hospitals who are better resourced and have better connections, do better. Or in some cases we found that you call up one of your trustees or big donors and have them use their business connections. I think, you know, I think there is a, there can be a role for governments in coordinating or playing a role in market failures. And I say that very cautiously talking to a Chicago audience. But I think that there is a role for centralized purchasing governments to use their levers of policy to encourage more production and then to allocate to hospitals on the basis of need and cases rather than who could get things on the market. We tried to, well states did some of that when Remdesivir was first released for use with hospitalized patients. There was an attempt at least in California to allocate two counties and hospitals on the basis of the number of cases. So it made some attempt to be accrued to allocate the basis of need. But it's a great series of questions and I think the staffing is key. Let me also just say, because I'm going to say a little about this tomorrow, I think medical students who said graduate us early, we will work as interns in our own hospitals almost ready. You teach us, we'll do it. So the next question then is, I agree that triage formulas and guidelines are incredibly important. How publicized should the algorithms be in order to make appropriate decisions, but also not turn off the public and make them distrustful? Great questions. So Italy clearly takes one side of the equation. They said, look, you have to make some tough decisions in life and it's better you don't talk too explicitly because then everybody just appreciates how awful the choices are. I think the problem by not being transparent is that people don't know what's going on and that they can't say, hey, let's rethink about that. If you look at that part of the policy, this is what it implies for this group of people. Is that really right? So I think a very good friend of mine has had very senior positions in public health. And he has said that who is the spokesperson? How good is the spokesperson and what message is that? I don't know how much I can give away Tamara's talk mark. So leaders vary a lot. We've had a lot of bad examples around the world. I think a good example is the Prime Minister of New Zealand, Jacinda Atern. Her message has always been spot on. We are in this together. We have to work together. It's going to be difficult. All of us would prefer not to have to do this, but we're all going to do it. And I'm going to do it with you because it's important for all of us. And it's that kind of, these are tough decisions. I wish we didn't have to make them. We're doing everything in our power not to have to make these tough choices. And here's what we're doing, prone positioning, sharing ventilators, plugging two people into the same ventilator, having do-it-yourself inventors come up with ventilator replacements. But I think part of things are serious. COVID is a serious illness. The pandemic really hit hard when the mortuaries can't do their job. Something is wrong. And not to acknowledge that just seems to be, I'd like to see more from leaders. So there are a number of questions about the disparities issue that you brought up. And so I'll throw one out there. I'll try to do a few rapid fire. But allocating resources fairly within the hospital only addresses disparities for those once they get to the hospital. So do you think using a reserve system would do a better job of fairly allocating resources at the community level? Yeah, I think, and I would certainly urge that for other interventions that are given out in community settings. So certainly, I think with vaccines in particular, it's really important to read double efforts to communicate with people in hearted communities, to help them to understand their concerns and to try and address them. I think stockpiling equipment is important to touch on that. Hospitals, you know, sure, you can have a floating hospital pull up to a dock, you can put a hospital in Central Park. But no one's talked about putting hospitals in the middle of Harlem, Bedford Stiles, which is where they're needed. And, you know, a hospital, a floating hospital in western, the western side of Manhattan went empty. So a great idea couldn't hold off. And to get a patient from an overworked public hospital to those settings was hard. In the long term, I think there's clearly an answer that we've got to rebuild the safety net structure, which, you know, has really deteriorated in terms of safety at hospitals. New York County shut down when that was an hour's house off to the traditional place. And I'm sure to get care. So I think there's always a question of how far back do you go? And I think you need to address the root causes in the community. And for community level interventions, I think you need to make sure the supply is adequate and the infrastructure to engage the public is adequate. And that's a disproportionate investment resource. Great. And this is sort of a question that sort of tax onto that in terms of thinking about safety net hospitals. Do you have some thoughts about how you get high level institutions to accept patients from safety net hospitals, especially when patients require ICU therapies, which the higher level hospitals excel at? Yeah. So just ask the question straight out, how many people get transferred from a safety net hospital to a quaternary referral center for ECMO, which you have to do there. So I spent all my faculty career in a medical center that has a safety net hospital at San Francisco General, one of the three primary rotations for the house. And everybody rotates there. And the faculty who work there are very highly regarded. So I think it's got to be part of the mission of academic hospitals and referral centers that if we're going to train students, residents, and fellows, we need those hospitals. We need to serve those people because you know, we are also a public institution at UCSF, so we have some support from the state. So I think we have consciously made part of our mission to serve the community. Seattle, King County, I think is another example of a safety net hospital that has not only survived the threat, and they have a wonderful fundraiser every year where they say if you're in a car accident on whatever that highway runs through Seattle, you'll come to that safety net hospital's trauma center. You have a stake in making that a strong hospital. And it's not just a trauma team, it's all the other nurses and staff are going to take care of it. So safety net hospitals are part of all of this, even if we don't think of getting primary care. Another question then is what is the appropriate level of authority for declaring that the time for crisis standards has arrived? Is this a statewide decision, metropolitan statistical area, county, city, individual institution, and how prepared is the public health sector of the U.S. to lead such a decision? Wow. So it depends. I think the states are supposed to have policies. Governors make formal declarations and they should do that. One of the things under our governmental structure we've seen is counties and municipalities disagreeing with the government, let alone the government disagreeing with the federal. So that the people closest to the actual crisis on the ground may have a clearer view. It has to be through an authorized law. So if the county allows or if the city allows the mayor or the county supervisor to declare public health emergency, that's okay. Hospital, I think hospitals need to buy into state policy and I think a given hospital may have a need for a policy at a time when the rest of the geographic area doesn't. So if you think about mass disasters, one-shot mass disasters, so there could be a crisis within a city or even just their trauma center that doesn't affect the rest of the state. And so I think you want to preserve some flexibility, but it needs to be done in an authorized manner. Sort of along those lines, and this is something sort of I noticed when sort of doing the math that 17 states had public policy, 17 were working on them, that doesn't add up to- I was going to give you a clear majority. Yeah. And so the question from the Q&A is it is probably fair to say that even post-COVID, many states will refuse to complete preparedness planning or develop crisis standards of care. How do you recommend health systems move forward? These are fabulous questions. No, I think health systems should do their own planning because they may be stressed in ways that the rest of the area is not. And they can certainly redeploy things, transfer patients within their own hospital, their own system. But let me just say that there is value, I believe, to preparing this planning, even if it doesn't come out with a blue ribbon policy. I think just- I don't know how many of you remember Katrina, but it was a total disaster that different emergency services operations operated on different radio frequencies. So they literally could not talk to each other. They didn't know who to call if they said, we need help with this or that. So just knowing who the people are to talk to so that they recognize you and you recognize them because you're at this meeting, even if the policy didn't come out, those connections are important. And I'll contradict what I said before about Zoom. I tend to think that those building of bonds works better person to person rather than Zoom. Brian? Yes? Can I say a quick word? I want to tell the attendees that tomorrow at about one o'clock there will be a Bucksbaum symposium for which Zoom links will be available. And Bernie will be speaking on the topic physician and medical student responses to COVID-19. That will be the topic tomorrow. What the plan for today is that at 1.30 we'll be meeting, Bernie will be meeting with our fellows. And I see that you still have 15 or 18 questions that have been raised. I think my suggestion would be that we just continue this discussion right now with the fellows online and continue the number of questions that are there rather than breaking up and removing the audience. I know part of the audience will have to go back to their clinical work and will give some focus to the fellows who are with us, but continue the questions that you have if that sounds all right. Can I just ask for like a three minute break? Yes. Just to say, as an added inducement for the talk tomorrow, I am shamed by Mark and I will be wearing a tie tomorrow and I will be using a University of Chicago aircraft. I apologize. No, I think it's great. So I'll be back in three minutes. Okay, good. So the only problem with saying on this line is that the fellows cannot talk. They'll have to continue to write questions. But Brian's doing a great job, but I just want the fellows to realize that they can't talk because of the way this is set up. If in writing the questions, the fellows say McLean fellow and then write the question, let's give a certain priority to those issues and those questions. Brian, you can keep an eye out for that. Sure. How many points are we giving them? We'll try for five or below. Brian, since I actually can't write into the Q&A, I just want to add a question after the fellows, which is just the whole decision of using the SOFA score, which wasn't really designed for COVID-19. And so therefore raises issues, not just the fact that it has some biases in it, but actually being used for a purpose that was not originally developed or intended. Could you tell us what it was originally designed for? Yeah, it was designed for sepsis. Interesting. And so, well, Bernie is back, so I'm going to hand it back to Brian. Okay. Let me just raise a technical point. Yolanda, you was on the call, but actually, I was given a separate Zoom login for the session of the Q&A with the fellows. I'm just wondering if there are people who are logged on there as opposed to here and whether they can be redirected. Yeah, I can go check, but they should all still be on this Zoom since we haven't ended yet. Oh, okay. Stop sharing the screen. Laney, do you want to repeat that question or should Brian do it? Oh, Brian's in charge. Laney, I mean, you can repeat it. I don't need to throw out these. So, Bernie, one question that we'd like to ask is just the whole decision of using the SOFA score for sepsis. And given that it's known to have certain biases, given that it gives people lower scores for certain diseases like diabetes, which are found more in minority communities. Yeah, so I guess the question is, do we think that, I agree, totally with what you said. So, the question is, is there a better objective easily to calculate score that would just roughly separate people into prognostic levels? I think it would be great to have something better. As you know, it's really hard to derive and validate a score. And there've been some things written about prognostication in COVID, but they're single site institutions, they have their own independent variables that are not easily calculated universally. So, there's a compromise between practicality, accuracy and fairness. And you've probably called attention to two or three problems. So, I'll sort of try to go down the order of questions as they were asked, because previously I skipped around a little bit. So, one of the earlier questions was, if survivability according to SOFA score is nonlinear, in the sense that 10 is similar to 9, but 12 is significantly worse than 11, how do you ethically justify tie breakers and adjustments that do not account for those jumps in survivability, and why not have tie breakers within SOFA four times? Great question. So, again, I appeal to those of you who are quantitative modeling types to actually model that and see. So, I guess part of it has to do with how much, I guess it's a technical question, how much overlap and separability are there between individual increments of a point in SOFA scores? And so, I guess the thing is, I would say that all these problems are true. And so, I think the thing is to replace SOFA with something better that will work in a hospital. Great. I think the point was that it was nonlinear. And so, your bucketing isn't sort of adapting to the nonlinearity of the SOFA score. Okay, so the suggestion is we should give more than a point difference between different levels, or make the buckets more... Well, so some have argued, so Will Parker, who's one of the people asking many of these questions, is trying to argue why not just do it within each score and do a continuous, since it's all can be done on computers now. It's not like you're collecting it, having to do it by hand. Yeah. And again, I would say that's something I would love to see someone said we compared strategy A and strategy B, which is just doing it by an individual score. Here's what came out in a retrospective look at the data center, several datasets from different hospitals. It's just, I don't want to just warn, it's important to do it in multiple sites because things vary from hospital to hospital. I think these are all great points. I would be glad to have these kinds of corrections published and analyzed. The next question, you know, thanks you for addressing the moral issue of disparities. And the question is, who do you think should decide what scoring systems or policies to implement to ameliorate disparities, doctors, legislators, politicians, people? Yeah. So again, it's a political philosophy question. I don't think doctors and academics should be deciding. There's a question as to whether politicians currently without more input are the best people. You know, I know that deliberative democracy exercises are controversial and really hard to do. But I think what you're looking for is informed opinion from people who have a particular perspective to contribute. I think the other thing is to have a commission that is very broadly represented and includes representatives from people with various kinds of disabilities, people from various disadvantaged and marginalized communities. Over the course of developing a policy, they learn a lot in terms of hearing about the sort of clinical aspects and statistics. And presumably they can also then go back to their communities for feedback. I think it's really hard when you choose people, like how are they selected? Who do they represent? What qualities do you look for? But I would favor a broader process and favor and strongly encourage a kind of educational engagement process as part of it. So this is something that I sort of thought about throughout your talk in terms of just and you mentioned the form sort of informed democracy. I think, you know, a fair number now argue, one, that we're not informed and two, we're sort of a failing democracy, not to sort of be too political. But somebody did ask the question then, in your take-home message, how do you engage the public where mistrust has been impacted by infodemics and sort of disinformation campaigns? And what would be a quality first step in considering structural injustices that have deepened our community? That's kind of two questions, but I guess focusing on the lack of, you know, an informed democracy maybe. Well, I think, so I think you have to really go to the grassroots level. And I actually think, I like to sort of try and draw analogies with sort of what we know clinically. So clinically, the first thing is you've got to listen to the patient, hear their story, understand their concerns, which may not be apparent from the onset shows you use a doctor-driven H&P. And I think there are people who really are in tune with the committee, the communities, their communities connected with them, who can be informed if they're not waiting for a wonderful talk by the director of public health from the District of Columbia. And she made the point that she really engages the pastors in the African American community because they have a lot of credibility and really understand what's going on. And she said, where would you send people for things like testing? She said, what institutions do people trust? She said, it's the fire department. So people trust the fire department in African American communities in Washington, the way they don't trust police or hospitals. And she said, they're geographically distributed around the city, much more equitable. And she said, okay, then you have to sort of work with the firefighters. And, you know, they're not represented by the community. But I think it's trying to find who's knowledgeable about community concerns and who is willing to put the time in there for you. Right now, there's a huge effort to try to, how do you talk to people about assuming a COVID vaccine will become proven to be effective and safe? How do you talk to people about it and overcome all kinds of concerns and objections? And I think you really have to start with what's the nature of objections. And we have an article coming out next week in the Annals of Contact Tracing. And one of the things about contact tracing is where it's been, you know, this trust is rampant. People don't cooperate. They don't want to even answer the phone. Where it works is people start by saying, contact tracers says, how can I help you? So it's not sort of I'm in the punishment government mode. So you have to figure out what's going to make people want to engage with you and then understand what they want. I don't have an answer to that, but I think those of you who have been working on health disparities in Chicago and working with community organizations might have a much better idea. So one of the fellows that that's on has the question, what are your thoughts on post op transplant patients and ventilator or bed rationing, given that they have sort of already received a scarce resource? Yeah, I think I would, you know, I think there are people who are in incredibly high cost, high resource use patients, not just them, but people who've undergone personalized therapy for cancer. I mean, I think I would prefer to go back to the broader principles and not exclude people on that level. I also think then you have, once you start talking about lifetime use of resources, then you start running the other question. How about someone says, well, I'll build a new safety net hospital, you know, $10 billion. Just give me the ventilator. I think that again, transplant patients are at very high risk because they're immunosuppressed, but depending on the transplant, I mean, if you have a five year survival that's likely, I think I would try and apply the same criteria with this modified sofa score that you guys are replacement sofa score. You guys are going to be working with us. You brought up the sofa score. There is another question from one of the fellows about the sofa scoring. And so can you comment on the use of the sofa score and the inherent bias? Should we be providing additional adjustments for the patients that will suffer most from the inherent bias of the sofa score? And so does one point adjustment for high ADI sufficiently account for the difference? I think again, I don't have any magic way to weigh those. I think you could easily argue two, three, or even four. But I think the issue would be, I think, I mean, what you're saying is, no matter what you do for the scoring and the weighting, it should be justified. And you should just not just throw out, oh, we said one. And here's why we chose one. And I would be, you know, there's something, there was something similar to this adjusting scores to take into account disparities in cadaver kidney translation. Again, some of you may probably, I'm sure I know a lot more about this than I, to try and address the question of African American people with end-stage renal disease are much less likely to get a kidney transplant for multiple reasons. There was an adjustment made to the scoring system. But that was modeled very carefully by whether it was Yunos or Patel at the time. I don't remember. And here's what would happen under the current system and under the modified system. So I think saying, if we tinker here, this is what happens. I actually like that problem-solving approach. So again, my appeal is out to those of you young fellows who have a strong client-aided background or have a joint degree in economics or something, go to it. Great. I guess a sort of a potentially sort of devil's advocate or contrarian viewpoint may look that in trying to adjust for past injustices, are you just creating new injustices? Yeah. So again, this is a really good and I think profound question. So I think, you know, we're facing a terrible set of very difficult set of issues in this country. How far back do you go? I think that within the more proximate you are to the current situation, I think my own view is the stronger the warrant for making an adjustment. So knowing that there are real disparities in access to care, access to hospitals that have a lot of ventilators, I think those corrections really need to be made. I think doing it on a sort of neighborhood basis makes sense. It also sweeps in a lot of other things about education, poor job opportunities, crowded housing, everything else. Similarly, you know, I guess I'm putting an advertisement to this paper coming out next week. We argue in the analyst paper that contact tracing really needs to offer material support that if you can't quarantine or isolate because you live with a lot of people in cramped space, it's in society's interest to support human housing and other countries have done that. And also if you can't afford not to work even when you're sick because you're the sole income owner for the family, other countries and some, to be fair, some places in the US are doing that as well. But that should be part of both adjusting for current inequities, but also for with a public health purpose, but not all counties and states or municipalities are doing that, which I think is a real problem. So the next two questions actually sort of bring up other systems that you mentioned, both the lottery system and sort of the first come first serve. Given the challenges in constructing and implementing a formal triage system that would function as intended, should the default just be a lottery system? Well, so the lottery system is fair in very many ways. But I think if you work it out, just sort of pick people who have bad prognoses and good prognoses, a lottery will give you more impatient dance than a system that even imperfectly is adjusted to prognoses. And extend, you know, I think we've gone a long way from, you know, some of the older policies are the first and most important principle is a utilitarian, save the greatest number of lives in the community. I think we're sort of saying, well, that's a thin moral vision. But I think to throw that over and say, we're so concerned about fairness that outcomes don't matter. And it goes too far the other way. Okay. And so one of the fellows asked the question, do you think there's an ethical difference between allocating ventilators and reallocating ventilators and other scarce resources? So if you can't reallocate, then isn't it a de facto first come, first serve system? So I think you do have to reallocate taking into account the natural history disease so that we now know that COVID improvements can be very slow. So you don't, you make a commitment to see people through a natural history. But I think it's really the people who come in and start doing worse and worse and more organ systems go down. I think at a certain point, whereas you might in a ordinary clinical setting say that, well, we're starting to talk about palliative care, we're starting to talk about spiritual care, really working on getting family to agree as surrogates, that you may need to really shorten that and free up that ventilator for someone who's coming in and hasn't had a chance and has a much better prognosis at that point than this other patient does four or five days later. I'm sorry, there's a double-barred question. I've forgotten the second part of the question. No, that was okay. Here's about sort of a question about sort of disadvantaged populations. Can you please comment on the management of incarcerated populations during the pandemic? Yes. First of all, I have somewhat dismayed that the number of things, the number in the Q&A bubble is going up rather than that. Some of the biggest outbreaks of COVID have been in state and federal prisons. Where that is really a problem is those people are then transferred to community hospitals and they're often overwhelmed. Some colleagues of mine in San Francisco, Brie Williams and Leo Rory have a paper under review that talks about the dilemmas that community hospitals are facing, taking care of large numbers of incarcerated people, particularly when the prison guard and the warden are not allowing the doctors and nurses to talk to the next of kin or to provide medical information to the patient. So I think it is a terrible problem now. That's the very tail end. What about prevention early treatment? I personally think, but I just thought we just, I was just thinking about this last night, so tell me if I'm wrong, that if it turns out to be the case that monoclonal antibodies are safe and effective for early treatment and prophylaxis, are congregate settings like prisons and nursing homes at the top of the list for receiving priority because of the possibility of uncheck spread. So I think that given how devastating COVID has been in prisons, I think we need to really think creatively about that. And let me just say a lot of state and even federal prisons do not receive the top quality medical care that we all would like to think that prisoners should get, and I should have a constitutional right too. Next question then is, I'm curious why the one year life expectancy horizon was chosen rather than say a five or 40 year one? And on a related note, what are your thoughts on age being a tiebreaker, but not a primary consideration? Good question. So I think the problem is that it's several fold. First, I think it's a lot hard to predict five year prognosis and 40 year prognosis. We're not great at predicting one year prognosis. I think we have a better handle on that, better statistics. I actually think there is merit to the argument of having a chance to live through all stages of a life cycle. And it's actually interesting, in Italy and to some extent in the UK, a lot of elderly people said, you know, I know there's a shortage, give it to someone younger, like the age of my grandchildren rather than someone like me. So I think there's a natural sense that if you're kind of had a chance to live for all your life stages, priority is someone who hasn't had that chance makes ethical sense. Whether that can be a national policy or an official policy, I think that's questionable. The American Geriatric Society strongly objected to using age as a criterion saying it was just a slight age discrimination. Let me see, there's a question in the chat then that you mentioned that one important portion of triage is that the individual physician should not be burdened by this but be able to focus on the patient at hand. How do you do this while at the same time encouraging physicians to practice with responsible and thoughtful use of resources? And then how do you suggest measuring unintended impacts of policies put in place? Okay, so yeah, I think again those in the ICU can say more. I think it's incredibly stressful for ICU physicians and nurses because when they're overwhelmed it's really overwhelmed. I think their natural reaction as caregivers is to try and do the best for the patient in front of them. So I think separating the role of resource allocation from the bedside treating physician and nurse I think makes sense. I also think it's particularly important here because with so much of sort of family support is now missing for hospitalized patients, I think to the extent there's some anecdotal evidence that families really appreciate the sense that their doctors and nurses are doing their very best. So I think to put them in a dual role as a conflict of roles. So I would favor. So how do you assess untoward consequences? So I've been giving plugs for the quantitative researchers. So I'm going to do some plugs for mixed methods and qualitative researchers. I think you have to do in-depth interviewing with people in a systematic way and ask them how is this policy working out? Was it like to try and work under this policy? I must say, by the way, parenthetically, and Mark again, this is like a teaser for tomorrow. Some members of the press have done a really great job sort of trying to understand and put out in public what it's like to be a healthcare worker on the front lines and feel overwhelmed. I'll be talking some about this tomorrow. But I think qualitative research is so important because it gives that rich in-depth perspective that it's really hard to get with just quantitative tools. There's another question that just came in. If the flu and COVID overwhelm the healthcare system in the coming months, will the cause of disease, so flu versus COVID, be a factor in determining who receives the scarce resources? What if we think the prognosis is materially different? I think one thing we are finding with COVID is that the time course on a ventilator is longer than it is for other causes of acute respiratory distress. By the way, that question really points up the importance of putting some time in now to develop policies that are improved over what's been proposed so far because we need them in place because things are almost certainly going to get worse this fall. Even if we have a vaccine approved or at least released to emergency use authorization. People don't even get the flu shots and that works fairly well. Not great. Yeah, a question came in about vaccines that earlier, and this is certainly something we're going to address later in the series with at least two lectures on allocation of vaccines, but just briefly, how do you suggest we determine who gets vaccines earlier and who gets them later? Well, I actually think the National Academy of Science, Engineering, and Medicine report that just came out a couple weeks ago does a pretty good job. I really recognize these different phases. I think it's really important that there be a uniform policy that is advocated at all levels. I mean, the CDC, the ACIP, HHS, they need to be on the same page, and the state health directors need to be on the same page. To the extent that you have some people saying vaccines don't work, they're a trick of the elites or the devil and people should avoid them. They cause all these horrible illnesses. I think there's so much distrust of vaccines already, but I think it's really going to end up in a battlefield battle. I mean, I think we could end up in a situation where there is a good vaccine, at least one, and people don't take it because they don't trust anything anymore. I think, are there any additional questions? I think we made it through. Take your message form. All the questions there, are there any? I have a question, Brian. Bernie, can you hear me? I can, yes. I would like to know if you are aware of any instances in the United States of people who are on vents being removed from the vents because someone comes along with a better SOFA score or other factors. And if you are aware of such a thing, which states has it happened in and how often? Yeah, I don't know that, Mark. I don't have any information. My guess is that it's much more likely that someone is not doing well, that the in-hospital team talks to the family and says, look, he's really going downhill. He's not in proof. He's developed this and that. And we're just wondering if it's time to shift to think about comfort and what can we do, you know, good palliative care to make his passing as dignified as it could be and what can we do to support you. My sense is that that's the preferred way to do it. That's the traditional way that we've done it and to the extent that that's always better if to do that than to sort of say, well, we're going to just pull it off. Well, as someone who many, many years ago started and ran an ICU at the University of Chicago, I can say that that kind of perspective and attitude is driven more strongly if there's someone else who is healthier and more likely to survive who is waiting to come in than if there is no pressure to do such a thing. Has there been anything written about this? I've not seen anything. And I guess the other thing is I think it's more likely to have something someone would say in formal ways than to write it up as a case study. Well, are there any other final questions? Did we get Theresa Williamson's question? Brian? The one in the chat. Yeah. Yes, you got that. Bernie, I can't thank you enough. I'm excited about your talk tomorrow about how physicians and medical students deal with COVID-19. And that'll be at one o'clock Chicago time. And I want to thank the attendees so much for being here. And I very much want to thank Brian for taking us through the questions and moderating them. Thank you all. It's been a lovely meeting. Okay. And thanks for the invitation, Mark. It's always a pleasure to interact with you and your group. Take care. Honored to have you. Bye-bye. Bye-bye.