I recently read an article about the challenges of being a leader during COVID-19. Without question, I empathized with the author. Since mid-March, I have been the Clinical Lead and only full-time physician in our COVID-19 Command Center. Early on, this meant managing COVID-19-positive patients, PPE, quarantine for employees, deployments–a myriad of things. For the most part, my role had some kind of “data” to back up recommendations: Society Guidelines, CDC and precedent in other hospitals and countries. However, with the vaccine rollout, we had the freedom, which of course came with the inherent criticism, to do what we felt was best for our institution. In the case of vaccines, our “society guidelines” have been the court of public opinion and social media, and they are the litmus test by which our response has been judged.

As a government institution, we are subject to a different level of transparency and accountability than other hospitals. Our salaries are paid by the taxpayers, and we are held to standards that are steeped in protocols, evidence base, government regulations, unions and so on. Typically, government facilities have dry runs, practice and time to prepare. And there is an expectation that we are prepared. For anything. At all times. So how does a government hospital stand up something without precedent? In the case of VA Boston Healthcare System, we just did it. Perhaps it was the surgeon in me who was accustomed to the unexpected in the operating room and the need to turn on a dime–to react immediately and not freeze–that made me comfortable with managing a vaccine rollout in a matter of hours. Maybe it was my faith in our institution, leadership and coworkers that settled any anxiety I might have felt. I suspect it was both of those things.

We received Moderna, which meant we were 1 week behind those institutions and Facebook posts associated with Pfizer, which heightened the anticipation. Seven days “behind” was an eternity, and everyone wanted to be first in line. VA Boston has 4,600 employees with over 3,000 who initially signed up. An immediate response was expected by our staff. Moderna received approval for use on Sunday, December 20, 2020. We received our first doses the following day and by that night, vaccinations had started in high-risk patients and employees. The next day we stood up an employee clinic that did double what we had anticipated. After 3 days, approximately 1,000 doses had found their forever homes. As leaders, we were so proud, despite the bumps along the way: the appointment process needed modifications; communication during a time of untenable email volume was imperfect; some employees walked in while others waited for notification; we had to manage staff anxiety and those who felt if they did not immediately get the vaccine, they wouldn’t survive the night. The COVID-19 pandemic has brought out both the good and bad in people, but as a leader, that is what you have to manage as you also manage your employees and utilize whatever skills they bring to the table.

The logistics of something this massive is truly monumental. Lack of staff for vaccine clinics is a major hindrance. Each vaccine clinic requires 20 staff, not to mention all the behind-the-scenes work: check-in/-out admin staff, vaccinators, observers to monitor for reactions, pharmacists and runners. With 3 clinic locations, 60 deployed personnel have to leave their current posts to help. We have largely relied upon staff with time on their hands to volunteer. During normal hours, this fills the gaps. However, for after hours, weekends and now with the Community Outreach clinics we just started, it is not so easy. Those who are members of a union, despite whether they would gladly denounce union restrictions to participate, fall under rules that must be honored. As such, our go-to resources are physicians, research and psychology staff–those on salary who do not fall under overtime or duty hour limitations. As the Associate Chief of Surgery, my role has allowed me to activate “my people,” many of whom have come in off tours and over holidays to vaccinate, observe, or run clinics, simply to be part of this historic effort. The need for a cohesive team and staff from all areas coming together on equal ground has never been more vital. To be in these clinics is to witness a welcome euphoria, excitement, relief, tears, photo ops and yes, anxiety too. But like spring coming after a long winter, hope has again sprung eternal, as vaccine pics on social media posts bear witness.

While we were well ahead of the general public in the state of Massachusetts and extremely proud of our rollout, tragedy hit. A series of unfortunate events led to the compromise of 1,900 doses. This was truly a vicious blow to those of us leading the vaccine charge. We had done everything right, so how could this have happened? Being a transparent High Reliability Organization, we were truthful while also grieving the loss in very personal ways. I was able to visit with Congressman Lynch when he came to brief on the loss but had to resist the temptation to talk to the swarm of reporters. Fortunately, the media blitz died down surprisingly quickly and we carried on with even more fervor.

As of this writing, 20% of our 60,000 enrolled veterans are vaccinated. The state is still at 75 years and older, but we are already down to age 55. If the rumors are true, soon we will take on the Veteran Affairs “4th Mission”, which would open up vaccines to civilians. This would be exciting, indeed, but as one of my nurse friends has said, we have to be careful we do not trip at the finish line. This is certainly a marathon, and we have a long way to go. Yes, being a leader during the COVID-19 pandemic is hard, but to be allowed to contribute and play such a pivotal role during these unprecedented times has been my great honor and an incredible journey.

Dr. Lori Lerner, Chief of Urology for the VA Boston Healthcare System, has also served as the Physician Lead of the VA Boston COVID-19 Incident Management Team since March of 2020. The pictures associated with this article were taken at the Veterans of Foreign Wars Club in Boston on the weekend of February 6 and 7. Dr. Lerner designed and made the t-shirts for this Outreach walk-in vaccine clinic herself. (In the large group photo, she is the one kneeling in front.) In her own words, Dr. Lerner remarked that these 11 months have been “an incredible journey.” The AUA is grateful to all members who gave selflessly of their time and expertise this past year to help us all navigate this pandemic. And a special thank you to Dr. Lerner for sharing these photos and for reminding us of what a “Weekend Warrior” truly looks like.