ACLGIM Leadership Forum

Vaccine Implementation and Policy

COVID-19 Vaccination: Leadership Decision-Making at One Institution

Dr. Lawrence ( is the assistant dean for curriculum and a professor of medicine in the Division of Infectious Diseases at Washington University in St. Louis. Dr. Aagaard ( is the Carol B and Jerome T Loeb Professor of Medical Education, vice chancellor, and senior associate dean for medical education at Washington University in St. Louis.

The COVID-19 pandemic has generated multiple challenges for medical education leaders. Regardless of the problems being considered, developing guiding principles up front helps to provide a framework upon which fair, transparent, and respected decisions can be made. Some of Washington University School of Medicine’s guiding principles in relation to COVID-19 vaccination implementation in undergraduate education included: 1) medical students are important healthcare providers, 2) medical student education is a critical pillar of the institution’s mission, 3) medical students should be engaged in meaningful activities to respond to the pandemic, including learning how to care for COVID-19 patients, and 4) a fully vaccinated campus allows us to more fully achieve all missions of the medical school. While the availability of COVID-19 vaccines in late 2020 was a welcome game-changer, it posed a unique set of shifting challenges that required frequent situational reassessment and timely decisions grounded in these pre-established guiding principles.

In early 2021, when vaccine supply was unable to meet demand, medical schools, in conjunction with their local health authorities, were faced with deciding when medical students would fit into the prioritization schema, specifically whether (and/or which) medical students would be considered healthcare workers who would be eligible for receiving vaccine within the first Phase (1a) of the rollout. Important questions to inform that decision included: 1) will the students be required to engage in face-to-face clinical interactions in the next few months, 2) is face-to-face training required or can a similar quality learning experience be obtained virtually or through simulation, 3) will the receipt of vaccine by students directly result in delayed vaccine receipt amongst higher risk individuals in the public? The implications of such a decision were tangible. For institutions that determined medical students, including pre-clerkship students, would be considered healthcare providers eligible for Phase 1a vaccine receipt, the realized benefits included less disruption to the academic year, allowance for all students to more safely continue patient care activities and learning in the clinical environment, and improved confidence in the institution taking care of its students. A potential negative ramification of designating all medical students as healthcare providers eligible for early vaccine was the possibility of diverting vaccine from those at higher risk of complications. However, in some states, vaccines sent to healthcare systems were earmarked specifically for healthcare providers and could not be used to vaccinate lower Phases until the state declared a new vaccine Phase opening. This was the case in Missouri and allowed us to consider all medical students vaccine-eligible in Phase 1a.

When the inflection point of vaccine supply exceeding demand occurred in late spring 2021, the attention shifted to consider whether medical schools would require COVID-19 vaccination, including for medical students. Important questions again guided decision-making: 1) can adequate levels of immunity within the institution be achieved without a requirement such that the risk of COVID-19 case clusters can essentially be eliminated, 2) is it ethical to require vaccination for some groups within the institution but not others, 3) can full educational (and other mission-critical) activities occur without mandatory masking/distancing for all, 4) will a fully immune campus protect the vulnerable who cannot be vaccinated or who have medical conditions that prevent adequate immune responses, and 5) do unvaccinated individuals only put themselves and other unvaccinated individuals at risk? Implications for institutions requiring vaccination include fewer cases amongst faculty, staff and students, and resumption of most in-person activities without requiring masking and distancing. However, the COVID-19 vaccines remain under emergency-use authorization and have engendered significant controversy among many across this nation.

At Washington University School of Medicine, we have decided to require vaccination for all trainees, staff, and faculty. We believe the data surrounding the safety and efficacy of the vaccines is clear and that a vaccine requirement provides us with a safer community for all who work, learn, and receive care here while allowing us to fully achieve our missions of clinical care, research, and education. The vaccine requirement was recently announced. Overall, the response to the announcement has been positive. As anticipated, some students, faculty and staff have raised a variety of concerns and fears that we are trying to address through town halls, individual conversations, and FAQs. Guided by the questions above and grounded in our mission, we stand by our decision. We will also do all we can to support those who are struggling with this decision through education, personal outreach, and reasonable access to religious and health exemptions.

#Year 2021

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