Normally, Matt Troup’s job as chief executive and president of a hospital group is to make sure all his care centers are functioning optimally, day to day and year to year. But ever since Conway Regional Health System instituted a coronavirus vaccination mandate for its employees, he’s been devoting a chunk of his workday to something new: figuring out who the holdouts are and enduring torrents of backlash.

The vast majority of the Conway, Ark., hospital group’s 1,800 employees were voluntarily vaccinated earlier this year. But Troup also got 45 requests for religious exemptions and had to disentangle the genuine conscientious objectors from those looking for a proverbial fig leaf.

“It has been ugly, ugly, ugly,” Troup says. “I’ve been compared to Hitler, been called a moron.”

Now that the FDA has fully approved the Pfizer coronavirus shot, vaccination has swiftly become a requirement for companies, universities and even the military. Meanwhile, just over 1 in 10 Americans “definitely” does not plan to get vaccinated, according to a Kaiser Family Foundation poll conducted in September. The clashes are inevitable: When faced with the choice between getting vaccinated and giving up their jobs or enrollments, many Americans have sought loopholes or ways to claim exemptions they don’t in good faith qualify for. People such as Troup have wound up with the unenviable job of stopping them — which can be awkward and logistically nightmarish, and it can get confrontational fast.

Almost all of Troup’s applicants for religious exemptions objected to taking a vaccine developed using fetal cell lines (whose origins can be traced back to cells from electively aborted fetuses several decades ago). So Troup and his team devised a strategy: Those employees would have to sign an agreement not to take any other medical treatments developed using fetal cell lines. Among the 28 medications on the list: Tylenol. Motrin. Preparation H. Claritin. Benadryl. Tums.

He hoped that would force the exemption-seekers to confront just how selectively they’d applied their argument. A few applicants signed the form, no questions asked. Others, of course, pushed back.

Troup has had conversations with people seeking the exemption. Some have sighed and eventually rolled up their sleeves; others have drawn a distinction between fetal cell lines being used in development of a medication versus being used in testing.

Mostly, though, he finds that what’s being described as a sincerely held religious objection is actually a sincerely held fear of the vaccines. He says that one applicant “told me, ‘Matt, if I sign this, you’re asking me to lie.’ ”

“I very gently and politely asked, ‘Well, you know, tell me: What medicines on that list … do you think were not developed with fetal cells or tested on fetal cells?’ ” Troup recalls. “The response was this diatribe about how evil the vaccine was, how much harm it causes, how data and reports are being covered up. Which told me that it really wasn’t about fetal cells at all. It’s all about a vaccine hesitancy.”

“I have learned to be careful. I’ve learned compassion throughout this exercise, maybe in a bigger way than I ever have,” Troup adds. “We have to give people some space and we have to respect people’s concern, because this individual, they were really afraid.”

Indeed, there are limits to how much the vaccination loophole police can do without creating a hostile environment or flirting with discrimination. Ann, for example — a human resources manager for a small restaurant group in California, who spoke on the condition of anonymity to avoid unwanted attention for her company — harbors a few doubts about the sincerity of one employee’s request for a religious exemption. But “part of the role is to make sure that people with divergent backgrounds and beliefs all have space,” Ann says. The employee received a “temporary exemption” and agreed to get tested weekly.

Mark Owczarski is the associate vice president for university relations at Virginia Tech, where 134 students were recently “disenrolled” for not complying with a vaccination mandate. In an interview, however, Owczarski clarified that although about 96 percent of students are vaccinated, Virginia Tech gave religious or medical exemptions to every student who asked for one on the condition that they would agree to be tested weekly.

“Do we then ask people to go through that process [of submitting their vaccination documentation or their exemption request] and then elect to question whether they really mean it, or whether their card is real, or whether they really have a doctor who signed that, or whether that doctor is, you know, their next-door neighbor?”

They do not — because the university’s priority is curbing the spread of covid-19, Owczarski says, not “ferreting out scammers.” By the university’s logic, making students feel that they can safely admit to being unvaccinated and opt for weekly testing serves that end better than creating an environment that makes them feel pressured to, say, upload fake vaccination cards. (Virginia Tech also recently began requiring indoor mask-wearing for everyone.)

Arguments that mask mandates violate an individual’s constitutional right to liberty might not cut it with the Supreme Court. Here's why. (Drea Cornejo/The Washington Post)

Indeed, whether to get a coronavirus vaccination can often be a question of identity. “For some people, vaccinating means sort of giving up their credentials as a good conservative and all of their conservative friends and family members. We tend to live in social networks that have this ‘birds of a feather flock together’ feature,” says Gretchen Chapman, a professor of social and decision sciences at Carnegie Mellon. In an employment context, “depending on how much you love your job and depend on your job, you might think that fitting in with your social group is more important.”

Loophole-hunting, of course, has become endemic to institutions that mandate vaccination — and naturally, authorities have caught on. In the U.S. Army, for example, applicants for religious exemptions to its Dec. 15 vaccination deadline will have to talk to a licensed health care provider and sit for an interview with a chaplain, who must then, according to a paper drafted by the Army’s health-care operations directorate and obtained by the Army Times, “provide a memorandum that summarizes this interview and addresses the religious basis and sincerity of the Soldier’s request.” Other authorities have avoided playing whack-a-mole with individual cases by going straight to the source: In Connecticut, health authorities suspended the license of a retired doctor who was mailing out signed forms that alleged an allergy to ingredients in the vaccines to virtually anyone who wanted one.

Every week, San Diego attorney Dolan Williams gets at least one phone call from a complete stranger who sounds angry or even desperate. Williams isn’t sure how they get his number — most likely they’re frantically Googling attorneys and calling the first one with a prominently listed phone number, he says — but they all call with the same question. If my employer says I have to get the coronavirus vaccine to keep my job, do I really have to do it?

The calls often come on Friday afternoons, after employers have sent out companywide memos about vaccination requirements. Nurses frequently ask how they can circumvent hospital-system mandates. Workers from tech and communication companies ask whether being Catholic or Christian is enough to qualify for a religious exemption. One man kept him on the phone for 45 minutes to tell him in detail about a new church he had started with his mother — then sent a two-page doctrine that outlined why it was against coronavirus vaccination.

Williams, whose wife has lost multiple relatives to covid-19, did his best to stay professional. “I just said, like, ‘All you can do is present this to your employer. They’re probably going to tell you that they still can’t accommodate you.’”

“I was impressed,” Williams adds with a laugh. “Saddened, but impressed.”

Many of his cold-callers, he adds, are people who have dug their heels in after their concerns have been dismissed one too many times. So Williams makes a point to listen politely while they express their fears. “I at least try to just give them the respect of talking to them,” Williams says. “That’s a lot of times what I realize that they’re missing: people just respecting their opinion.”

Ultimately, the calls give him hope about the effectiveness of vaccination mandates. Once he’s broken the news that an employer can in fact deny employment to a person who’s unvaccinated, he says, most of them head into the weekend sounding as if they understand they have a big decision to make. “I haven’t heard anybody call me back and say, ‘Yeah, I got out of it.’ Or ‘I decided to quit,’ ” he says. “I’m pretty sure what’s happening is they’re keeping their jobs and getting the vaccine.”