Spring Fertility, a clinic in Midtown Manhattan, looks like the place where the main characters on “Broad City” would have wound up if the millennial sitcom had done an episode about egg freezing. The waiting room has books by America’s youth poet laureate Amanda Gorman and its Instagram poet laureate Rupi Kaur. The kitchen is stocked with Spindrift. A conference room also serves as a venue for “shots nights,” less raucous than they sound, where patients inject themselves with fertility drugs communally, with encouragement from staff.Spring’s medical director in New York, Catha Fischer, dressed in a loose blouse and a low ponytail, beamed as she showed me the phlebotomy stations and operating room, where patients are anesthetized so that a doctor can puncture their ovaries with a needle and suck out eggs for freezing. The room, Dr. Fischer noted, “looks like a Grey’s Anatomy O.R.”There is always a market for products, from skin care to weight loss, promising to ease the angst of womanhood. Efforts to slow down the reproductive clock are no different. The business of egg extraction is thriving, among the privileged group of people who can access it.Across Spring’s clinics nationwide, the number of egg freezing cycles undertaken last year jumped 37 percent from the year before. That surge is visible at fertility clinics around the country, according to data from the Society for Assisted Reproductive Technology. The prototypical patient also seems to be getting younger, doctors say, a change coinciding with a steady uptick in corporate benefit packages that cover fertility preservation. In 2015 just 5 percent of large employers covered egg freezing; in 2023, nearly one in five did.At Spring Fertility in Midtown Manhattan, the fridge is stocked with Spindrift and some patients attend “shots nights,” where they inject themselves with hormones in a group.Sara Messinger for The New York TimesSome medical technologies spread slowly, but the embrace of fertility preservation has grown at a remarkable rate. In 2015 there were about 7,600 egg freezing cycles recorded nationwide, and by 2022, that number hit 29,803, a nearly 300 percent increase.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

In a letter to teaching hospitals, the federal health agency said that institutions could lose Medicare funding if they didn’t comply.The Department of Health and Human Services said on Monday that hospitals must obtain written informed consent from patients before they undergo sensitive examinations — like pelvis and prostate exams — especially if the patients will be under anesthesia.A New York Times investigation in 2020 found that hospitals, doctors and doctors in training sometimes conducted pelvic exams on women who were under anesthesia, even when those exams were not medically necessary and when the patient had not authorized them. Sometimes these exams were done only for the educational benefit of medical trainees.On Monday, the secretary of Health and Human Services, along with top officials from the department’s Centers for Medicare and Medicaid Services and Office for Civil Rights, sent a letter to the country’s teaching hospitals and medical schools denouncing the practice of doctors and students conducting the exams without explicit consent. “The Department is aware of media reports as well as medical and scientific literature highlighting instances where, as part of medical students’ courses of study and training, patients have been subjected to sensitive and intimate examinations,” the letter said. “It is critically important that hospitals set clear guidelines to ensure providers and trainees performing these examinations first obtain and document informed consent.”The department issued a set of guidelines clarifying a longstanding requirement that hospitals must obtain written informed consent as a condition for participating in Medicare and Medicaid programs.“Patients who are participating in future clinicians’ education should be aware, should have the opportunity to consent, should be given the same opportunity to participate in that education that they would be given if they were awake and fully clothed,” said Ashley Weitz, who underwent an unauthorized pelvic exam while she was under sedation in an emergency room. “We can only expect to have better trust in medicine when both patients and providers can expect a standard of care that prioritizes patient consent.”

To some, the pursuit of workplace happiness — and its price, like an $18,000 “happiness M.B.A.” for managers — can seem like a corporate attempt to turn feelings into productivity.Garry Ridge, who runs the chemical company WD-40, has a leadership style guided by two sources — Aristotle, and the BlackRock chief executive Larry Fink.“Pleasure in the job puts perfection in the work,” Mr. Ridge said first, quoting the Greek philosopher.Then he picked up a recent BlackRock memo. “Companies who forged strong bonds with their employees have seen lower levels of turnover and higher returns throughout the pandemic,” Mr. Ridge read aloud.This he punctuated with his own commentary: “Well, duh!”WD-40, which comes in a bright blue-and-yellow canister familiar to many homes with squeaky doors, is a cleaning product with a secret formula that can loosen a rusty bolt, scrub crayon off the wall, get bug splats off a car and remove rust from a bike chain. Mr. Ridge likes to remind the nearly 600 employees across his 17 offices about the usefulness of their work.But he also believes that some are buoyed by the company’s unorthodox culture. WD-40 has no managers, only coaches. Workers can receive “Mother Teresa” awards for giving their “time, talents and treasures” to the community. They might remind their colleagues during meetings to create “positive lasting memories” together.Long before the pandemic, many were skeptical of companies that advertised themselves as being in the business of keeping workers feeling happy. There were the tech companies whose college campus-style offices had ball pits and slides. There were the offices with lunch buffets and frozen rosé. There was the growing number of employers assessing staff happiness with surveys, often contracting consultants to cook up workplace fun.A gym at WD-40’s offices in San Diego. While the company’s chief executive quotes Aristotle, the gym wall favors James Brown.Ariana Drehsler for The New York TimesTo some people, the pursuit of workplace happiness — and its associated price tag, like an $18,000 program for managers on how to lead happy teams — can seem like a corporate alchemy that tries to turn feelings into productivity. It can feel like a push to smile and put aside demands that are less convenient for bosses, like remote work or higher pay.Those critiques have taken on new urgency as workers and employers clash over return-to-office plans, in what economists continue to characterize as a tight labor market. Some workers say they prefer flexibility, or raises adjusted to inflation, to corporate carrots like a Lizzo concert for Google employees and beer tastings at Microsoft.“It’s ‘I’m not going to help you solidify your schedule in advance in a way that will help you, but here’s a discount code,’” said Jessica Martinez, 46, a program officer at a global foundation that has long held Wine Wednesdays and is now distributing return-to-office gifts, like water bottles.The Return of Return-to-Office PlansAfter the Omicron variant crushed companies’ hopes for a return to in-person work late last year, a new R.T.O. chapter now appears to be opening.Conference Rooms:  These once-boring spaces are getting a reboot, with more democratic designs and cozier spaces.New Perks: Tech companies are hoping to lure their employees back to the office with concerts, food trucks and other offerings.The Right Mind-Set: Back at the office, the gossip, the loud talkers and the nosy colleagues are making a comeback. Here is how to deal with it.Work Wear: Retailers are scrambling to cater to the new demands of the hybrid workweek. Enter the “power casual” wardrobe.Inflation Woes: As prices continue to go up, the cost of an R.T.O. routine — travel, coffee, food — is adding to workers’ concerns.“People are trying to get everything back to ‘normal,’ but the truth is normal was terrible for some people,” she continued. “Why not just give people what they actually want?”At some workplaces, “happiness” can mean letting employees pick their own supervisors. It can mean getting rid of performance reviews. It also typically means measuring happiness levels — though not everyone agrees on what happiness even means. See the Dalai Lama, Dale Carnegie and Barbara Ehrenreich for starters.Behavioral economists and psychologists have, in recent years, shown employers that there’s a business case for their fixation on positivity. One study in the Journal of Labor Economics found that people who were given chocolates to eat and comedies to watch — common happiness generators — were 12 percent more productive than a group left alone. Another study in the Journal of Financial Economics showed that companies appearing in the list of the 100 best workplaces have higher shareholder returns than their peers.“There’s evidence that we get the causal arrow of happiness wrong,” said Laurie Santos, a cognitive scientist who teaches Yale’s popular course on happiness. “You think, ‘I’m feeling productive at work and things are going well at work and therefore I’m happy.’ But the evidence seems to suggest that the other arrow exists as well, that happiness can really affect your work performance.”Garry Ridge, right, who runs WD-40, with Jeff Lindeman from human resources, likes to remind employees about the usefulness of their work.Ariana Drehsler for The New York TimesThe notion that businesses should care about happiness arose with the increase of nonmanual jobs, said Alex Edmans, a finance professor at London Business School. As some work output became harder to measure — shifting to the quality and quantity of ideas, not the number of pins manufactured or tops screwed onto toothpaste tubes — managers determined they should ensure that their employees felt motivated. Compensation mattered, but so did the way people felt on the job.But many see a risk for workers in believing that their employers are cultivating an emotional relationship with them, when in reality the relationship is about money.“Your boss is not there to provide you with happiness,” said Sarah Jaffe, author of “Work Won’t Love You Back.” “No matter how much they say they’re focusing on happiness, they’re focusing on profits.”“Somebody is getting paid to bring in this new exciting culture of workplace happiness,” Ms. Jaffe added. “I would want to know how much my boss is spending.”Happy Ltd., a British consultancy, calls a program it runs for senior leaders its Happy M.B.A. The cost is roughly $18,000, and participants receive a certificate, not an actual degree, through the Institute of Leadership and Management. At a recent session, nonprofit and company managers traded tips that included letting employees pick their own supervisors.Woohoo, a Danish firm that helps create happiness staff surveys, and its software partner, Heartcount, typically charge companies roughly $4 per employee per month, on top of consulting fees that Woohoo’s founder, Alexander Kjerulf, declined to share because they vary widely.Woohoo and Heartcount consult with psychologists and statisticians to ensure that their assessments focus on people’s emotional, rather than logical, responses to their work. The weekly surveys, emailed out on Fridays, include questions like: Are you proud of the job you do? Have you been praised lately for the excellent work you have done? Woohoo then helps employers interpret the data.This quote on another WD-40 wall is from A.J. Downey’s novel “Cutter’s Hope.”Ariana Drehsler for The New York TimesWD-40 employees can receive “Mother Teresa” awards for giving their “time, talents and treasures” to the community.Ariana Drehsler for The New York TimesThis data, though, raises its own set of questions more slippery than those typically covered by an online survey. What does it even mean to be happy?Mr. Kjerulf defines it as the extent to which people experience positive emotions at work, or while thinking about work during their personal time. Leaders at WD-40 understand it to include a combination of meaningful work and a sense of belonging.Another workplace assessment firm, Culture Amp, which works with about 4,500 companies, doesn’t believe in measuring happiness at all, favoring instead metrics like engagement and well-being. Its leaders view happiness as something unstable that differs from person to person and is largely beyond employer control.“I admire the sentiment behind it, but the measurement is where it gets tricky,” said Myra Cannon, Culture Amp’s director of people science. “Happiness is fleeting.”One of the companies that Woohoo has supported is Vega, a software developer in Serbia. Vega publishes a monthly newsletter called Happiness Central, part of its intent to “over-communicate our achievements.” In twice-a-year “meme wars,” employees are rewarded for creating memes that “make fun of people at C-level positions” in the company. The chief executive sometimes surprises everyone walking through the door with fruit salad.“If people have better relationships with each other, especially within teams, we can expect better performance,” said the chief executive, Sasa Popovic, a Vega co-founder. “We can expect people to be more engaged, and then at the end our clients get a better service and are happier with our work.”But those office relationships don’t pay workers’ bills, a critique that has heightened as happiness becomes a fixture inside boardrooms.“In the early aughts, a lot of start-ups gave people terrible benefits and overworked their employees, and they tried to gloss over that by having snacks in the kitchen,” said Ms. Martinez, the foundation officer. But, she noted, the labor shortage is giving more workers leverage to say they won’t tolerate what they once did.“Vacancies are going unfilled because you treated people badly,” she said.The flexibility of working from home has made some workers more comfortable telling employers what actually makes them happy — the freedom to spend time with family, not free dinners at the office.A wellness room at WD-40.Ariana Drehsler for The New York TimesOutdoor space for eating or relaxing.Ariana Drehsler for The New York Times“Having cereal in the break room doesn’t make up for not being able to pick up your kids,” said Anna King, 60, a parent who works at an energy utilities company in Portland, Ore. “The real concerns are do your employees feel like they’re part of the team — not because they’re playing Ping-Pong together but because they’re accomplishing real goals and working decent hours?”As millions of workers make bold demands of their employers, especially around permanent flexibility, some say the focus on happiness is a distraction. “Mother Teresa” awards, after all, don’t improve worker conditions — and in fact can encourage workers to pour more hours into their corporate community at the expense of their personal lives.“I don’t think these things like meditation or whatever employers may be doing to increase well-being are bad initiatives,” said Heidi Shierholz, president of the Economic Policy Institute, a progressive think tank. “But they do not substitute for decent wages, decent benefits, sane scheduling.”

Virginia’s workplace safety board voted on Monday to withdraw the state’s emergency rules for protecting workers from Covid-19, leaving employers to follow looser guidelines to prevent the spread of the coronavirus in the workplace.Virginia, which has its own workplace safety agency, was the first state in the country to put in place emergency standards to protect workers from the virus. Under those standards, which were enacted in July 2020 under Governor Ralph Northam, a Democrat, employers had to require indoor masking in higher-risk areas, as well as report Covid outbreaks to the state’s Department of Health.The current governor, Glenn Youngkin, a Republican, instructed the state health board to re-evaluate the standards earlier this year, arguing that they presented a burden to businesses.“The Virginia Covid-19 permanent standard became out of step with current C.D.C. guidance as well as what a lot of other states were doing to address the current state of the pandemic,” said Nathaniel M. Glasser, a lawyer at Epstein Becker & Green, who specializes in Covid-19 and employment law, adding that nothing prevents employers from going above and beyond the state guidelines.The rules will be replaced by guidelines for employers recommending that they promote vaccination, encourage employees with symptoms to stay home and require those infected with coronavirus not to come to work.Governor Youngkin said in a statement that “it is undeniable that Virginia is open for business.” The president of the Virginia A.F.L.-C.I.O., Doris Crouse-Mays, said the state had “opted to abandon safety protections for working people” and that “the Covid-19 crisis is still a pandemic.”States with their own workplace safety agencies must have rules that are at least as effective as those set by the federal Occupational Safety and Health Administration. OSHA, under President Biden, tried to enact a sweeping rule requiring Covid vaccines or regular testing for some 84 million American workers. But the rule was withdrawn in January after being blocked by the Supreme Court, leaving workers and their employers across the country to confront a patchwork of state and local regulations.

Prescriptions for ivermectin have jumped to more than 88,000 per week, some pharmacists are reporting shortages and people are overdosing on forms of the drug meant for horses.For the past week, Dr. Gregory Yu, an emergency physician in San Antonio, has received the same daily requests from his patients, some vaccinated for Covid-19 and others unvaccinated: They ask him for ivermectin, a drug typically used to treat parasitic worms that has repeatedly failed in clinical trials to help people infected with the coronavirus.Dr. Yu has refused the ivermectin requests, he said, but he knows some of his colleagues have not. Prescriptions for ivermectin have seen a sharp rise in recent weeks, jumping to more than 88,000 per week in mid-August from a prepandemic baseline average of 3,600 per week, according to researchers from the Centers for Disease Control and Prevention.Some pharmacists are even reporting shortages of the drug. Travis Walthall, a pharmacist in Kuna, Idaho, a town of about 20,000 people, said that this summer alone he had filled more than 20 ivermectin prescriptions, up from two or three in a typical year. For the past week he has not been able to obtain the drug from his suppliers; they were all out.Mr. Walthall was astonished, he said, at how many people were willing to take an unapproved drug for Covid. “I’m like, gosh, this is horrible,” he said.While sometimes given to humans in small doses for head lice, scabies and other parasites, ivermectin is more commonly used in animals. Physicians are raising alarms about a growing number of people getting the drug from livestock supply centers, where it can come in highly concentrated paste or liquid forms.Calls to poison control centers about ivermectin exposures have risen dramatically, jumping fivefold over their baseline in July, according to C.D.C. researchers, who cited data from the American Association of Poison Control Centers. Mississippi’s health department said earlier this month that 70 percent of recent calls to the state poison control center had come from people who ingested ivermectin from livestock supply stores.Dr. Shawn Varney, a toxicologist and medical director for the South Texas Poison Center, said that in 2019 his center received 191 calls about exposure to ivermectin; so far this year the center has received 260 calls and is on pace to reach 390 by the end of the year. The vast majority of the recent calls came from people who took a veterinary product in an attempt to treat or prevent Covid-19.“Everyone wants some cure for Covid because it’s such a devastating illness,” Dr. Varney said. “I plead with people to stop using ivermectin and get the vaccine because it’s the best protection we have at this point. Everything else is risk after risk.”Dr. Varney said people calling the poison control center after taking ivermectin sometimes reported nausea, muscle pain and diarrhea. He noted that there have been ivermectin overdose deaths in the past, though he did not know of any specifically associated with Covid-19.The biggest risk, he added, comes from people taking the livestock product and ingesting a far higher dose than is appropriate for humans — sometimes 10 to 15 times the amount that a capsule approved for humans might contain.“People are going to animal feed stores and getting a formulation that’s highly concentrated because it’s for 1,000-pound animals,” Dr. Varney said. “They’re opening themselves to great potential harm.”Ivermectin was introduced as a veterinary drug in the late 1970s, and the discovery of its effectiveness in combating certain parasitic diseases in humans won the 2015 Nobel Prize for medicine.Though it has not been shown to be effective in treating Covid, people are now clamoring to get the drug, trading tips in Facebook groups and on Reddit. Some physicians have compared the phenomenon to last year’s surge of interest in hydroxychloroquine, though there are more clinical trials evaluating ivermectin.The Food and Drug Administration weighed in last week. “You are not a horse,” the agency tweeted, with a warning explaining that ivermectin is not F.D.A.-approved for treating or preventing Covid-19 and that taking large doses can cause serious harm.A recent review of 14 ivermectin studies, with more than 1,600 participants, concluded that none provided evidence of the drug’s ability to prevent Covid, improve patient conditions or reduce mortality. Another 31 studies are still underway to test the drug.“There is great interest in repurposing well-known inexpensive drugs such as ivermectin that are readily available as an oral tablet,” Maria-Inti Metzendorf and Stephanie Weibel, the authors of the review, said in an email to The Times. “Even if these circumstances seem ideal, the results from the available clinical studies carried out so far cannot confirm the widely advertised benefits.”One of the largest trials studying ivermectin for Covid-19 treatment, called the Together Trial, was halted by the data safety monitoring board on Aug. 6 because the drug had been shown to be no better than a placebo at preventing hospitalization or prolonged stay in the emergency room. Dr. Edward Mills, a professor at McMaster University who led the study, which enrolled more than 1,300 patients, said the team would have discontinued it earlier were it not for the level of public interest in ivermectin.“The data safety person said, ‘This is now futile and you’re offering no benefit to patients involved in the trial,’” Dr. Mills said.Another study of the drug found that ivermectin could be fairly benign unless taken at high doses. Dr. Eduardo López-Medina, a researcher at the Center for Pediatric Infectious Diseases in Colombia, led a randomized control trial for the study last spring on the effects of ivermectin and found that it had no statistically significant effect on reducing the duration of Covid symptoms. But he also found that there was no statistically significant increase in adverse events for the patients receiving ivermectin, though they were taking a fairly high dose of 300 micrograms per kilogram.“It appears to be a safe medication, but that is not enough to prescribe it openly,” Dr. López-Medina said. “People should use it in trials but not necessarily to treat patients. The data is not robust enough to support its use.”Researchers and physicians are particularly alarmed by people seeking out ivermectin as a form of possible prevention or treatment instead of getting one of the highly effective Covid vaccines. The F.D.A. fully approved the Pfizer-BioNTech Covid vaccine for people 16 and older last week, and an approval of Moderna’s vaccine is expected in the coming weeks.“The only functional strategy we have for getting control of Covid-19 is vaccination,” said Dr. Irwin Redlener, a physician in New York and founding director of the National Center for Disaster Preparedness at Columbia University. “If people are not getting vaccinated because of nonsense they’re reading on the internet, that interferes with our ability to get this pandemic under control.”

Vaccination remains the best defense, health experts say. But some infections occur regardless, and can come as a traumatic surprise.For Moira Smith and her mother, July promised a glimmer of normalcy after months of isolation. The two flew from Alaska to Houston and visited family, celebrating the first birthday of their cousin’s granddaughter. Ms. Smith’s mother bought a patterned pink onesie to give as a gift, and they all snapped photos of the baby’s face smeared with chocolate.Ms. Smith, 46, knew that her cousin’s family was not vaccinated but tried not to dwell on that. She and her mother had both received their Pfizer shots months earlier. In the hotel room one evening, Ms. Smith’s mother made an offhand comment to her relatives: “You can take your masks off but you have to promise to get vaccinated,” she chided them.The next morning Ms. Smith and her mother were headed home, on a layover in the Seattle airport, when they got the phone call: Their relative’s baby had come down with a fever and tested positive for Covid-19.Two days later, Ms. Smith woke up feeling like she had been “hit by a Mack truck,” with body aches and a sore throat, and tested positive for the coronavirus. The next week, her mother, who is 76 and has lung cancer, texted her an emoji of a thermometer indicating she, too, had spiked a fever, and she later wound up in the emergency room with Covid.Ms. Smith and her mother are part of a wave of Americans falling sick with Covid even though they are fully immunized, in what are known as breakthrough infections.Public health experts continue to believe that breakthrough infections are relatively uncommon, and rarely result in severe illness or hospitalizations. The vaccines available in the United States offer powerful protection from serious Covid illness, hospitalization and death. A recent analysis of state-reported data from the Kaiser Family Foundation found that more than nine in 10 Covid-19 cases that resulted in hospitalization and death occurred among people who were not fully vaccinated.“We always anticipated that there would be some breakthrough infections because the vaccines at their very best were 95 percent effective,” said Dr. William Schaffner, professor of infectious disease at Vanderbilt. “The vaccines were designed to prevent severe illness, and they’re spectacularly successful at that.”But as the more transmissible Delta variant becomes dominant in the United States, rising numbers of breakthrough cases are being reported, although most are mild.“Delta is vastly more contagious, so as it is spreading among the unvaccinated there is spillover into the vaccinated population,” Dr. Schaffner said. “The unvaccinated are a big highway of transmission. The vaccinated are a little side street.”Elaina Cary-Fehr’s father Isaac was transferred to long-term care facility after being hospitalized with Covid in June.“I hate that this had to happen to my family,” she said.Cindy Elizabeth for The New York TimesBecause people infected with the Delta variant have far more of the virus in their nose and upper respiratory tract, the importance of mask-wearing has become paramount. After the Centers for Disease Control and Prevention shifted its guidance on masking, recommending that vaccinated people in hot-spot areas resume wearing masks in public indoor spaces, millions of Americans who are fully immunized struggled to adjust their expectations for autumn months that had seemed to offer some semblance of festivity. And a small subset of Americans has already seen their routines upended by breakthrough infections.Spurred by concerns about breakthrough infections, federal health officials recently recommended that Americans who received the Pfizer or Moderna vaccines receive a third dose in the coming months. This week Johnson & Johnson reported that a booster shot of its vaccine raised levels of antibodies against the coronavirus.For some, breakthrough infections have felt like mild allergies, coming with symptoms including a cough, sniffles and a scratchy throat. Others have had more severe cases, where they are bedridden with body aches, fevers and chills. And still others have had some of the telltale signs of Covid such as loss of taste and smell, “Covid rash” and brain fog.“We were calling it floaty-head syndrome,” said Molly O’Brien-Foelsch, 47, a marketing executive in Pennsylvania who tested positive for Covid after a trip to the British Virgin Islands with her husband last month. “It felt like there was a huge marshmallow on my head.”Scientists believe that breakthrough infections rarely result in severe illness, but there have been cases of prolonged hospitalizations. Elaina Cary-Fehr’s father Isaac, a 64-year-old Uber driver in Austin, was transferred to a long-term care facility after being hospitalized with Covid pneumonia in June and later receiving a tracheotomy tube. He was released from the facility this week.“I believe in the vaccine, I kept holding on to hope that it would work and it did,” Ms. Cary-Fehr said. “But I hate that this had to happen to my family.”Dr. Rebecca Hughes, 32, works as an emergency medicine resident in Boston, so she had spent the last year with a simmering sense of anxiety about Covid exposure. She can still recall the fear she felt the first time she treated a coding Covid patient and wondered for hours whether her mask might have slipped and put her at risk. But all year she was kept safe by her protective equipment.Then, last month, her family took a vacation to visit her grandparents in Utah. It was a trip they had hoped to take last February but postponed as Covid case rates rose. Four days after they landed, Dr. Hughes felt her throat becoming scratchy. She was certain it was allergies but took a Covid test just in case; it came back positive. Shortly afterward her newborn, who was 9 weeks old, started sneezing and tested positive too, along with Dr. Hughes’s three other children, ages 8, 6 and 3.Jimmy Yoder, right, and his partner, Kyle Smith, felt ill after a weekend in Provincetown last month. “In the back of my mind I was like, ‘There is no way I’m going to get Covid,’ “ Mr. Yoder said.Gabriela Bhaskar/The New York Times“It felt ironic after I spent so long caring for Covid positive patients on every single shift since the pandemic started,” Dr. Hughes said. “My 8-year-old knows I’ve been seeing people die from this. She looked at me and said, ‘Am I going to be OK?’”Although some breakthrough infections like Dr. Hughes’s are difficult to trace to a precise exposure event, other Americans have found their vacation plans intersecting with well-known outbreaks..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}Jimmy Yoder, 25, felt no trepidation as he and his boyfriend, both vaccinated, packed their bags to spend a weekend in Provincetown in July. And because their days and nights there were a blur of clubs and dancing, he assumed that the Monday morning fatigue that greeted him back in Brooklyn was just a bad hangover.“I was feeling a little rundown but attributed it to a weekend of partying,” Mr. Yoder said. “In the back of my mind I was like, ‘There is no way I’m going to get Covid, I’m immune.’ ”By Wednesday morning, Mr. Yoder no longer felt so confident. “I felt like I had a really bad flu,” he said, with a high fever and congested sinuses. He and his boyfriend both tested positive that day. Mr. Yoder slept for the next 18 hours, and when he and his boyfriend were both starting to feel better they ordered a celebratory pizza. They realized then that they had both lost their sense of taste and smell.Mr. Yoder was relieved to find that of all the people he had exposed — friends who had driven him home from Provincetown, an office full of colleagues — only one tested positive. “Obviously it shows the vaccines are still working a lot,” he added.As many Americans begin the familiar exercise of questioning and calling off plans, scientists are stressing the continued importance of mask-wearing to reduce transmission and infection.“If you get infected and breathe virus out, it will get trapped by your mask,” said Dr. John Moore, a professor of microbiology and immunology at Weill Cornell. “These viruses don’t have pairs of scissors that can cut through masks.”

The institutions are expensive, often operated for profit and eager to accept applicants. But graduates have trouble landing residencies and jobs.Last summer, when Dr. Sneha Sheth went online to begin filling out applications for residency — the next stage of her training after medical school — she was hit with a jolt of disappointment.Of the 500 residency programs she was considering, nearly half had been labeled unfriendly to international medical students, like her, by the website Match a Resident, which helps medical students abroad navigate the U.S. residency application process. Dr. Sheth submitted her applications in September and spent months on edge. Then came the distress of rejections from numerous programs, and no responses from others.“There are 50 percent of programs that don’t want you, which is a scary feeling,” said Dr. Sheth, 28, who graduated recently from a Caribbean medical school. “It’s like, if they don’t want you, who will?”The frustrations of the match process, which assigns graduates to programs where they can begin practicing medicine, made Dr. Sheth question whether she had been foolish to enroll in a Caribbean medical school. She had spent tens of thousands of dollars but ended up shut out of American residency programs (although she recently landed a spot in a Canadian one).In the 1970s, a wave of medical schools began to open across the Caribbean, catering largely to American students who had not been accepted to U.S. medical schools; today there are roughly 80 of them. Unlike their U.S. counterparts, the schools are predominantly for-profit institutions, their excess revenue from tuition and fees going to investors.Admissions standards at Caribbean schools tend to be more lax than at schools in the United States. Many do not consider scores on the standardized Medical College Admission Test as a factor in admissions. Acceptance rates at some are 10 times as high as those at American schools. They also do not guarantee as clear a career path. The residency match rate for international medical graduates is about 60 percent, compared with over 94 percent for U.S. graduates.In 2019, Tania Jenkins, a medical sociologist, studied the composition of U.S. residency programs and found that at more than a third of the country’s biggest university-affiliated internal medicine programs, the residency population was made up overwhelmingly of U.S. medical graduates. Caribbean medical school students match into residencies at a rate 30 percentage points lower than their U.S. counterparts.“U.S. medical school graduates enjoy tailwinds,” Ms. Jenkins said. “Caribbean medical students experience headwinds. They have a number of obstacles they have to overcome in order to be given a chance at lower-prestige and lower-quality training institutions.”The campus of St. George’s University Medical College in Grenada.AlamyThe challenges that Caribbean medical students face in career advancement have raised questions about the quality of their education. But with the rapid rise in the number of medical schools worldwide — from around 1,700 in the year 2000 to roughly 3,500 today — tracking and reporting on the quality of medical schools abroad has proved a difficult task.In recent years, medical educators and accreditors have made a more concerted effort to evaluate the credibility of those institutions, with the goal of keeping applicants informed about subpar Caribbean schools, which charge tens of thousands of dollars in tuition and fees and sometimes fail to position their students for career success.That effort has largely been led by the Educational Commission for Foreign Medical Graduates, which reviews and provides credentials for graduates of foreign medical schools, including documentation of their exam scores and their academic histories. In 2010, the commission announced an initiative requiring every physician applying for certification to have graduated from an accredited medical school. The group also said it would more closely scrutinize the standards for organizations that accredit medical schools around the world. The new rule will take effect by 2024.The commission has already penalized two Caribbean medical schools — the University of Science, Arts & Technology Faculty of Medicine in Montserrat and the Atlantic University School of Medicine in Antigua and Barbuda. The group refused to grant credentials to any of those schools’ graduates, saying it had found the schools to be “egregious in terms of how they treated students and misrepresented themselves.” The medical school in Montserrat subsequently sued the commission, but the case was dismissed in a U.S. federal court. The University of Science, Arts & Technology Faculty of Medicine in Montserrat did not respond to requests for comment.“I’m very concerned about students’ being taken advantage of by schools that may not give them proper information as to how they’re going to learn and what their opportunities are going to be when they finish school,” said Dr. William Pinsky, head of the commission.He said he hoped that students would be better protected by 2024, when accrediting organizations plan to complete evaluations of all international medical schools through a more rigorous accreditation process.One of the primary accrediting bodies for Caribbean medical schools is the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions, known as CAAM-HP. Lorna Parkins, executive director of the organization, said that some of the key factors the group considers in denying accreditation include high attrition rates and low exam pass rates.Dr. Eltiganivia Yasien EltiganiBut Caribbean schools occasionally misrepresent their accreditation status on their websites, Ms. Parkins added. She sometimes hears from students who are struggling to transfer out of lower-quality schools.“It’s my daily concern,” Ms. Parkins said. “I know students have very high loans, and their families make great sacrifices to educate them.”Applying to medical school in the United States requires a certain level of know-how: how to study for the MCAT; how to apply for loans; and how to make yourself competitive for a select number of spots. Applicants with less access to resources and mentoring are at a disadvantage and are sometimes less aware of the drawbacks of international medical education.Dr. Yasien Eltigani, 27, who is Sudanese and immigrated from the United Arab Emirates to the United States, said he had little assistance in navigating the obstacle course of medical school applications. He applied to only nine schools, all in Texas, not realizing that most U.S. students apply more widely, and was rejected from all of them. Two years later, when he saw a Facebook advertisement for St. George’s University in Grenada, he decided to apply.Looking back, he says he wished he had reapplied to American schools instead of going the Caribbean route. Although he was able to match into a residency program, which he recently started, he found the process to be anxiety-inducing.“If you fall behind in a U.S. medical school, your chances of matching are decent, whereas in a Caribbean medical school you’re at risk,” he said. “As an immigrant, I didn’t have much in the way of guidance.”Caribbean medical school administrators say their intentions are straightforward: They aim to expand opportunities for students to go to medical school, especially those from racially, socioeconomically and geographically diverse backgrounds, to include people who might not have traditionally pursued careers in medicine.“U.S. medical schools have more applicants than they know what to do with,” said Neil Simon, president of the American University of Antigua College of Medicine. “So why do they object to medical schools that have obtained approval and are educating a student population that is much more diverse? Wouldn’t you think they’d welcome us with open arms?”Mr. Simon said that he was aware of the bias that A.U.A.’s graduates confront as they apply for residency positions in the United States and that he saw the stigma as unfounded. He added that international medical graduates were more likely to pursue family medicine and to work in underserved areas, especially rural communities.Students from the Ross University School of Medicine were evacuated from Dominica after Hurricane Maria in 2017.U.S. Air Force photo, via AlamyBut experts say that the proliferation of for-profit medical schools does not always serve the best interests of students. The Liaison Committee on Medical Education, which credentials U.S. schools, did not recognize any for-profit schools until 2013, when it changed its stance following an antitrust ruling mandating that the American Bar Association accredit for-profit law schools. Among medical educators, substantial skepticism still exists toward the for-profit model.“If medical students are viewed as dollar signs rather than trainees that require lots of investment, support and guidance, that fundamentally changes the training experience of these students and the way their education pans out,” Ms. Jenkins said.Some students at Caribbean medical schools said the quality of their education had declined even further in recent years as some campuses faced natural disasters.In 2017 when Hurricane Maria hit Dominica, where Ross University School of Medicine’s campus was situated, the school decided to offer its students accommodations on a ship docked near St. Kitts. To some of the students, this sounded like an adventure. But as soon as they arrived on the boat, they realized that it did not lend itself to rigorous study.With few study spots or electric outlets available on the ship, Kayla, a first-year-student, awoke each day at 2 a.m. to claim a place where she could study for the day. (Kayla asked to be identified by just her first name so that she could freely share her experience.) Her exams were held in a room filled with windows that looked out over the ocean waves. She and her classmates said that if they looked up from their tests, they had immediately felt nauseated. She couldn’t take Dramamine, she said, because that exacerbated her fatigue. Some of her classmates left before the semester ended because they could not handle study conditions on the ship.“We understand that extenuating circumstances posed challenges for all,” a spokesman for Adtalem Global Education, the parent organization of Ross University School of Medicine, said in an email. “We took extraordinary measures to provide options for students to continue their studies or to take a leave of absence until campus facilities could be restored.”But the combined challenges of these schools have given way to a saying: “It’s extremely easy to get into Caribbean schools,” said Abiola Ogunbi, a recent graduate of Trinity Medical Sciences University in Saint Vincent. “But it’s tough to get out.”As accreditation standards evolve, Ms. Jenkins said one of the most critical ways to protect students was to ensure transparency from the schools. “People should go into their training with their eyes wide open,” she said.

Medical schools and students alike have had to adapt to remote cadaver dissections and bedside-manner training via Zoom.Jerrel Catlett’s eyes narrowed on the large intestine, a gloppy, glow stick-like object whose color matched the stool stored inside of it. He chose to isolate the organ, and it expanded on his screen as the body parts surrounding it receded — the gall bladder bright green with bile, the ribs white and curved like half moons.“My old boss used to tell me that when I did this, I’d be so wowed by how complex the human body is,” said Mr. Catlett, 25, a first-year student at Icahn School of Medicine at Mount Sinai, gesturing to the image of a body on his laptop screen. “But it feels like there’s something missing from the experience right now.”For generations, medical students were initiated to their training by a ritual as gory as it was awe-inducing: the cadaver dissection. Since at least the 14th century, physicians have honed their understanding of human anatomy by examining dead bodies. But amid the coronavirus pandemic, the cadaver dissection — like many hands-on aspects of the medical curriculum — turned virtual, using a three-dimensional simulation software.Of the country’s 155 medical schools, a majority transitioned at least part of their first and second-year curriculums to remote learning during the pandemic. Nearly three-quarters offered lectures virtually, according to a survey by the Association of American Medical Colleges, and 40 percent used virtual platforms to teach students how to interview patients about their symptoms and take their medical histories. Though the cadaver dissection posed a trickier challenge, nearly 30 percent of medical schools, including Mount Sinai, used online platforms to teach anatomy.Though medical students in many states have been eligible for and able to receive the vaccines, some have not yet fully shifted back to in-person learning, with school administrators saying they preferred to wait until Covid case rates decline further. Some in-person training, like practicing clinical skills, has largely resumed.Medical schools adapted in the past year with inventive approaches to clinical training. Case Western Reserve University School of Medicine and Stanford used virtual reality technology to teach anatomy. The Vagelos College of Physicians and Surgeons at Columbia University offered students the opportunity to shadow doctors virtually, sitting in on tele-medicine appointments. And at Baylor College of Medicine last fall, students were assessed via video on giving physical exams by describing what actions they would be taking in person, according to Dr. Nadia Ismail, Baylor’s associate dean of curriculum: “Now I would hit you at this part of the knee and this is the reflex I would see.”The Keck School of Medicine, at the University of Southern California, opted to have faculty members dissect cadavers while wearing body cameras so students could watch remotely. The cadavers were also imaged using three-dimensional scanners, so students could practice manipulating the sorts of images produced by magnetic resonance imaging and CT scans.“When the faculty came up with this, I was like, ‘Oh my goodness, this is amazing,’” said Dr. Donna Elliott, vice dean for medical education at Keck. “These scanned, three-dimensional images approximate the type of imaging you’ll use as a clinician.”Educators are aware that for all the promise of new technologies, there’s a sense of loss for students who aren’t able to be in hospitals, classrooms and dissection laboratories in person. “The classroom of the medical school is the clinical environment, and it’s so stretched right now,” said Lisa Howley, senior director for strategic initiatives and partnerships at the A.A.M.C. “That worries me.”Students said they felt some frustration as they watched the pressures mount on frontline providers without any capacity to help. “We know more than the average person, but we feel generally powerless,” said Saundra Albers, 28, a second-year student at Columbia.Both faculty members and students realize that watching organs move on a laptop screen is not the same as removing them, one by one, from a human body. “A cadaver’s body parts wouldn’t look as smooth and perfect as they do on a screen,” Mr. Catlett said. “Let’s say the cadaver was an alcoholic, you might see liver cirrhosis with bumps and ridges covering the liver.”He and his classmates know that they missed a medical rite of passage: “We don’t get to feel what the tissues are like, or how hard the bones are.”Mr. Catlett and his classmates have now been offered vaccines, and they are beginning to resume some in-person activities, including meeting with patients for the first time this month. Their lectures are still online.Sarah Calove, 26, near her home in Castaic, Calif. late last year.Jenna Schoenefeld for The New York TimesSarah Serrano Calove, 26, is a second-year student at the University of Massachusetts Medical School, which offered a blend of in-person and virtual learning last semester. Since the start of medical school, Ms. Calove had been eager to practice interacting with patients — taking their medical histories and delivering news of diagnoses — so the transition to learning clinical skills on Zoom was a letdown.She was assigned to interview a medical actor, referred to as a standardized patient, about his financial troubles, an emotional conversation that she found awkward to conduct virtually.“When you’re on Zoom, you can’t tell if the person is clenching their hands or shaking their legs,” she said. “For some of my classmates, the feedback was we had to show more empathy. But how am I supposed to make my empathy known through a computer screen?”Medical schools were often unable to arrange for students to practice their skills on medical actors last semester, because these actors tend to come from older, retired populations that are at heightened risk for Covid-19. Some schools, including the University of Massachusetts, had students conduct practice physical exams on their classmates, forgoing the parts of the exam that involve opening the mouth and looking into the nose.For Ms. Calove, being assessed on her physical exam skills was challenging because she could prepare only by watching videos, whereas any other year she would have had weeks of in-person practice.“Normally, you’d listen to lungs wheezing, feel an enlarged liver, find the edges of the abdominal aorta,” she said. “Listening to a heart murmur recording online is different than hearing it in person.”Still, she appreciated the school’s efforts to check in with her and her classmates about how they were faring as they adapted to partially remote learning.Some students pointed to a silver lining in their virtual medical training: They’ve become adept at speaking with patients about sensitive issues over video, a lesson very likely to prove essential as the field of tele-medicine expands. Through remote clerkships at schools like Sidney Kimmel Medical College at Thomas Jefferson University, medical students assisted hospital staff by following up virtually with patients who had been discharged earlier than usual because of the pandemic.“Other doctors got thrown into the deep end but we get to practice using this technology,” said Ernesto Rojas, a second-year student at University of California San Francisco School of Medicine. “We learned how to build rapport and ask the patient things like, ‘Are you in a place where you can talk privately?’”Students have also said they’ve felt particularly motivated to complete their training amid the pandemic. Medical school applications are up by 18 percent compared with this time last year, according to the A.A.M.C.For Prerana Katiyar, 22, a first-year medical student at Columbia, the first few months of medical school didn’t look anything like she had anticipated. She started the semester living in her childhood home in Fairfax, Va., where she shared lessons from her anatomy classes with her family over dinner. “When my dad said his abdomen hurt, I was able to talk to him about the quadrants of the abdomen,” Ms. Katiyar said.Halfway into the semester, she had an exciting update for her parents. “My skull finally arrived in the mail,” she said. Ms. Katiyar’s anatomy professor arranged for each student to order a plastic model of the skull.“Now I can see the bony landmarks and where the nerves are,” she continued. “I’m a very visual person so it’s been helpful to trace it with my finger.”