4:00 p.m. Right on time.

I am walking down the street with my brother on his first visit to me in residency; I’m only two weeks in.

I turn to him: “Wait a second.”

I place my hand on the cement wall next to us, and I start to heave.

“Um … are you OK?”

“Yeah. No worries. My body’s just adjusting.”

I go on to describe how every day at 4 p.m. after a 24-hour shift, I have a little dry heaving episode. So far no emesis. So far.

My brother is absolutely horrified.

Intern year is universally hard.

As interns, we share experiences of days when we get to the hospital before the sun rises and do not have anything to eat after our 4:30 a.m. breakfast until signout is over at 6:30 p.m. If you are lucky, you catch a few minutes during the day to grab your sustenance of crackers and peanut butter from the nutrition closet. If you are really lucky, you are on a pediatric ward, and your diet expands to Goldfish and the occasional bag of animal crackers. Some days, you get home, and you have waited so long to eat that you are past the point of being hungry. Then, of course, for a 24-hour call, your body is so confused about day and night that you are simultaneously exhausted and cannot sleep when you lie down because your mind is racing with the thoughts of the day: Did I remember to replete all my patients? Did I order all the correct labs for tomorrow? Did I toss the extra lists and stickers into the HIPAA bins? And don’t forget, you still have to read and practice your hand skills.

I remember back to my first medical school course: “Introduction to the Profession.” We read When the Spirit Catches You and You Fall Down; we wrote letters to ourselves to open after four years of medical school; we had small group discussions about what we thought it meant to be a doctor; mostly, we got to know our classmates and basked in the warmth of professors’ words about the noble profession we were joining. Perhaps if they had been honest about all the aspects of becoming a doctor, we would have reconsidered.

Now, sometimes, the patients ask me if I even go home.

The “internship” was only made readily available to all American medical graduates in the 1930s after a growing desire on the part of many for more training after medical school. Later, this developed into formalized residency programs centered in hospitals or homes that were converted to hospitals (hence the term “house staff”). William Osler, one of the founding fathers of modern medicine, was clear about how a good resident should live:

What about the wife and babies, if you have them? Leave them. Heavy as are your responsibilities to those nearest and dearest, they are outweighed by the responsibilities to yourself, to the profession, and to the public … Your wife will be glad to bear her share in the sacrifice you make.

Given all of these sacrifices, those attached to the resident must make, he added sagely: “Marry the right woman!”

The most recent major change to residency has been the increasing interest in burnout and residency culture which began with an attempt at limiting resident work hours. Some physicians bemoan this as detrimental to resident learning while others are applauding these and other efforts as important to physician well-being and patient safety. Study after study is being done, questioning whether fewer hours is helping or harming physicians and patients. I was told by senior residents on my first day of residency this summer that I was lucky I got to have back 24-hour call as an intern. Now, over a decade after the duty hour restrictions, our profession is questioning whether our question about duty hours is the even the right one to ask.

The ACGME this year renamed the Section on “Duty Hours” to “The Learning and Working Environment” and issued a “Statement on Commitment to Clinician Well-Being and Resilience,” which included a definition of excellence in professionalism as “the effacement of self-interest in a humanistic environment that supports the professional development of physicians (and) the joy of curiosity, problem-solving, intellectual rigor, and discovery.” I am not one with enough experience yet to weigh in on these matters, but of two things I am sure:

Intern year is still universally hard.

Intern year is also universally great. For example:

When your senior comes to find you in the workroom after your patient passes away to check in on you.

When you complete a case on your own in the O.R.

When you do a physical exam on a baby, and he starts to giggle.

When you get a call from a nurse because your patient wants to hug you before she leaves.

When a family waiting for their loved one to pass smiles and tells you how much they appreciate that you are there.

And I am no longer dry heaving at 4:00 p.m. post call.

Grace Faith Chao is a surgery resident.

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