An excerpt from First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement.

Residency requirements have changed drastically since my father completed medical school in the 1970s. Residents needed to be fully focused and alert despite working forty-eight- or seventy-two-hour days, which led some to substance misuse. Some residents took stimulants to help perk themselves up and alcohol to bring them back down when they had the chance to sleep. The residents that turned to alcohol and drugs did so because of the stigma associated with being viewed as “weak.” Given the years that these residents spent completing undergraduate and medical school, they were under immense pressure to avoid “washing out” because they “couldn’t keep up” or showed signs of physical or mental distress. Self-medicating became a way to endure the long hours and relentless stress of their job.

No, not every resident of my father’s era used stimulants or alcohol to get through grueling times. I don’t think my father did during residency (according to my mom), but he did later in life. Eventually, he relied on alcohol to “stabilize” his moods. He kept this drinking hidden from his patients and employers as best as he could. But he also tried to conceal his drinking from his wife (my mother). She came from a conservative Christian background with an alcoholic father, and he didn’t want to disappoint her by letting her know of his dependance on alcohol.

A physician’s sources of pressure: sleep deprivation and long hours

All jobs have a certain element of stress and pressure, but medical professionals have some unique to their profession.

Roles where an employee must stay focused and mentally alert as a matter of life and death usually come with safeguards such as these examples from another profession (U.S. Dept. of Transportation 2022). These employees:

• Can work a maximum of eleven hours only after having ten consecutive hours off.
• Are required to take a thirty-minute break after eight consecutive hours at work.
• Can work no more than seventy hours each week, after which they need at least thirty-four hours off before starting the next workweek.
• Are required to “sleep” (or not work) for ten hours each twenty-four-hour period.

Sadly, these rules don’t apply to medical professionals. They apply to truck drivers. A tired truck driver runs the risk of falling asleep behind the wheel, something that could have dire, deadly consequences for others. According to the Federal Motor Carrier Safety Administration, more than 750 people die each year due to fatigued truck drivers. Another 20,000 are injured (Arnold & Itkin 2023).

Let’s compare that to residency where, as of 2023, new doctors are limited to eighty hours each week. Eighty hours! Compare that with the thirty-five-hour work week of the average American.

“But at least they get paid well,” you might say.

That can be true, but it might not be as much as you think. First-year residents earn an average of $55,000 per year (Buga 2021). Let’s do the math. Making $55,000 each year while working fifty-two eighty-hour weeks comes to $13.22 per hour. Considering that the average hourly wage in the US is now over $33 per hour, it’s inaccurate to say that residents get paid well (YCharts 2023).

When I worked in residency, the eighty-hour work week maximum wasn’t enforced. One night, some colleagues and I broke down how many hours we worked each week. We were averaging one hundred hours. Using our salary and the number of hours we averaged, we learned that we as residents made less than minimum wage—which was less than $6 an hour at that time!

After residency and completing the medical boards, residents who choose to work at an academic medical center (AMC) can become supervising physicians (a.k.a., attendings). Attending doctors are the senior physicians that oversee the work of a group of residents. Unlike residents, attendings have no limitations on the number of hours they are allowed to work. They work until the job is done and the patients are taken care of.

It’s common for attendings to work for thirty-six hours straight without sleep. In fact, some surgeons stay at the hospital for more than three days without going home, and they rely on infrequent catnaps to keep them going. Others, like me, take calls from home after working for eight to twelve hours in the day, at times only getting one to two hours of sleep at a time between addressing phone calls from the hospital, needs of patients, and outside physicians requiring a consult. And I do this for seven days or more at a time!

How comfortable would you feel if you knew the doctor rushing you into surgery hadn’t slept for the last thirty-six hours?

Attendings often brag about their lack of sleep and how they spend every other night on call, as those stressors are badges of honor. Calling in sick or asking for help was considered a weakness in the past, and still is by some. Few attendings miss their work shift, mostly because patients don’t stop getting sick just because their doctor is sick. Even leaving on time at the end of a long shift can be viewed as a sign of disinterest. The message these behaviors send to residents is this: if you wish to practice medicine, you must be willing to accept the costs.

My father never called in sick unless he was admitted to the hospital. He pressed on when he hadn’t slept for days. For him, as it is for many still today, accepting the costs became his way of life, and it changed how he perceived himself and his responsibilities. For example, I visited my parents when I was very pregnant, and I ended up heading to the hospital in premature labor to give birth to his first grandchild. At the same time I left to give birth, Dad headed to work at a different hospital because, as he said to me, “I could not find someone to cover.” He continued to work at all costs until the day he died.

Katherine Twombley is a pediatric nephrologist and author of First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement.