During her residency in emergency medicine, Archana Shrestha, MD, MS, would fall asleep at stoplights on the drive home after night shifts.
“It happened a few times,” she recalled. “It was scary; I didn’t feel safe driving.” To power through night shifts, Shrestha snuck in 2-hour naps beforehand.
And maybe you’ve heard something like this from a senior physician: “If you see a chair, sit in it. If you see a bed, sleep in it. If you see food, eat it. That’s how you survive residency.”
Elsa Alaswad, MD, now a fourth-year neurology resident at the George Washington University School of Medicine, Washington, DC, learned that “rule” from her cardiologist father. She trained herself to sleep when she had the chance. “It was untenable,” she said. “I wanted to quit so many times.”
Segmenting sleep was just one of several habits that Shrestha, Alaswad, and many physicians have internalized for decades. From stress eating to repressing emotions, Shrestha said she learned these behaviors by emulating senior residents, attendings, and peers. Transmitted implicitly, these values and habits are part of medicine’s so-called “hidden curriculum.”
“It’s ironic. You basically learn: Do no harm to the patient, but it’s okay if you do harm to yourself,” Shrestha said.
“There’s an understanding within medicine as old as the Hippocratic Oath that the patient comes first, and you come second,” explained Tania M. Jenkins, PhD, associate professor of sociology at the University of North Carolina-Chapel Hill and author of Broken Promises: Why So Many Physicians are Sick and Tired.
Jenkins has interviewed hundreds of physicians about their work and heard the same refrain: “That translates to your own needs — drinking water, eating breakfast, getting enough sleep, or fresh air — being secondary to the patients’ needs.”
The result is that young physicians ingrain unhealthy routines and, often, never give them up, even years into their careers. That is, unless they make a conscious shift in mindset. The first step is recognizing the unhealthy habits and behaviors frequently learned during medical training.
The second step — well…are you willing to do anything about it?
Part 1: The Physical Toll
Ultimately, medical training comes down to one word: endurance. That means learning to ignore your bodily needs, said Stefanie Simmons, MD, FACEP, chief medical officer at the Dr Lorna Breen Heroes’ Foundation.
Shrestha agreed, “You need to tough it out; it doesn’t matter what is happening to your body. Whatever it takes is what is required.”
Hydrating and urinating. “When a patient codes, you’re not going to say, ‘I’m sorry, your intubation will have to wait 2 minutes while I pee,’” said Simmons, who once worked as an emergency medicine physician.
An unhealthy logic takes over: If I don’t drink anything, I won’t have to go. Unfortunately, as physicians know, urinating fewer than four times and consuming fewer than eight cups of water daily are risk factors for urinary tract infections, according to research. Plus, dehydration can impair cognitive performance, especially executive function and motor coordination.
Starvation or junk food. During her second year of residency, Alaswad would work from 6 AM to 6 PM. Many nights, she’d skip dinner and fall asleep, then leave for work the next morning without time to eat breakfast. “I trained myself not to need consistent meals,” she said. “I would be starving a lot of the time, and when I’d eat again, I’d be ravenous. I would lose a lot of weight and then regain it.”
During Shrestha’s medical training, “there were always cupcakes for someone’s birthday and doctors’ lounges stocked with pastries and donuts,” she said. Finding nourishing fare during night shifts, when the hospital cafeteria is closed, was even more difficult. “Students sometimes grab food at 2 AM from the vending machines or raid the nurse’s stations for ginger ale and soda crackers,” said Jenkins. “That’s what’s available.”
As any primary care doctor will tell you, a lack of nutrient-rich food can impair the immune system and lead to headaches, dizziness, irritability, and even fainting.
Working through illness. “During my first 2.5 years of residency, I would get sick almost every 3-4 weeks,” recalled Alaswad. “Night shifts were brutal for my health.” But she never took a day off. She didn’t feel she could.
“Getting sick doesn’t mean getting to be home recovering. It means getting to work while sick,” she said. “Because otherwise you’re seen as the weak link who lets down their peers. It’s hard to prioritize yourself when calling out sick means someone else must carry your load. There is simply no wiggle room.”
Can You Fix It?
The obvious fix is a series of tricks designed to make healthy choices easier or automatic: an apple or a bag of nuts in a coat pocket, exercise snacks, carry a water bottle, duck in a bathroom anytime a 2-minute window opens. You’ve heard them all before: This is a healthy lifestyle via opportunism.
But in the end, even if you remedy the physical toll — and some do — what are you fixing?
Understand not just what you learned, but how you learned it. Gutting it out, pushing through, demanding more from your body, and then pulling it all off…that’s an accomplishment. A lot of physicians value that accomplishment.
Working to eliminate this entire aspect of physician training requires a mindset shift, said Shrestha. And often that requires help. She spoke from personal experience. A few years ago, Shrestha began exercising and seeing a nutritionist to address her own weight gain. After improving her health, she became a certified wellness coach to help other doctors do the same. She founded the Mama Docs School and is also the chief wellness officer at Physician Wellness Solutions.
You are a physician, she said. What’s really driving your self-neglect? Are you willing to seek the help you need?
Part 2: The Psychological Toll
Medical trainees absorb psychological habits as well, which are often rooted in the culture of physicians as stoic and self-sacrificing, said Jenkins. These can be even more damaging than bad physical habits because they can in themselves take a physical toll.
Isolation. Isolation can contribute to depression, according to research. But many trainees don’t have time or energy to socialize. A common result is impaired personal relationships. “It’s a cycle of social isolation,” said Alaswad. “You’re isolated because of your work hours. And you’re too tired to see friends on the weekends — instead, you just want to sleep.”
Many medical students even avoid study groups, said Christen C. Hairston, PhD, associate dean, Center for Holistic Student Success, Emory University School of Medicine, Atlanta. The reason: They don’t want peers to witness them not always knowing the answers. So, they cram alone. Now that medical schools don’t always require students to attend classes, this isolation has become more acceptable, she added. “Being alone on a laptop is part of the culture now. It’s a lot easier to appear connected even if you’re really suffering.”
Repressing emotions. Shrestha recalled feeling surprised when a med student once started crying after a patient’s death. Then she took a step back. “I realized this med student was having a very normal human reaction to death. What was surprising was my surprise. I realized how much I had numbed myself. I’d gotten good at stuffing down emotions as a self-defense mechanism.”
Repressing emotions can feel necessary in medicine, especially during residency, said Simmons. But many doctors continue to hide even severe emotional distress. On licensing forms, applicants must disclose their personal experience with mental health struggles. If they admit such history, there’s been a “profound lack of transparency” around the consequences, she added.
The result is medical trainees who are suffering but feel they cannot get help. If they do seek treatment for mental health issues, they sometimes pay out of pocket for sessions or see providers in different health systems, as Jenkins has observed during her research.
Not to mention, getting help can be logistically challenging. “Residents are constantly being evaluated,” said Hairston. “Everyone is watching you all the time, and you want to show up in the best possible way. You don’t want to lose time in clinicals to go to a mental health appointment. Students get a half day for wellness sometimes, but that’s for everything they must do, including laundry,” she added.
Can You Fix It?
In an essay for Doximity, Shrestha described relearning how to respond to her needs appropriately. If she had a headache, she learned a glass of water might do the trick. If she felt stress, she acknowledged her emotions without reaching for a sweet treat to help blunt them.
To encourage her coaching clients today, she shares these messages with them:
“Doctoring is what you do. But it’s not your entire identity. It’s helpful to separate doctoring from all the other facets of yourself.
You must take care of yourself so you can have a long career and help more patients in the long run. If you don’t take care of yourself, who will? Certainly not your employer.
We’re not superheroes. We are smart, caring, hard-working humans, but humans nonetheless with real human needs for rest and recovery.
We take care of patients and advise them to take care of themselves. We should do the same thing for ourselves.”
Self-care doesn’t need to be a zero-sum game, Shrestha emphasized. Doing no harm should extend to doctors too, not only patients. It just might take a bit of unlearning.