All-Nighters is an exploration of insomnia, sleep and the nocturnal life.

“I’m a sleep doctor.” Silence. There is a pause in the conversation, which is common.

Sleep medicine, as a field, is new enough that people are often taken off guard: “You do what?” The disheveled older man, who seems to have Ritz crackers woven into the fabric of his tie, leans closer. He appears to have misheard or misunderstood. (I often wonder what goes through peoples’ minds in that split second; what do they think they heard me say: “I’m a peep doctor”?) I repeat and explain that I do sleep medicine, “you know, insomnia, sleep apnea, that sort of thing.” “Oh, yes. I see.” His eyes widen with interest; now he steps really close, and a trembling hand lightly lays itself on my forearm.

Doctors preach the importance of sleep, yet medical students and residents are trained to be sleep-deprived.

I know that if I am not extremely creative and diplomatic, I will be stuck in the corner all night doing what I do all day — listening to some sad soul pour out his story of tortured, restless sleep. At a party, I am right up there in popularity with the dermatologist and plastic surgeon. Everyone needs our help and no one is embarrassed to say so.

Don’t get me wrong; I feel for this sleep-deprived, soiled and seemingly desperate man, but not much can be solved in a few minutes over canapés and gin. I am happy to help out and give useful advice where I can; it’s just that most people want to talk to me about their insomnia, and insomnia is the “dreaded disease” of sleep medicine. Every medical specialty has the one patient complaint that makes the doctors groan. For neurologists, it is headache; for rheumatologists, chronic fatigue; and for gastrointestinal docs, it is irritable bowel. What these all have in common is that we doctors don’t know how to treat them very well. One reason is that they are disorders, which means they are sets of symptoms, rather than one clear-cut, pathologically definable disease, and in their complexities, they are often not well understood and consequently not well treated using Western medical paradigms.

If there were a medical solution to sleeplessness, there would not be this need for sharing stories of nocturnal misery and outlining strategies for persevering. There have, however, been advances in our understanding of the disorder. The latest biomedical explanation for insomnia is much like the one for depression: There is an imbalance in the neurotransmitters in the brain, in this case, the ones that control the sleep/wake cycle. However, mapping out exactly what the problem is in which part of the brain remains the challenge for medical scientists.

One piece of advice I have to give to all insomnia suffers is to beware of the word “insomnia.” The problem is that the word is used by patients and doctors to describe the symptom of not being able to initiate sleep or maintain sleep or having persistent early morning awakenings. But it is also the word used for the final diagnosis. Patients walk into their primary care doctor and say: “Hey doc, I can’t sleep. I have insomnia.” And they are getting into their car before the ink has dried on the prescription for Ambien. People don’t walk into their internist’s office and say, “I’m having appendicitis.” They tell the doctor about the horrible pain in their “stomach,” and it is the doctor’s job to think of all the problems this might represent and to narrow the possibilities by asking further questions, doing a physical exam and running tests. Insomnia is not that easy to work up, and it takes the one thing that doctors have so little of: time for questions and discussion with the patient.

So be a proactive patient and do not easily accept chronic insomnia as your final diagnosis. There are, after all, so many medical problems that can masquerade as insomnia. Sleep disorders like sleep apnea and delayed sleep phase disorder can mislead patients and non-sleep doctors. Psychiatric disorders, cardiovascular disease, lung disease and rheumatologic and endocrine disorders (as well as the medications used to treat them) can all disrupt sleep and lead people to think that they suffer from insomnia.

The gentleman with the crumb problem (which is likely secondary to being sleep deprived and living without a wife as most phenomena are multifactorial) wanted to know what got me interested in the area of sleep medicine. I answered: “Because it is an oxymoron — sleep and medicine do not go together at all.” Doctors preach to patients how important sleep is to lower their risk of all sorts of diseases: high blood pressure, heart disease, stroke, diabetes, weight gain and obesity, depression and dementia. Yet the institution of medical training in this country practices systematized sleep deprivation of medical students and residents. By the way, we use the term “resident” because junior doctors used to live in the hospitals.

Driving while sleep deprived can be just as dangerous as driving drunk.

For the majority of the three years I trained in internal medicine (and during the two years before that when I did clinical rotations as a medical student), I would work 30 to 36 hour shifts every fourth night with no guarantee of sleep. Why, you might wonder, are students and residents pushed so hard, for so long? One reason is that medicine is a very tradition-bound profession and this is just the way “things have always been done.” But there are myriad other reasons: a culture of hard work that tests the mental stability and physical stamina of these brave young men and women; a belief held by many doctors that residency training is simply too short to teach doctors all they need to know unless they are pretty much working non-stop during that period seeing all the “interesting cases” that come through; and the simple economic fact that residents are a cheap way to man the hospital around the clock.

After 24 hours on duty, I would crave sleep like other people desire food or sex. And like an addict, I would plot and plan and structure my activity around getting the balm I so desperately needed. I would try to squeeze some sleep in, no matter how short the time allotted, no matter the location. I have slept in wheel chairs and on a patient gurney; I have dozed in stairwells and while riding on elevators. I, like almost every resident physician I know, would routinely fall asleep during the morning and noontime lectures that were meant to teach me how to be a decent doctor. Every woman doctor I know, and quite a few men, have wept from sheer exhaustion. The question is not only how did I live through this, but how did my patients?

I have a friend who wrecked her car three times in the first two months of her surgery internship. The same surgeon fell asleep with a needle-driver in her hand. Luckily, a senior attending caught her before she fell into the open wound. I was so tired driving home one afternoon after a call, that I had to roll down the window in the middle of Chicago winter, blast the radio and light a cigarette. I was shifting in my seat and flailing my arms so erratically that I thought other drivers on the road would think that I was having an epileptic fit. I didn’t worry about being mistaken for a drunk driver because even a drunk wouldn’t have acted as crazy as that. (Years later, in my training as a sleep medicine doctor, I learned that driving while sleep deprived can be just as dangerous as driving drunk.) It may assuage the reader’s fears to know that there are new regulations prohibiting resident physicians from working more than 80 hours per week, not to relieve the residents so much as to protect the patients because there was mounting evidence that many medical errors are attributable to physician fatigue.

Now I get my 7 to 8 hours without fail. Although I have not suffered much from insomnia, that inner, unwanted drive to wakefulness, I do know sleeplessness driven by external exigencies. I have a lot of sympathy and not a small amount of empathy for those sleepless souls who bleary-eyed and sallow-skinned must go forth into “the desolation of reality,” in Yeats’s memorable phrase. Day after day, they drag themselves into my office. Their minds are muddled; their hearts are heavy; and many are just plain angry. So I tell them: “I have no quick fix, no miracle pill, but I will listen long and hard to your story of chasing the elusive elixir of sleep. Although I might not cure you, I’ll go through this with you, as your witness, your night watchman, as someone who knows how long one night can seem.”

Lisa Shives, a doctor and the medical director of Northshore Sleep Medicine in Evanston, Ill., is an official spokesperson for the American Academy of Sleep Medicine. She is working on her first book which will focus on pediatric sleep disorders.