The on-call room is hardly bigger than a closet, and the bed is just a plank with a sheet. I stay in my scrubs and keep my shoes on, since there’s no point taking them off. The trauma pager rests on my chest, face up. I close my eyes, and within ninety seconds, I’m asleep.
Sometimes I’d get half an hour of sleep, maybe a few hours if the night was quiet. Then the pager would go off, and I’d rush down the corridor into the bright trauma bay, where someone needed their face rebuilt. As a young reconstructive surgeon, I worked 24- and 36-hour weekend shifts. You learn two rules quickly, and they’re really the same: eat when there’s food, not just when you’re hungry, and sleep when there’s time, not just when you’re tired. You never know when the next call will come. So you lie down, fall asleep in minutes, and get rest whenever you can.
Maybe I was lucky, or maybe I learned it under pressure. Either way, I could fall asleep on a hard bed in a noisy hospital with a pager on my chest, and then do it again a few hours later. I still sleep that way. After reading a page or two of a book, I’m out. You could move me to another room and I wouldn’t wake up.
On paper, that probably makes me the wrong person to write about sleep problems.
Sleep is the topic you ask me about most. Whenever someone new joins this newsletter, I ask what they’re looking for, and the answer I hear most often is sleep. Not how to make it perfect, but how to get any at all. How to fall asleep when your body is tired but your mind won’t stop. How to get back to sleep after waking at 3am with your thoughts racing, when it feels like the night is over even though there are still hours left.
That’s not my struggle, so I did the next best thing. I read what sleep experts say, looked through the research, and listened to dozens of your replies. Most sleep problems come down to one main issue with a real name, and the real solutions are rarely things you can buy.
The Night Shift
While you sleep, your body takes care of things it can’t do when you’re awake.
You might have heard that sleep clears the brain of the plaque linked to Alzheimer’s. It’s a good story, but it’s often overstated. The idea comes from a 2013 mouse study showing that sleeping brains cleared waste faster, including amyloid-beta [1]. But a 2024 mouse study found the opposite. The debate continues in animal studies.
The evidence in humans is less dramatic. If a healthy adult stays awake for one night, amyloid levels rise about 5% by morning [2]. Sleep brings those levels back down. Over many years, though, the risk adds up. One study followed nearly 8,000 adults for 25 years and found that those who slept six hours or less in midlife had about a 30% higher rate of dementia [3]. This is a link, not proof, since early disease can shorten sleep before symptoms appear. Still, a 30% increase over 25 years is hard to ignore.
The effects you feel the next day show up quickly. After just one night without sleep, your amygdala (the brain’s threat detector) becomes about 60% more active, while the part that keeps it in check gets quieter [4]. That’s why you might have a short fuse or make a decision at 4pm you wouldn’t make if you were rested. Your judgment slips before you even realize it.
The Hangover You Didn’t Drink For
If you lose sleep, your hormones start to show it within just a few days.
When healthy young men sleep only four hours a night for six nights, their blood sugar control becomes as poor as someone decades older and at risk for diabetes, all in less than a week [5]. A week of five-hour nights lowers their daytime testosterone by 10 to 15%, which is about what aging does over 10 to 15 years [6]. These are small studies in young men, so take the numbers with caution. Still, the trend is clear, and it explains why you might feel foggy on a Tuesday.
You also can’t make up for lost sleep on the weekend. When researchers had people sleep short nights and then let them sleep in, the extra rest didn’t fix the damage. Their blood sugar levels remained poor, and some even worsened because they ate more and shifted their sleep schedules later [7]. Sleeping in on Saturday doesn’t undo a week of short nights.
Your immune system notices too. In one study, healthy adults tracked their sleep for a week, then were exposed to a cold virus. Those who slept less than six hours were about four times more likely to get sick than those who got seven or more [8]. Same exposure, but a different defense.
The Basics, Fast
You already know the basics: get seven to eight hours, keep your room cool and dark, and avoid screens before bed. All of that is true, but it’s not the reason you’re lying awake. There are two less obvious things worth mentioning.
Consistency might matter more than total sleep time. In a study of 60,000 adults wearing wrist monitors, regular sleep patterns predicted longer life better than total hours slept [9]. Going to bed and waking up at the same time every day is better than sleeping in on Sunday to make up for lost sleep during the week. Your body runs on a clock, and it doesn’t like when that clock keeps changing.
And remember, you’re not the same as your neighbor. I’ve always woken up at first light. As a kid, I’d be up at seven while my cousin would sleep until someone dragged him out at eleven. Sleep is personal, even though most advice makes it seem like it isn’t.
Even careful people can get tripped up by two basics. Caffeine stays in your body for five to six hours, so a coffee at 4pm still has a quarter of its effect at 10pm. In one study, 400mg of caffeine six hours before bed cut sleep by more than an hour [10]. Alcohol can also backfire. It might help you fall asleep faster, but it breaks up the second half of the night and reduces your REM sleep. That’s why two glasses of wine can leave you wide awake at 4am, feeling like you never slept [11].
Why You Can’t Switch Off
For most high performers, the problem isn’t sleep itself. It’s the 90 minutes before bed, and a nervous system that stays active even after you lie down. Insomnia in someone who’s trying hard is really about being too alert. The body is too tense to relax, and trying to force sleep only makes it worse.
That’s why using a sleep tracker can sometimes make things worse. There’s even a name for it now: orthosomnia. Sleep doctors use this term for people who worry so much about getting a perfect sleep score that it actually ruins their sleep [12]. And those scores aren’t even that reliable. When researchers compared seven trackers to a sleep lab, the devices could tell sleep from waking, but missed 30 to 50% of deep and REM sleep [13]. People end up worrying about a deep-sleep number that the device is only guessing at.
Trying to sleep is often what keeps you awake. Clinicians call this sleep effort. The harder you try to fall asleep, the more you activate the alert, goal-focused part of your brain, which is exactly what sleep doesn’t need [14]. You can’t force yourself to sleep. The best you can do is stop getting in your own way.
This is the Recover part of my Upward ARC framework, which is about helping your nervous system return to calm between stresses. Sleep is also an input, so it connects to Activate as well. But the reason you’re awake is usually in Recover, and you can’t reset by trying harder. The reset happens when you slow down and stop pushing.
The Theory That Didn’t Survive
My wife is away tonight. She travels a few times a year, never far, and tonight she’s a few hours from here, still in Germany. The kids are asleep down the hall, and I’m the only adult in the house.
And here I am, lying in the dark with my eyes open.
This never happens to me. But tonight, I’m very aware of how deeply I usually sleep. If Karla calls out at 3am, the part of me that normally sleeps through anything won’t hear her. So I keep myself just below waking, listening, not willing to fall all the way asleep. For once, I can’t let go.
As I lay there, I thought I understood something. Maybe this is why so many women sleep more lightly than men. They keep an ear out for the kids, just like I was doing tonight, always a little alert. It seemed obvious, even a bit profound, at 1am. So I did what I always do now. I checked the data. And it humbled me.
Women do carry the heavier load. Insomnia is about 1.4 times more common in women than in men across more than a million people [15]. If you’re a woman reading this at 3am, that struggle is real, and I won’t wave it away with a lab result.
But when sleep is measured with electrodes rather than surveys, healthy women actually get more deep sleep than men of the same age, fall asleep faster, and spend more time asleep [16]. The hard nights are real, but so is the deeper sleep. The difference between the two is the real story.
My caretaker theory didn’t hold up. When researchers tested it directly, women woke up a little faster, but only to the faintest sounds, and just as quickly to a beeping alarm as to a baby’s cry [17]. That’s just a small difference in hearing. It’s not the mother’s radar I imagined. Who gets up at night depends on who’s on duty, and that’s shaped by life, not biology.
Two things explain the gap, and both are stronger than my late-night theory. On average, women go to bed with a more alert, worried mind, which breaks up sleep [18]. And women deal with hormonal changes, I never will. Throughout the monthly cycle, during pregnancy, and especially during menopause, sleep can really suffer. 40 to 60% of women say their sleep falls apart during menopause, mostly because they wake up during the night [19]. If that’s you, know this: you’re not failing at sleep, and you’re not imagining it. Your biology changed, and that deserves a real conversation with a doctor, not just a shrug or a supplement.
Try This Today
None of these are supplements or gadgets. These are the tools sleep clinicians actually use, organized by the kind of sleep problem you have.
If you can’t fall asleep, stop trying so hard. The effort itself is the problem, so take the pressure off. First, get tomorrow’s worries out of your head and onto paper. In one study, people who spent five minutes writing a to-do list for the next day fell asleep about nine minutes faster than those who wrote about their day [20]. The more specific your list, the better, because it helps your brain stop running through tasks. Next, slow your body down with your breath. Five minutes of cyclic sighing, a double breath in through the nose, and a long, slow breath out through the mouth calmed people better than meditation in a controlled trial [21]. The goal is to slow down, so sleep can come naturally.
If you wake up at 3am and can’t get back to sleep, get out of bed. It might feel wrong, but it works. If you’ve been awake for more than about 15 or 20 minutes (just by feel, not by watching the clock), get up. Leave the bedroom, sit somewhere dim, do something boring, and only go back to bed when you feel sleepy. This is called stimulus control, and it’s one of the best-proven tools [22]. Lying in bed, frustrated, teaches your brain that bed is a place to be awake and anxious, so you’re breaking that link. Also, remember that waking up in the night isn’t the emergency it feels like. For most of history, people slept in two shifts, with an hour of quiet awake time in between, and didn’t think anything of it [23]. Waking up is normal. It’s the panic that turns a 20-minute gap into a lost night.
If you wake up at every little sound, focus on fixing your room before trying to fix yourself. Make it cool, dark, and as quiet as possible. Earplugs or steady background noise can help cover sudden sounds that wake you up. One honest note: the machines that promise deeper sleep are overhyped. Steady sound can help mask a barking dog or a snoring partner, which is useful, but it doesn’t actually make your sleep deeper like the ads claim.
If you wake up every couple of hours, try spending less time in bed, not more. It might sound backward, but if you lie in bed for nine hours to get six hours of broken sleep, you’re actually training your body for broken sleep. Instead, shorten your time in bed to match the sleep you actually get, with a minimum of about five hours. Keep a fixed wake time, and let your sleep pressure build until your nights become more solid. Then, you can gradually increase your time in bed again. Even a nurse-led version of this approach worked better than standard advice in a large 2023 trial [24]. Also, rule out one thing: if you wake up tired no matter how long you sleep, and you snore, get checked for sleep apnea. Nearly a billion adults have it, most without knowing, and it’s common in middle-aged or heavier people [25]. No breathing trick can fix a blocked airway.
Most importantly, anchor your wake time. Get up at the same time every day. This is the strongest signal you can send your body clock [9], and it’s more effective than any bedtime rule, because morning light and a steady start set the tone for the rest of the day.
If you’ve been struggling for months, seek real treatment. Insomnia that happens three nights a week for three months or more is a diagnosable condition, and the best first treatment is cognitive behavioral therapy for insomnia (CBT-I), which major medical organizations recommend over sleeping pills [26]. It works. In studies, people fall asleep about 19 minutes faster and spend much less time awake at night, and the benefits last even after stopping [27]. Talk to your doctor, or try a reputable CBT-I app.
What the Pager Taught Me
I still fall asleep in an instant, and now I understand why. Those years in the trauma unit taught me, without me realizing it, how to lower my alertness on command. I could go from fully awake to asleep fast, because the next emergency could happen at any moment, and I had to get rest when I could. The pager trained my nervous system to let go quickly.
That’s the real secret, and it’s what most people are missing—the ability to turn down the volume and stop fighting. I learned it the hard way, under bright lights with a pager on my chest. You can build this skill on purpose, using the tools above, and skip the trauma unit. And if it’s not just your nights but your whole week that’s wearing you down, check out my earlier piece on choosing the few habits that last when everything else is falling apart: Three Bikes, Four Habits.
Readers who tell me sleep is what they want most are really asking for one thing: permission. Permission to stop trying so hard and just let sleep happen. So here it is. You don’t have to earn your sleep tonight. Let it happen.
One question, since I read every reply and it shapes what I write next: When you wake up at 3am, is it because of a specific worry, or are you just awake for no clear reason? Reply with the one that fits you. The solution is different for each, and I’ll write a future piece based on what most of you say.
Stay healthy.
Andre
PS: I wrote this because so many of you replied to my welcome email with one word: sleep. Thank you for being honest about what keeps you up. If you know someone who lies awake at 3am and quietly blames themselves, please forward this to them tonight. That’s how this newsletter grows, and it’s the main way I want it to.
PPS: If a friend sent you this, you can get the Sunday editions here: https://www.andreheeg.com
References
[1] Xie, L., Kang, H., Xu, Q., Chen, M. J., Liao, Y., Thiyagarajan, M., O’Donnell, J., Christensen, D. J., Nicholson, C., Iliff, J. J., Takano, T., Deane, R., & Nedergaard, M. (2013). Sleep drives metabolite clearance from the adult brain. Science, 342(6156), 373-377. https://doi.org/10.1126/science.1241224
[2] Shokri-Kojori, E., Wang, G.-J., Wiers, C. E., Demiral, S. B., Guo, M., Kim, S. W., Lindgren, E., Ramirez, V., Zehra, A., Freeman, C., Miller, G., Manza, P., Srivastava, T., De Santi, S., Tomasi, D., Benveniste, H., & Volkow, N. D. (2018). β-Amyloid accumulation in the human brain after one night of sleep deprivation. Proceedings of the National Academy of Sciences, 115(17), 4483-4488. https://doi.org/10.1073/pnas.1721694115
[3] Sabia, S., Fayosse, A., Dumurgier, J., van Hees, V. T., Paquet, C., Sommerlad, A., Kivimäki, M., Dugravot, A., & Singh-Manoux, A. (2021). Association of sleep duration in middle and old age with incidence of dementia. Nature Communications, 12, 2289. https://doi.org/10.1038/s41467-021-22354-2
[4] Yoo, S.-S., Gujar, N., Hu, P., Jolesz, F. A., & Walker, M. P. (2007). The human emotional brain without sleep: A prefrontal amygdala disconnect. Current Biology, 17(20), R877-R878. https://doi.org/10.1016/j.cub.2007.08.007
[5] Spiegel, K., Leproult, R., & Van Cauter, E. (1999). Impact of sleep debt on metabolic and endocrine function. The Lancet, 354(9188), 1435-1439. https://doi.org/10.1016/S0140-6736(99)01376-8
[6] Leproult, R., & Van Cauter, E. (2011). Effect of 1 week of sleep restriction on testosterone levels in young healthy men. JAMA, 305(21), 2173-2174. https://doi.org/10.1001/jama.2011.710
[7] Depner, C. M., Melanson, E. L., Eckel, R. H., Snell-Bergeon, J. K., Perreault, L., Bergman, B. C., Higgins, J. A., Guerin, M. K., Stothard, E. R., Morton, S. J., & Wright, K. P. (2019). Ad libitum weekend recovery sleep fails to prevent metabolic dysregulation during a repeating pattern of insufficient sleep and weekend recovery sleep. Current Biology, 29(6), 957-967.e4. https://doi.org/10.1016/j.cub.2019.01.069
[8] Prather, A. A., Janicki-Deverts, D., Hall, M. H., & Cohen, S. (2015). Behaviorally assessed sleep and susceptibility to the common cold. Sleep, 38(9), 1353-1359. https://doi.org/10.5665/sleep.4968
[9] Windred, D. P., Burns, A. C., Lane, J. M., Saxena, R., Rutter, M. K., Cain, S. W., & Phillips, A. J. K. (2024). Sleep regularity is a stronger predictor of mortality risk than sleep duration: A prospective cohort study. Sleep, 47(1), zsad253. https://doi.org/10.1093/sleep/zsad253
[10] Drake, C., Roehrs, T., Shambroom, J., & Roth, T. (2013). Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. Journal of Clinical Sleep Medicine, 9(11), 1195-1200. https://doi.org/10.5664/jcsm.3170
[11] Ebrahim, I. O., Shapiro, C. M., Williams, A. J., & Fenwick, P. B. (2013). Alcohol and sleep I: Effects on normal sleep. Alcoholism: Clinical and Experimental Research, 37(4), 539-549. https://doi.org/10.1111/acer.12006
[12] Baron, K. G., Abbott, S., Jao, N., Manalo, N., & Mullen, R. (2017). Orthosomnia: Are some patients taking the quantified self too far? Journal of Clinical Sleep Medicine, 13(2), 351-354. https://doi.org/10.5664/jcsm.6472
[13] Chinoy, E. D., Cuellar, J. A., Huwa, K. E., Jameson, J. T., Watson, C. H., Bessman, S. C., Hirsch, D. A., Cooper, A. D., Drummond, S. P. A., & Markwald, R. R. (2021). Performance of seven consumer sleep-tracking devices compared with polysomnography. Sleep, 44(5), zsaa291. https://doi.org/10.1093/sleep/zsaa291
[14] Broomfield, N. M., & Espie, C. A. (2003). Initial insomnia and paradoxical intention: An experimental investigation of putative mechanisms using subjective and actigraphic measurement of sleep. Behavioural and Cognitive Psychotherapy, 31(3), 313-324. https://doi.org/10.1017/S1352465803003060
[15] Zhang, B., & Wing, Y.-K. (2006). Sex differences in insomnia: A meta-analysis. Sleep, 29(1), 85-93. https://doi.org/10.1093/sleep/29.1.85
[16] Mong, J. A., & Cusmano, D. M. (2016). Sex differences in sleep: Impact of biological sex and sex steroids. Philosophical Transactions of the Royal Society B, 371(1688), 20150110. https://doi.org/10.1098/rstb.2015.0110
[17] Vermillet, A.-Q., Skewes, J. C., & Parsons, C. E. (2025). Men and women’s waking patterns to infant crying: Preparenthood differences are insufficient to explain uneven sharing of nighttime care. Emotion, 25(5), 1108-1121. https://doi.org/10.1037/emo0001478
[18] Hantsoo, L., Khou, C. S., White, C. N., & Ong, J. C. (2013). Gender and cognitive-emotional factors as predictors of pre-sleep arousal and trait hyperarousal in insomnia. Journal of Psychosomatic Research, 74(4), 283-289. https://doi.org/10.1016/j.jpsychores.2013.01.014
[19] Baker, F. C., Lampio, L., Saaresranta, T., & Polo-Kantola, P. (2018). Sleep and sleep disorders in the menopausal transition. Sleep Medicine Clinics, 13(3), 443-456. https://doi.org/10.1016/j.jsmc.2018.04.011
[20] Scullin, M. K., Krueger, M. L., Ballard, H. K., Pruett, N., & Bliwise, D. L. (2018). The effects of bedtime writing on difficulty falling asleep: A polysomnographic study comparing to-do lists and completed activity lists. Journal of Experimental Psychology: General, 147(1), 139-146. https://doi.org/10.1037/xge0000374
[21] Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., & Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Reports Medicine, 4(1), 100895. https://doi.org/10.1016/j.xcrm.2022.100895
[22] Bootzin, R. R. (1972). Stimulus control treatment for insomnia. Proceedings of the 80th Annual Convention of the American Psychological Association, 7, 395-396.
[23] Ekirch, A. R. (2001). Sleep we have lost: Pre-industrial slumber in the British Isles. The American Historical Review, 106(2), 343-386. https://doi.org/10.1086/ahr/106.2.343
[24] Kyle, S. D., Siriwardena, A. N., Espie, C. A., Yang, Y., Petrou, S., Ogburn, E., Begum, N., Maurer, L. F., Robinson, B., Gardner, C., Lee, V., Armstrong, S., Pattinson, J., Mort, S., Temple, E., Harris, V., Yu, L.-M., Bower, P., & Aveyard, P. (2023). Clinical and cost-effectiveness of nurse-delivered sleep restriction therapy for insomnia in primary care (HABIT): A pragmatic, superiority, open-label, randomised controlled trial. The Lancet, 402(10406), 975-987. https://doi.org/10.1016/S0140-6736(23)00683-9
[25] Benjafield, A. V., Ayas, N. T., Eastwood, P. R., Heinzer, R., Ip, M. S. M., Morrell, M. J., Nunez, C. M., Patel, S. R., Penzel, T., Pépin, J. L., Peppard, P. E., Sinha, S., Tufik, S., Valentine, K., & Malhotra, A. (2019). Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis. The Lancet Respiratory Medicine, 7(8), 687-698. https://doi.org/10.1016/S2213-2600(19)30198-5
[26] Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125-133. https://doi.org/10.7326/M15-2175
[27] Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M. W., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163(3), 191-204. https://doi.org/10.7326/M14-2841
Solid read. In answer to your question…work-related stress.