One of the most memorable episodes of MASH, the 1970s dramedy set in a Korean War surgical hospital, takes place after 48 hours of combat triage. The exhausted staff falls asleep but finds little relief.

Hawkeye dreams he’s back in medical school, unable to reattach a patient’s arm and ordered to remove his own arms instead. Margaret’s wedding bed fills with wounded men and blood stains her white dress, as her new husband marches off to war. Klinger peers through a grimy window to see Colonel Potter doing surgery — on him. And Major Winchester in a cape and top hat performs magic tricks in the operating room (OR), but a wounded soldier arrives on a gurney and dies, silencing the applause.

MASH is 50 years old (and fictional), but healthcare workers in today’s domestic “war zones” are still plagued by bad dreams. Search Reddit and Quora, and you’ll find long threads of healthcare workers sharing their recurring nightmares and wondering what they mean.

Specifics vary, but common themes emerge:

Feeling overwhelmed: “I’m in a warehouse in Alaska with a hundred bodies that were pulled from a shipwreck, all lying on a wet concrete floor. I’m unable to secure an airway no matter what I try.”

Having to redo a test: “I’ve been a nurse for nearly two decades, but I still wake up panicked a few times a year that my university discovered I never attended a required gen-ed math class...Now I must retake freshman-level algebra and the NCLEX.”

Making mistakes: “I have dreams of losing my patients. Forgetting their room numbers. Finding them in the closet at the end of the shift. Not having given them any meds or food.”

Getting lost: “I’m transporting a patient to the OR, but I’m lost in the hallways, and I can’t find my shoes.”

Losing control: “I’m in the OR, and my patient has been asleep for hours, but delays keep happening. The set-up is contaminated. We’ve run out of CHG prep….Finally, I start the surgery, but the nurses tell me they don’t have a critical piece of equipment, or the lights go out.”

Being naked on rounds: “I’m about to start a shift, but I can’t find my hospital scrubs, so I just do my rounds naked. I think it’s a fear of not being ready.”

‘Armies of Cockroaches Racing at Me’: The Science of Clinician Dreams

Deirdre Barrett, PhD, a clinical psychologist and dream researcher at Harvard Medical School, confirmed these themes are common across medicine. Based on her research and observations, Barrett believes medicine is “right at the top” of professions that produce bad dreams, given the life-or-death stakes and rapid pace of change.

The COVID pandemic provides an extreme example. When Barrett examined how the pandemic affected the dreams of 600 front-line healthcare workers (mostly nurses), she uncovered a surprisingly specific theme.

“I found a big sub-cluster of bug dreams,” she said. “Swarms of every kind of flying insect you can imagine. Or armies of cockroaches racing at the dreamer. Or masses of wriggling worms or grasshoppers with vampire fangs.”

The “bugs,” of course, represented the virus itself, as did other dream metaphors involving tsunamis, tornadoes, and earthquakes. These are all examples of trauma-induced nightmares. They can be literal or fantastical, and they’re common in the wake of wars, accidents, and pandemics.

But more often, clinicians’ bad dreams are creative manifestations of everyday anxiety and stress, rooted either in a personal feared incompetence or in being overwhelmed or stymied by the medical system.

A Swiss study published in the International Journal of Dream Research in 2022 found that medical students’ dreams mostly involved threats to their professional self-esteem and competence rather than physical injury to themselves or their patients.

Such perceived threats can extend beyond graduation and far into a career, Barrett said. One Reddit contributor asked, “I’m 6 months out of residency, do these dreams go away?” To which someone responded, “I’m 7 years out. Sorry!”

Why Do We Dream?

No one knows for sure, but one widely accepted theory is the “continuity hypothesis.” “Dreams are basically concerned with all the same things we’re concerned with by day,” Barrett explained. “In the dream state, these concerns are being represented in a more visual, more fanciful, less logical way….Dreaming is just thinking in a different biochemical state.”

Patrick McNamara, PhD, a neuroscientist at Boston University School of Medicine, Boston, ventured deeper into the synaptic weeds. Bad dreams result from a “breakdown” in emotional memory consolidation, he said. When something traumatic or stressful occurs, our brains try to make sense of it so it can be integrated into our long-term memory, and we can move on with our lives. REM sleep facilitates this integration. If our REM sleep is disturbed, which is often the case with healthcare workers, any traumatic or stressful event that our brains are trying to process gets stalled and remains unintegrated. That’s why so many bad dreams recur.

Remember the dream from earlier about the Alaskan warehouse with shipwreck bodies on a concrete floor?

“I started having that nightmare around the time I was taking a gross anatomy class in med school, and I kept having it for years,” said Robert Frantz, MD, an emergency medicine physician with 30-plus years of experience who’s now the president of TeamHealth West in Knoxville, Tennessee. “The class met in this windowless basement, and there were bodies in tanks for us to dissect….The terrifying part of the dream for me wasn’t the bodies. It was the overpowering futility of the whole situation. Medical training is overwhelming. They throw a mountain of material at you, which creates this conscious angst of Can I do this?”

His nightmare, although triggered by anatomy class and depicted in a very specific and graphic way, wasn’t about those bodies or patients; it was about the burden physicians carry and the limits of competence. Frantz said his dreams have evolved over time. Sometimes he’d be in the ED, other times in the back of an ambulance, and as his work became more administrative, occasionally even in an office. “But they always centered around being overwhelmed or being pulled in multiple directions,” he said. “As you transition to different roles, you’re giving something up to become something else, and there’s angst in the becoming,” which can manifest in dreams.

The Curious Case of Counterfactuals

Besides integrating emotional memories, dreams also facilitate learning. They do this by simulating future scenarios. Say your hospital shift ends, it’s raining, and by the time you get to your car, you’re drenched. Later that night, as the brain processes this experience, it generates what’s called a “counterfactual” – a thought that if you’d taken an umbrella, you wouldn’t have gotten soaked.

“Conscientious people are constantly running counterfactual simulations in their waking consciousness and in their dream life,” said McNamara. “If only I’d checked that patient’s blood pressure….If only I’d referred them to a surgeon sooner….This is how human beings learn, and one of the primary places where counterfactuals are generated and run are in dreams.”

Moral Injury in Medicine

There may be another reason why healthcare workers have disturbing dreams.

“In an increasingly business-oriented and profit-driven healthcare environment, clinicians must consider a multitude of factors other than their patients’ best interests,” said Wendy Dean, MD, a psychiatrist, former ER physician, and co-founder of the Moral Injury of Healthcare nonprofit. “When we take our oaths, we make a commitment to the profession that’s not just about doing a job – it’s about who we become. And when that’s threatened, it can injure us morally.”

Unresolved moral injury can trigger feelings of anger, resentment, frustration, and betrayal that can surface in dreams, as our brains try to integrate those strong emotions and search for a protective shield.

“I had a dream where I arrive to a complete mess on the floor and decided to just walk out instead of clocking in,” said one Reddit user. “My manager was so desperate for me to stay that she offered me a huge pay raise. Can you tell I’ve been wanting to quit?”

“In my dream, call bells are going off,” wrote another. “I’m the only one trying to answer them, but the floor is full of zombies that I have to fight off. It’s not scary, just stressful.”

Both examples could be interpreted as stemming from moral injury – the first from not being able to deliver proper patient care because of understaffing, and the second from working in a system where compassion is no longer a priority.

Frantz believes moral injury among healthcare workers is rising. In his book The Cost of Caring, he talks about the “fantasy/fact problem,” where what physicians and nurses think helping patients will be like collides with healthcare’s realities. “Coming to terms with that can damage people,” he said. “It can assault you at your core.”

Frantz contends that unresolved moral injury can lead to an “emotional cancer that is beyond burnout – something you can’t compartmentalize or yoga your way out of.”

“We’ve been talking about burnout in the healthcare field for decades,” said Dean, “but it hasn’t made a substantial difference, maybe because it’s not a complete diagnosis. Moral injury is one more way to explain the challenges that healthcare workers face. And it doesn’t just affect physicians and nurses. We did a study during the pandemic that found 40% of healthcare executives and managers also experienced moral injury. It’s across the board.”

How to Banish Bad Dreams

Instead of trying to interpret the specific elements of a nightmare (why am I naked on rounds?), McNamara recommends looking for the dream’s central image or core (maybe I fear being unprepared?). Recurring dreams can be signposts to hidden stressors that need addressing.

Occasional bad dreams are usually nothing to worry about. But if they begin disrupting your life, either by depriving you of sleep or distressing you during the day, then see a psychologist or therapist. In addition, try these potential solutions:

Get more quality sleep. Remember that a recurring nightmare means your brain isn’t getting enough REM time to process an emotional memory. “We go into REM sleep every 90 minutes,” said Barrett. “Each REM period is longer than the last, just a few minutes at first and up to 30 minutes for the final one….When you sleep 6 instead of 8 hours, you don’t lose one fourth of your dream life; you lose almost half.” Avoid alcohol before bed (it suppresses REM sleep), review medications for sleep-disrupting side-effects, swear off screens in bed, and try to wake up naturally without an alarm clock.

Incubate your dreams. Barrett recommends falling asleep thinking about some pleasant dream you want to have. If it involves a favorite person or place, put a photo on your nightstand so it’s the last thing you see. Similarly, imagery rehearsal therapy involves consciously rescripting the scariest parts of a bad dream. Write down the new version, rehearse it, visualize it, and often when the dream reappears it will have a less-disturbing outcome.

Share your nightmares. McNamara recommends creating a small support group where you can not only share what’s happening in your professional lives but also any related dreams. “Just sharing the dreams will facilitate the memory consolidation process,” he said. Even sharing them on Reddit or Quora helps.

Treat moral injury. If your bad dreams are stemming from a fantasy/fact discrepancy, Dean said the best antidote is speaking out about what’s frustrating you and trying to create positive change. “That can be risky,” she admitted, “but the first step is recognizing those moments when you’re being asked to transgress and realizing you have a choice. If you don’t want to speak out alone, then find others who are experiencing the same thing and build a coalition.”

How Future Tech May Help

McNamara said the most exciting thing in dream science these days is the developing involvement of AI. “We’re using signals from an EEG tracing machine to train AI models to decode what the brain is seeing when it’s dreaming,” he said. “So if EEG Signal X is associated with somebody reporting seeing a bear in a dream, then we show that to AI thousands of times, and it learns that association. This is all still in the initial stages, but it has revolutionary potential. Imagine watching AI-generated images of what a person is dreaming and, if it’s a bear, altering that EEG signal to get rid of it.”

Unfortunately, there’s been no progress yet on identifying the EEG signal for being naked on rounds.

The experts cited in this article had no relevant disclosures.