Purpose – The purpose of this paper is to explore the incidence of “extreme jobs” among middle managers in acute hospitals, and to identify individual and organizational implications. Design/methodology/approach – The paper is based on interviews and focus groups with managers at six hospitals, a “proof of concept” pilot with an operations management team, and a survey administered at five hospitals. Findings – Six of the original dimensions of extreme jobs, identified in commercial settings, apply to hospital management: long hours, unpredictable work patterns, tight deadlines with fast pace, broad responsibility, “24/7 availability”, mentoring and coaching. Six healthcare-specific dimensions were identified: making life or death decisions, conflicting priorities, being required to do more with fewer resources, responding to regulatory bodies, the need to involve many people before introducing improvements, fighting a negative climate. Around 75 per cent of hospital middle managers have extreme jobs. Research limitations/implications – This extreme healthcare management job model was derived inductively from a qualitative study involving a small number of respondents. While the evidence suggests that extreme jobs are common, further research is required to assess the antecedents, incidence, and implications of these working practices. Practical implications – A varied, intense, fast-paced role with responsibility and long hours can be rewarding, for some. However, multi-tasking across complex roles can lead to fatigue, burnout, and mistakes, patient care may be compromised, and family life may be adversely affected. Originality/value – As far as the authors can ascertain, there are no other studies exploring acute sector management roles through an extreme jobs lens.