Wake-Promoting Therapeutic Medications Not an Appropriate Alternative to Implementation of Safer Work Schedules for Resident Physicians

Abstract

We appreciate the comments from Dr Czeisler in response to our recent editorial in Mayo Clinic Proceedings on whether wake-promoting drugs could be used by resident physicians to improve their performance during sleep deprivation. Our editorial recognized that the carefully controlled study conducted by Czeisler et al in shift workers did not compare a pharmaceutical alternative to work-hour restrictions for resident physicians, did not analyze a population that worked shifts longer than 12 consecutive hours, and did not evaluate the use of stimulants in the military. Some of these differences between his study population and resident physicians were specifically noted in our editorial, including the age of the study participants relative to the typical age of resident physicians, the fact that most residents work more than 5 night shifts per month of greater than 12 hours' duration, and the fact that residents seldom work night shifts for 3 or more consecutive days. Our editorial did not advocate the use of armodafinil (or any other wake-promoting medication) among resident physicians and liberally identified the ethical issues associated with performance-enhancing drug use among physicians. Nonetheless, we thought that the concept of a strategy, if there is a strategy, in which a pharmaceutical agent might be used to counteract the effects of fatigue on patient safety and physician learning is timely and provocative. As such, our editorial discussed the potential application and consequences of wake-promoting drugs in a population of health care professionals often discussed as being at risk of deficient wakefulness. Our editorial did not comment on current or further restrictions of resident physician duty hours. The ACGME is reviewing extensive data and recommendations from the Institute of Medicine, the American Academy of Sleep Medicine, and many other sources as it grapples with the complex issues related to resident physician work-hour restrictions in the programs they accredit. Duty hour restrictions remain the primary focus of the ACGME as it studies resident fatigue and its impact on patient safety and resident learning. However, further work-hour restrictions introduce new concerns about patient safety, including the quality of communication during transfer of patient care and assigning residents responsibility to care for a larger number of patients during call assignments. Another concern is that, unless appropriate countermeasures are taken, further resident duty-hour restrictions may be used by resident physicians to perform additional moonlighting physician work. In such a scenario, moonlighting residents might return to the residency training site fatigued, less able to learn, and less able to care for training-program patients. One school of thought suggests that, if resident physicians are required to work long hours (ie, a workload that will mimic their activities after completing residency training), the work is better performed in the supervised work environment of a residency training program than in unsupervised or undersupervised environments elsewhere. Currently available data are inadequate to definitively address the impact of restricted duty hours and/or the use of wake-promoting medications by physicians to provide safer patient care or to promote learning. We think that all the science available should be included in the debate on how best to ensure patient safety and adequately train our future physician workforce. Therefore, the concept that drugs shown to be effective in other forms of shift work might be used during physician training should not be dismissed reflexively.