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Mayo Clin Proc. 2010 March; 85(3): 301.
PMCID: PMC2843117

Fatigue, Countermeasures, and Performance Enhancement in Resident Physicians

To the Editor: While reviewing the November edition of Mayo Clinic Proceedings, I read the article by Drs Steven Rose and Timothy Curry1 regarding residents' fatigue and the medication armodafinil to improve performance, minimize risk of medical errors, and allow residents to work long shifts without feeling sleep deprived.

Being a third-year resident in internal medicine, I have worked 30 hours continuously and have committed medical errors due to fatigue and sleep deprivation. Therefore, I understand the rationale for trying to find means by which residents can cope with both fatigue and sleep deprivation and, if possible, eliminate errors and poor patient outcomes. However, as a physician, above all, I bear in mind the Hippocratic oath: First, do no harm. I strongly think that the authors are suggesting that this ethical law be broken, by harming residents both physically and mentally. They think that using medications to stimulate the release of neuromediators during normal sleep cycle would increase performance of residents, most likely without major adverse effects, and that this could be an appropriate strategy to enhance learning, training, and overall performance.

I feel insulted as a physician, a scientist, and a human being by the violence encrypted in that statement. I fear that our humanitarian qualities have been lost. Residents are human beings, and even though they are in training, they are not experimental subjects under a fascist regime. Nobody can expect a physician to use a sleep suppressant and an attention stimulant to perform better under any conditions. As physicians, we counsel our patients who use illegal stimulants to stop such “abuse;” now the authors are proposing that physician residents become drug users.

If resident training with a 16-hour call model is inadequate, the duration of residency can be increased to 4 or even 5 years. Since attending physicians do not have an hourly limit or a cap, physicians should press the Federal Government to pass a law to make their work hours more manageable. With this approach, residents would work the same hours after graduating from their residency program, and their quality of life would improve. This would not push physicians to use stimulants or other substances in order to tolerate the stress of the work hours, and this would definitely increase the time and the quality of that time spent with the physician's family and overall satisfaction.

Finally, I think that instead of moving backward, allowing residents to use stimulants to compensate for their fatigue, a policy should be instituted that respects the dignity and promotes the independence of all human beings; with this approach, such intense fatigue would not be a problem. This policy should respect the personality of the physician, during and after training. Such a policy should oversee the working hours and duties of both attending physicians and residents, in all specialties and training levels, and should strictly follow the Institute of Medicine recommendations.


1. Rose SH, Curry TB. Fatigue, countermeasures, and performance ehancement in resident physicians [editorial]. Mayo Clin Proc. 2009;84(11):955-957 [PMC free article] [PubMed]

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