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We read with great interest the comments of Dr Paparodis regarding our editorial. Paparodis vehemently objects to us raising the question of whether resident physicians should use stimulant drugs, such as modafinil, to promote attention and wakefulness. He thinks that by doing so we are breaking an “ethical law” and suggests that, if residents are allowed to use modafinil or other attention aids, it would be akin to treating residents as “experimental subjects under a fascist regime.” Paparodis further contrasts our comments with the efforts of physicians to keep their patients from using illegal stimulants.
We must point out that we did not advocate the use of modafinil by resident physicians. Additionally, we are not promoting, in any fashion, the use of illegal stimulants. Indeed, as practicing anesthesiologists, we are well aware of the career- and life-destroying effects of physician drug abuse and addiction and support the “one strike and out” stance that is gaining momentum.1,2 Instead, our editorial questioned whether the use of physician-prescribed wakefulness aids, such as the approved drug modafinil, could be translated from off-label use in other shift workers to use by resident physicians to improve their performance and prevent them from harming themselves and their patients because of errors caused by fatigue. Dr Paparodis stated “Nobody can expect a physician to use a sleep suppressant and an attention stimulant to perform better under any conditions.” The article by Czeisler et al,3 which prompted our editorial, suggests that this may in fact be possible. Physicians, including those in training, already legally and commonly use substances (eg, caffeine and nicotine) that alter the release of neuromodulators for the purpose of stimulating the central nervous system. The fact that these are not considered “drugs” because they are naturally occurring compounds (albeit highly processed) is only a matter of regulation. However, as discussed in our editorial, the data of Czeisler et al are from a nonresident physician population, and extrapolation of the data is difficult. We also raised a number of serious questions, including whether it would be ethical or feasible to permit or recommend the use of modafinil by resident physicians.
Duty hour restrictions currently in place in US residency training programs were not intended to increase the “time and the quality of that time spent with the physician's family,” as mentioned by Dr Paparodis, although that may be a welcome benefit. Rather, they were developed with the goal of reducing medical errors. Regardless of any regulations for physicians during or after training, medical decisions and actions must be made at times when the practitioner is experiencing fatigue. What if a legal stimulant that is shown to be safe could be used to improve medical care during periods of fatigue, regardless of the number of hours worked? Would not the more ethical choice be to promote the reduction of errors—First, do no harm? With publication of original research articles such as that by Czeisler et al in Mayo Clinic Proceedings, use of prescribed drugs to promote wakefulness in the absence of comorbidities, such as narcolepsy and sleep apnea, will undoubtedly move from the military into the public arena. As the debate on duty hours and their effect on physician training, patient care, medical economics, and resident well-being will continue to rage on, these types of discussions need to be held in hopes that we can find a strategy to train the next generation of physicians in the most safe, ethical, and efficient manner possible.