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Editorials

Pharmacological enhancement of performance in doctors

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2542 (Published 18 May 2010) Cite this as: BMJ 2010;340:c2542
  1. Colin Sugden, clinical research fellow1,
  2. Rajesh Aggarwal, clinical lecturer in surgery1,
  3. Charlotte Housden, graduate student2,
  4. Barbara J Sahakian, professor of clinical neuropsychology2,
  5. Ara Darzi, professor of surgery1
  1. 1Division of Surgery, Department of Surgery and Cancer, Imperial College London, London W2 1NY
  2. 2University of Cambridge, Department of Psychiatry and MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute, Cambridge CB2 2QQ
  1. a.darzi{at}imperial.ac.uk

    The benefits have not been proved, and more evidence is needed

    In recent years society’s attitude to various types of personal enhancement has shifted. Examples include the popularity of multivitamins and diet pills, the widespread use of caffeine (despite side effects such as anxiety, tremor, and tachycardia), and the unregulated off-label use of methylphenidate (Ritalin), fluoxetine (Prozac), and sildenafil (Viagra).

    Since the serendipitous discovery that drugs used to treat narcolepsy (modafinil) and attention deficit hyperactivity disorder (such as methylphenidate and atomoxetine) can improve the brainpower of healthy people, public and scientific interest has grown. Although the current level of use among doctors is unknown, data indicate that a large proportion of other groups in society (such as students and more senior academics) are currently choosing to use these substances.1

    The scientific, moral, and ethical questions about cognitive enhancement are complex and have been acknowledged as such by the Royal Society and the Academy of Medical Sciences; both have held workshops and public events on the topic. In addition, the BMA has produced a discussion paper about the ethical aspects of cognitive enhancement, which highlights the many challenging problems facing the medical profession should personal enhancement be widely adopted.2

    Fatigue is linked to impairment of human performance; people who are fatigued have frequent lapses of attention and impaired functioning in several important cognitive domains.3 Although measures to reduce doctors’ working hours have been instituted on both sides of the Atlantic, they are not a panacea. Surgeons performing long, arduous operations remain susceptible to the effects of fatigue, and frequent transitions from day to night work expose junior doctors to the risk of impaired psychomotor performance.4 Given the continued need for innovation in this area, pharmacological methods could conceivably be used to combat fatigue at some time in the future. However, they cannot be recommended until the benefits and risks associated with their use have been fully assessed.

    Modafinil, licensed for the treatment of excessive sleepiness associated with narcolepsy, obstructive sleep apnoea, and shift work sleep disorder, is the most suitable agent for promoting wakefulness. It is well tolerated by patients with these disorders,5 has a low risk of misuse, and is effective in combating the effects of fatigue on healthy individuals, military helicopter pilots, and emergency physicians.6 7 8 Although these findings are promising, the impact of modafinil on clinically relevant measures of performance currently remains unknown.

    Beyond increasing wakefulness, performance enhancing drugs may have benefits for healthy, non-fatigued individuals. Studies involving healthy subjects found that modafinil improved performance on tests of working memory and forward planning,9 methylphenidate improved performance on tests of working memory,10 and atomoxetine improved performance on tests of response inhibition (suppression of inappropriate actions).11 Given these findings, it is possible to speculate that doctors who take these drugs may be able to plan an intervention more effectively or show greater cognitive flexibility when approaching a challenging clinical problem. However, for the size and pattern of effects on clinical performance to be fully understood, small, well designed controlled studies, which draw on recent advances in the fields of simulation and neuropsychological assessment, must be performed. These studies will be the first step towards quantifying the effects of cognitive enhancing agents on the performance of doctors.

    When deciding whether or not to use these drugs, doctors must give primacy to the potential benefits and risks for patients and society. However, although most neurocognitive enhancers seem to be safe and are tolerated well by the clinical populations for whom they are prescribed, the risks they pose to a healthy population are not yet well understood. Therefore, in taking enhancing agents for the greater good of society, doctors will almost inevitably place themselves at risk of harms at an individual level. As a result, only when potential personal benefits of enhancement, such as a reduced risk of needle stick injuries or motor vehicle accidents in fatigued people, are considered is the risk-benefit ratio likely to be acceptable. If the benefits are found to outweigh the risks then employers, professional bodies, and policy makers will need to work together to develop standards, guidelines, and legislation to protect clinicians from the possibility of explicit or implicit coercion. The public must also be involved in the debate, and their views acted on. Early indications are that members of society are more likely to agree with cognitive enhancement if motivations for using them are seen to be unselfish.12

    Notes

    Cite this as: BMJ 2010;340:c2542

    Footnotes

    • Competing interests: The authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No support from anyone other than their employers for the submitted work; (2) BJS has consulted for several drug companies and for Cambridge Cognition in the previous three years and has shares in CeNeS; CS, RA, CH, and AD have had no relationships with companies that might have an interest in the submitted work; No spouses, partners, or children with financial relationships that may be relevant to the submitted work; and (4) No non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Not commissioned; externally peer reviewed.

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