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Modafinil has mixed effects on dozy surgeons

NEW YORK (Reuters Health) - The sleep-fighting medication modafinil may boost the brain power of weary surgeons, but doesn’t help their operating skills in a simulator, a new report shows.

While the authors stop short of urging healthy surgeons to take the drug, made by Cephalon Inc and sold as Provigil in the U.S., they say caffeine just doesn’t cut it for over-worked doctors.

“Our results suggest that fatigued doctors might benefit from pharmacological enhancement in situations that require efficient information processing, flexible thinking, and decision making under time pressure,” write Dr. Colin Sugden of Imperial College London and colleagues.

The debate over whether bleary-eyed doctors should be trusted with life-and-death operations that require quick thinking and lots of dexterity has been going on for years.

Experts say tens of thousands of Americans die every year due to medical errors, most of which are related to surgery. Although it is still unclear how lack of sleep affects performance in the operating room, several studies have shown it leads to a drop in both mental and manual skills -- especially in less-experienced surgeons.

The new study, funded by Imperial College London and published in the Annals of Surgery, is the first to test modafinil on a group of sleep-deprived doctors.

The researchers kept 39 young surgeons awake overnight, giving half of them a modafinil pill and the rest a dummy pill. At 6 a.m., the doctors completed a range of psychological tests and did a virtual surgery on a simulator.

Modafinil had no effect on most of the parameters in the tests, like how many attempts the doctors needed to move a bunch of colored balls into a certain arrangement or how long they took to deliberate before making a decision.

But the drug did seem to boost some types of mental agility. For instance, it cut the number of errors from 2.7 to 1.6 in a short-term memory task where the order of a series of boxes had to be recalled.

Modafinil also reduced the time doctors needed to plan a complicated move of balls into a given pattern.

According to the researchers, this is probably due to the chemical’s effect on the prefrontal cortex, a part of the brain intimately involved in high-level cognition like goal-oriented behavior and short-term memory.

The drug didn’t improve performance on the surgery simulator, however, and it remains unclear what impact it would have on real-life surgery, if any.

“The potential for performance-enhancing drugs to help fatigued doctors to help their patients is tempting,” Dr. James H. Lubowitz, a surgeon who was not involved in the work, told Reuters Health by email.

“However, like in sport, drug risks may outweigh benefits, and further investigation is warranted before the results of the published trial should be considered clinically relevant,” said Lubowitz, who heads the Taos Orthopaedic Institute in New Mexico.

While there weren’t any serious side effects in the new study, people who take modafinil commonly experience headaches, nausea or dizziness. In rare cases, the medication may also cause a serious rash or allergic reaction.

In the U.S., modafinil is only approved to treat sleep disorders such as narcolepsy and obstructive sleep apnea.

Lubowitz said that several countries, including the U.S., now have limits on the maximum duty hours and on-call time for resident doctors in an attempt to improve patient safety.

But after surgeons have completed their training, they are left to their own devices.

“Doctors must self-monitor, and be monitored by their peers, for signs of excessive fatigue,” said Lubowitz. “A good night’s sleep is the time-tested treatment for exhaustion.”

SOURCE: Annals of Surgery, online October 12, 2011.