Welcome to season 5, episode 5 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of a junior resident who witnesses her attending physician taking stimulants to function during his night shift. Check out the case and join the conversation in the comments section! We’d love to hear your thoughts on this controversial topic!

The Case of the Night Shift Stimulants

By Tamara McColl, MD FRCPC

“I can’t believe Dr. Shaw didn’t show up for his shift!” chuckled George. “He probably slept through his alarm. It’s harder for the old guys to work night shifts…”

Sam looked around the department.

It was a busy night and they were off to a rocky start. The night shift attending, Dr. Shaw, was nowhere to be found and the evening attending was waiting anxiously for the arrival of the on-call staff, Dr. Rivers.

Sam and George, both emergency medicine residents, had cases to review. They were seated by computers, waiting for Dr. Rivers. George was continuing to joke about the possible scenarios leading to Dr. Shaw’s absence, and was starting to get on Sam’s nerves. He suggested that maybe Dr. Shaw had stopped by the roadside to rescue a stray kitten.

Sam rolled her eyes and sighed, “I’m going to check if Dr. Rivers has made it in yet.”

She wandered over to the physician office and punched in the code. She was immediately met by a bleary-eyed Dr. Rivers. He looked like he had just rolled out of bed.

“Oh! you made it!” chirped Sam, excited to see him. He was one of her favourite staff physicians. Dr. Rivers was one of the younger doctors in the group and was well-versed in the latest evidenced-based medicine. He loved to teach and always found creative ways of making shifts educational with post-it pearls, practice oral cases, ECG cases, or bedside teaching.

Dr. Rivers rubbed his eyes and ran a hand through his hair.

“I was definitely not expecting to get called in tonight. I’m exhausted. Just worked two nights in a row at Riverside Emergency, so I was hoping to get a good sleep tonight. No rest for the wicked, right? Why don’t you get your cases and charts organized and I’ll meet you out there in two minutes.”

Sam was just about to exit the office when she realized she should grab an evaluation sheet while she was in the room rather than coming back for it later. She made her way to the back of the office and then stopped abruptly. Dr. Rivers took two pills out of a Ziploc bag and put them in his mouth.

“Sorry! I just came back to grab an evaluation sheet. You sick or something?” she asked with a skeptical tone.

“Oh no. Um, I just take these once in a while when I really need to wake up for a shift and coffee isn’t cutting it.” Dr Rivers laughed nervously. “It’s no big deal, really. It’s only Adderall, nothing dangerous. I don’t take them often at all.”

Sam smiled politely.

“Yeah, no big deal.”

She grabbed the evaluation sheet and walked back to the department, thinking about the encounter.

“I wonder if the other doctors use stimulants to stay awake? It’s probably pretty common among shift workers. I’ve been finding it harder and harder to deal with multiple night shifts as well. Maybe I should try something like that…”

Discussion Questions

  1. How should Sam deal with the situation of finding her attending physician taking stimulants before a night shift? Is it normal practice? Should she tell someone?
  2. What strategies can shift-workers incorporate into their routine to offset the challenges of working nights?
  3. What safety issues arise from this case? How can a department better protect the well-being of its staff and residents when it comes to sleep deprivation and burnout?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

Our 3 experts for this month’s case will be:

  • Dr. Lisa Thurgur
  • Dr. Marco Sivilotti
  • Dr. Taryn Taylor

On March 9th, 2018, we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba