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November, 2015
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The Competitive Advantage written on Friday October 21, 2011

When does a competitive advantage cease to be one? When competing, there are myriad ways that one may get an edge on his or her adversary. And, with burgeoning technology, that number gets larger by the day. My question really relates to when a simple advantage becomes an unfair advantage, maybe even cheating?

Does the distinction come in when the law is involved? Legal advantages are not cheating, but illicit ones are? With the slow adaptation of the legal system, particularly in the United States, the distinction cannot be as simple as that. Blood doping is a legal practice in the United States but most sports outlaw the practice as it provides an unfair advantage to the doper. Even when the source is one's own blood being collected, concentrated and reinfused, there are clear cut rules against it.

Obviously, amphetamines are outlawed for all competitions, right? Well, not all stimulants fit into the phenethylamine class of drugs, as amphetamines do. I sit here drinking my morning coffee and it surely gives me a competitive advantage, by just looking at how I would be without the coffee, one can easily see that the caffeine is performance enhancing. Sans coffee, I will be slow, sluggish, tired. With the coffee, I can easily make it through all my classes this morning without trouble, taking notes, paying attention and complete all of the activities necessary throughout the day with ease. Is that giving me an unfair advantage against my peers? All exams are curved by some percentage and the better I perform, the lower the curve is for the rest of the class. If we all fail, the curve ends up somewhere in the range of 10%, so there is significant wiggle room. Maybe coffee should not be included because it is readily available to everybody, simply prepared and the stimulant effects of caffeine are nowhere near that for other drugs.

What if we step it up a bit and concentrate on the amphetamines again? If I take speed prior to class, I will have heightened awareness, increased concentration; in general, I will be a better student. But, I will surely be breaking several laws and many ethical codes against cheating, right? What if the amphetamine is a prescription? What if I were diagnosed with Attention Deficit Hyperactivity Disorder? Would it be acceptable for me to take my dextroamphetamine/levoamphetamine (Adderall) prior to class? If it is alright for the one with the diagnosed disability, would it be the same for those who do not have ADHD? Or what about those who think they have ADHD and have found a source for the drugs? Do not even include those who are intentionally trying to gain an unfair advantage; I think that what they are doing is surely cheating, but what about those simply trying to level the playing field? It is hard to argue against those with the diagnosed disability from taking drugs which will help them be able to participate in society in a more 'normal' manner, but I think that many would argue that those who do not have the disability should not be abusing the drugs in order to get an advantage over their peers. But, they might argue, they are simply trying to perform better, to learn more, to become better doctors. Many were science majors in their undergraduate lives, so they should have the ability to analyze scientific literature and decipher the ill effects of taking these drugs on a regular basis, not limited to addiction, organ damage and death. Both drugs that I mentioned are Schedule II in the United States and similarly scheduled in the other industrialized nations. But, since there are so many people currently diagnosed with ADHD (approximately 9.5% of children, 5.4 million, between 5 and 17, according to CDC, these drugs are readily available to anybody wanting to take them.

Let us suppose, to consider this situation on a grander scale, that we do not have this grey area. We have decided that these individuals are allowed to do as they please with their bodies, that they are not directly injuring anybody else and, even though they are violating the law, they are not doing anything morally objectionable by taking drugs to do better in school. We could even argue that it is a positive thing. We want our physicians to be as knowledgeable as possible, to have done as well in school as possible, right? These are the people who will be treating our children, operating on us when we need surgery, potentially holding our loved one's life in their hands when everything is on the line.

And we have arrived at the situation that I want to get to. When everything is on the line, when it is a life or death matter, who do you want as your physician? The person who was the valedictorian of his or her medical school class? Or the one who barely made it through but still got licensed? I think that most would want the valedictorian, the one who knows the most, the one who is best able to diagnose disease, the one who will be able to easily treat you and have you home for Thanksgiving dinner. That is what the licensing exams and the residencies are looking for in the United States, or at least how I understand it. Schools are surely looking for that. But what if these highly above average performers do so by taking the above mentioned drugs, like Adderall or Ritalin? Assuming equal intelligence, they are studying equally to their peers, so they work just as hard, they just gave themselves a little help during medical school to learn the material. The thing about medicine, though, is that you are never done learning. After medical school, you cannot practice medicine on your own, you do not know enough. You need to complete a residency that takes between 3 and 5 years, usually, and then there is sub-specialty training and fellowships and all sorts of requirements for learning. And all that time, you are treating patients. So, our young physician took Adderall during medical school, scored high enough on the USMLE to be licensed, got a good residency and is on his or her way to becoming an excellent physician. But, he or she decided that Adderall during medical school just was not enough. There is more material during residency and then there is continuing medical education. And there are extremely long hours during internship and residency, Adderall is a necessity at that point. Somewhere in here, he or she becomes addicted to the medication. How could our young physician not? He or she has taken the drug regularly, or even off and on during particularly stressful periods, for upwards of four years. The real problem comes when the prescription bottle is empty or the Adderall is not enough. Even if the young physician does not move on to another, stronger stimulant, what happens when he or she has just laid down in the physician's lounge after a long 12 hour shift, or so, and a major trauma comes into the emergency department which he or she is now covering? Just pop a few pills, run down stairs and start triaging patients? What if there are no more pills? What does our young physician do? How does he or she handle the three, four, five or more critical patients that are on their way to the hospital? It is mere minutes until the first patient arrives. They cannot be directed to another hospital because this one is far from capacity. The young physician will just have to fight through the tiredness, probably make mistakes, maybe kill somebody in the process. But he or she does not have the skills to fight the extreme exhaustion, our young physician has been medicating for years to stave that off. What does he or she do now? And do you want to be one of the patients about to arrive in our hypothetical emergency department?

I do not really know how to end this post, but this is basically where I got to in my own thought process. And it will surely be the end for one of those patients in our hypothetical emergency department.

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