Dying for a kip:the importance of sleep medicine

Medical students get about two minutes teaching on it, and there are only a handful of dedicated consultants. Its time we woke up to the merits of sleep medicine say Andy Currie, Ed Peile, and Chris Hanning

Sleep takes up one third of our lives and yet is one of the most poorly understood areas of human physiology. Animals starved of sleep are known to die in a few weeks,1 and people are no different. Falling asleep at the wheel of a car kills more people on the roads than any other cause, and sleep deprivation has been blamed for many public health emergencies, including the Challenger shuttle disaster and Chernobyl. Problems sleeping is one of the commonest reasons a patient will present to their doctor2 and yet sleep medicine receives hardly any coverage in the undergraduate curriculum.

MAURO FERMARIELLO/SPL

UK situation

Sleep medicine in the United Kingdom is currently the preserve of a small number of interested clinicians, mainly with backgrounds in respiratory medicine, anaesthetics, or neurology (box 1). There is no formal training structure or official governing body. The British Sleep Society (www.sleeping.org.uk) has an active membership of clinicians, scientists, and healthcare workers and acts to promote awareness of sleep. In contrast, the USA has a very well circumscribed, well respected training system and it is possible to board in sleep medicine--the equivalent of gaining your CCST in the United Kingdom.3

How common are serious sleep problems?

Sleep medicine is not confined to rare respiratory or neurological conditions. Obstructive sleep apnoea (OSA) is an extremely common condition with 1-2% of middle aged men suffering--about the same number that have insulin-dependent diabetes.4 OSA is not just important to those interested in sleep. Diabetes mellitus, cancer, and chronic obstructive pulmonary disease (COPD) all have drastically increased morbidity when associated with OSA, and time and again it has been shown that the successful treatment of OSA improves the quality and length of life in people with these conditions.5 Simply by managing a patient with OSA using continuous positive airway pressure (CPAP) treatment reduces the blood pressure to such an extent that cardiac risk may fall by 20%, and stroke risk by 40%, over five to 10 years.6

Sleep medicine is also relevant to psychiatry (which came first--the depression, or the chronic fatigue?), paediatrics, and cardiology--in fact almost any specialty you can think of. So it helps if sleep physicians have wide-angle vision.

What do sleep physicians do?

Sleep medicine physicians spend most of their time working out the cause of excessive sleepiness and look after patients primarily on an outpatient basis. They have patients referred to them with advanced OSA and more complex sleeping disorders like narcolepsy and paediatric problems. Drawing up a sleep diary with a patient will often show an obvious cause (for example, sleep deprivation or shift work), but often further electrophysiological tests during sleep are required. Electroencephalographs (EEGs) of brain activity can give detailed information about sleep phases, but these studies require the patient to spend time in a sleep laboratory. However, cheap portable monitors worn on the wrist can detect muscle activity indicating if the patient is awake or asleep. These can help in narrowing down the cause of a patients sleepiness.

How does a sleep service work?

It takes around three to four months from sending the referral letter to getting an appointment in the clinic for a sleep study. The time it takes from a sleep study to follow up is about one to four months depending on the severity of OSA. The waiting list for definitive treatment (CPAP) is another one to four months, depending on severity so patients will take a long time to see you and you will have a long clinical relationship. A sleep disorders centre can receive about 800 new referrals per year, more than 2000 patients on CPAP and continuing follow up add about 220 per year.

RAY CLARK & MERVIN GOFF/SPL

Qualities of a sleep physician

Caring for patients with sleep problems requires doctors with excellent communications skills, since many patients find it very difficult to talk about their problem or believe it not serious enough to trouble the doctor. In addition, many individuals with chronic insomnia can suffer greatly with depression and will need a physician who feels comfortable in consulting. With upwards of 20% of accidents happening on Britains roads each year because of sleepiness,7 sleep physicians need to be aware of public health issues. Although pharmacological therapy is of benefit in some cases, many sleep related conditions are now being treated with psychological therapies and the modern sleep physician must be capable in using these. Diagnosing rarer sleep conditions can be intellectually challenging and satisfying (box 2).

Career progression

A higher degree, such as an MD or PhD, is an asset to an aspiring sleep physician. The focus of these could be either a lab-based investigation or a clinical sleep condition, like OSA. Several well respected sleep research centres exist in the United Kingdom such as Loughborough, Surrey, Edinburgh, and Oxford, which offer sleep research opportunities.

Those doctors wishing to practise sleep medicine in their future careers would also be advised to take some time in their higher specialist training to work in the USA, where there are more structured training programmes.

American training scheme

In the US, you can gain formal accreditation in sleep medicine. After completing their internships, doctors wishing to pursue sleep medicine accreditation (fellowship) will enter residency programmes, commonly in either neurology or general internal medicine. Fellowship training in sleep medicine is a subspecialty programme, post-residency, lasting 12 months to two years, leading to a physician being boarded, or board certified, with the American Academy of Sleep Medicine. The content of most fellowship training includes basic medical science, clinical aspects and management within internal medicine, neurology, psychiatry, and social medicine as related to sleep.

Yale, Stamford, and University of Texas South Western run very competitive fellowship programmes. The American Board of Sleep Medicine has an established policy allowing non-US doctors to take the fellowship exams, and to become registered with them as a Certified International Sleep Specialist.

Sleep medicine at medical school

Undergraduates have very limited exposure to sleep medicine--if any at all. Recent evidence suggests a median of just a couple of minutes is devoted to teaching the importance of sleep to medical students.8 Warwick Medical School is progressive in that it runs an SSM (special study module) in the subject, where students are exposed to all aspects of sleep and can see patients in sleep laboratories.

Advantages and disadvantages

Because sleep medicine is such a new field it means there is much room for research and creativity in providing a sleep service. A wide knowledge base is required, with an understanding of respiratory medicine, neurology, and critical care medicine all useful. It is unclear how Modernising Medical Careers will affect those wishing to train in sleep medicine, but it is hoped that opportunities for subspecialisation will be available in all the higher medical training programmes.

On the more negative side, sleep medicine is currently underfunded and anyone considering sleep medicine as a future career should take this into account. At the moment there are no consultant posts devoted exclusively to sleep medicine, and those wishing to lead a sleep service will probably have to gain their consultant post and then set one up themselves. This will require significant entrepreneurial skills and persuasive argument, although some may see this as an advantage (box 3).

Final words

Whether a career in sleep medicine interests you or not, an understanding of sleep is imperative. How can you ignore something the body does a third of the time? Modern society puts sleep at the bottom of a long list of problems, but modern medicine neglects the importance of sleep at its peril.

Andy Currie, second year graduate student,

Ed Peile, head of division of medical education and associate dean (teaching), Warwick Medical School, University of Warwick, Coventry
Email: a.c.currie@warwick.ac.uk

Chris Hanning, consultant in sleep disorders medicine, Leicester General Hospital, Leicester


studentBMJ 2005;13:89-132 March ISSN 0966-6494

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