Innovation stems from necessity. A nationwide shortage of medical specialists coupled with a tech-savvy patient population is an opportunity for advances in health care access. Because sleep medicine is a not a procedure-based specialty, our field holds special promise for telehealth-based approaches. Across the United States, there is a marked shortage of sleep medicine physicians, with an estimated patient to physician ratio of 43,000:1.1 Validated questionnaires for estimating pretest probability for sleep-disordered breathing, computer-based cognitive behavioral therapy for insomnia (CBT-I), home sleep testing, actigraphy, commercial wearables, and modem-enabled continuous positive airway pressure devices provide a robust platform for effective sleep telehealth. Sleep telehealth has already been evaluated in a number of settings and has promise for remote care in particular.2–4
Given the pace of advancing digital technologies, remote sleep technologies will move faster than earlier innovations in medical care that have impacted training programs to date. For example, widespread incorporation of laparoscopic surgical techniques and newer (computed tomography) imaging modalities have continued to evolve since they first entered mainstream practice > 2 decades ago.5 Today, the consumer obsession with self-monitoring activities such as fitness trackers and sleep is fostering innovation at an exponentially faster pace, with personal proprietary data for which patients look to their health providers for validation. If our community dismisses these digital innovations and attempts to force patients to fit into a narrow box of current sleep medicine diagnostic modalities, in all probability our specialty will be divided and incorporated into primary care or historic “home” specialties (neurology, psychiatry, pulmonology).
In the current issue of the Journal of Clinical Sleep Medicine, Fields and colleagues6 present results from a survey-based study exploring tele-sleep training/services among academic sleep medicine fellowship programs. This is an important and timely topic, especially as the field tries to understand how telehealth can best be utilized to enhance and expand patient care. The authors surveyed fellowship program directors, whose perspective best reflects the future of our field. Certainly, if telehealth is part of the future of sleep medicine, then those training our future clinicians should lead this evolution. At the same time, sleep medicine specialists practicing in academic settings do not have the same volume, demands, or financial considerations as do community-based providers. Thus, the opinions of program directors might differ substantially from providers outside of academia.
The present study by Fields et al6 demonstrates that, although most sleep program directors agree that sleep telemedicine is important and should be incorporated into fellowship curricula, there is a dearth of specific guidance, and concrete steps are vague and not actively pursued. Unfortunately, the majority of respondents in the study by Fields and colleagues reported that they do not provide any telehealth experiences for their trainees. Second, the response rate was low, even among a small sample. Less than half of program directors completed “at least part” of the survey, and the number of program directors who completed the entire survey is not reported. Even so, if we extrapolate results of this study to all sleep medicine fellowships, only 10% of fellowships currently include a tele-sleep program or any training in tele-sleep approaches. Given the national obsession with sleep and wellness, as well as the omnipresence of inexpensive wearable technologies worn by patients, the absence of structured training is concerning.
Although Fields and colleagues6 found that a slight majority of responders reported that tele-sleep is important, their results also demonstrate that the vast minority of fellowships do not include any related training. And, the few programs that do offer tele-sleep training do not follow a standardized curriculum. This inconsistency is disconcerting, and difficult to explain. A major risk is that our hard-working fellows and trainees are not being fully prepared to meet the future needs of the community.
Fields and his coauthors have put sleep clinicians and educators on notice that a serious gap exists in our training programs, which might be placing our specialty at risk. Perhaps a cultural shift in our thinking and practices needs to start with our academic centers.
So what is the solution? How do we embrace sleep telemedicine and effectively educate the next generation of sleep physicians? In our experience, the military has serious problems with access to care in sleep medicine, both at larger medical centers that have training programs for sleep as well as smaller medical clinics around the world. Sleep disorders are prevalent in the military due to mission requirements, deployments, and shift-work demands, and nearly 50% of the active Army have a documented sleep complaint.7 There is also a huge opportunity to use tele-sleep innovations to monitor sleep and rest for safety reasons in this population. At Walter Reed National Military Medical Center we are presently employing sleep telemedicine strategies as part of a funded study and looking at how to incorporate these strategies in graduate medical education at the sleep and primary care levels.
DISCLOSURE STATEMENT
E.M.W.’s institution has received research funding from the AASM Foundation, Department of Defense, Merck, and ResMed. E.M.W. has served as a scientific consultant for DayZz, Eisai, Merck, and Purdue and is an equity shareholder in WellTap. The other authors report no conflicts of interest.
CITATION
Collen JF, Wickwire EM, Capaldi V, Lettieri C. Losing sleep! Are we missing the future of sleep medicine? J Clin Sleep Med. 2020;16(4):473–474.
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