Sleep medicine exposure offered by United States residency training programs

Abstract

Study Objectives:

To understand the sleep medicine educational exposure among parent specialties of sleep medicine fellowships, we conducted an online survey among Accreditation Council of Graduate Medical Education–approved training programs.

Methods:

Target respondents were program directors of family medicine, otolaryngology, psychiatry, neurology, pediatrics, and pulmonary and critical care training programs in the United States. The survey was based on the Sleep Education Survey, a peer-reviewed, published survey created by the American Academy of Neurology Sleep Section. The modified 18-question survey was emailed via Survey Monkey per published methods totaling 3 requests approximately 1 week apart in January 2017.

Results:

A total of 1228 programs were contacted, and 479 responses were received for an overall response rate of 39%. Some programs in every specialty group offered a sleep medicine elective or a required rotation to trainees. Pulmonary and critical care and neurology reported the highest percentages of sleep medicine rotation as an option for housestaff (85.7% and 90.8%, respectively), and pulmonary and critical care had the highest portion of programs indicating a rotation requirement (75.4%). Teaching format was a mixture of didactic lectures, sleep center/laboratory exposure, and case reports, with lectures being the most common format. Didactics averaged 4.75 h/y. Few programs reported trainees subsequently pursuing sleep medicine fellowship (<10% produced a fellow over 5 years), and even fewer reported having a trainee who pursued grant funding for sleep-related research over 5 years.

Conclusions:

There is wide variability and overall low exposure to sleep medicine education among United States “parent” Accreditation Council of Graduate Medical Education training programs whose medical boards offer sleep medicine certification.

Citation:

Sullivan SS, Cao MT. Sleep medicine exposure offered by United States residency training programs. J Clin Sleep Med. 2021;17(4):825–832.

BRIEF SUMMARY

Current Knowledge/Study Rationale: Sleep education and exposure in Accreditation Council of Graduate Medical Education–accredited primary parent specialties with a stake in sleep medicine education has not been well studied. This study aimed to understand the prevalence, amount, and type of sleep medicine training opportunities among United States “parent” Accreditation Council of Graduate Medical Education training programs whose medical boards offer sleep medicine certification.

Study Impact: Evidence indicates limited and/or absent sleep medicine training in most parent specialty programs and suggests a consequent narrowing of the pipeline of sleep medicine providers and researchers. Results of this survey may help provide a valuable framework for development of curricula to include sleep medicine education uniformly across training programs.

INTRODUCTION

Sleep disorders are highly prevalent in the general population and associated with significant morbidity, mortality, and diminished quality of life. Yet, sleep disorders are commonly under-recognized and underdiagnosed among health care providers. A contributing factor to this issue is lack of education regarding sleep and sleep disorders, ranging from college to graduate and postgraduate training. Although core competencies for sleep education in US medical schools were developed by Dement et al in 1988¹ and Strohl et al in 2003², and for adult pulmonary and critical care subspecialists by the American Thoracic Society,³ there seems to be ongoing limited education at multiple levels of education in sleep medicine.⁴ Currently, a unified curriculum or requirements for sleep education for US medical residencies does not exist.

Previous surveys published in 1980, 1993, and 2011 reported the average amount of teaching time devoted to sleep education in medical schools of approximately 2 hours.^5–7 Mindell et al⁸ surveyed sleep education in 152 pediatric residency training programs across 10 countries and reported an average of 4.4 hours dedicated to sleep education, with 23% of programs provided no sleep education. Avidan et al⁹ surveyed sleep medicine education in 58 US neurology residency programs in 2013. The authors reported that 81% of neurology residency programs offered a formal sleep medicine rotation, and 24% included a forum for sleep medicine–related research. The program directors also noted that 5.7% of neurology residents entered sleep medicine fellowship programs, and those who entered formal sleep medicine fellowships were trained in institutions that offered more exposure to sleep medicine. In a survey of psychiatry chief residents, Khawaja et al¹⁰ reported that only 34% of programs offered an elective rotation in sleep medicine, and, with the exception of obstructive sleep apnea and restless legs syndrome, more than half of respondents felt uncomfortable diagnosing the majority of sleep disorders. Capasso et al¹¹ surveyed 103 Accreditation Council of Graduate Medical Education (ACGME)-accredited otolaryngology program directors on residency training experiences in adult sleep medicine and sleep surgery. The authors reported that, although 59% of programs reported at least 1 faculty specializing in sleep medicine, clinical time dedicated to the practice was particularly low. Also, a significant number of program directors reported wishing to expand resident exposure to sleep medicine and sleep surgery.

The aforementioned surveys suggest that exposure to sleep and sleep disorders at multiple levels within certain specialties may be variable and limited, and tools to assess this also vary. A standardized measure of sleep education to compare content across multiple training pathways has not previously been undertaken. Lack of exposure to sleep medicine may account in part for less familiarity of sleep disorders among medical providers. Residency training is a unique opportunity to formally provide sleep education in the fields where it is most relevant to proper patient management of adult and pediatric sleep disorders. The medical fields of internal medicine (including pulmonary and critical care subspecialty), family medicine, otolaryngology, psychiatry, neurology, and pediatrics are deemed to be most important for knowledge regarding healthy sleep and sleep disorders in adults and children. There are little to no data across residency education in these specialties assessing coverage of sleep education. Thus, the purpose for this study is to survey the current amount of sleep education provided in these primary and specialty training programs. This will provide a valuable framework for development of curricula to include sleep medicine education uniformly across training programs.

The aims of this study were to understand the prevalence, amount, and type of sleep medicine training opportunities among 5 of the US “parent” ACGME training programs whose medical boards offer sleep medicine certification plus 1 subspecialty (pulmonary and critical care medicine [PCCM]) and to understand trajectories into further exposure to sleep medicine via research projects or sleep medicine fellowship from the perspective of training program directors. We conducted a survey between December 2016 and June 2017 of training program directors to understand the content, modalities, time spent, and other features of sleep medicine education provided in 5 of the primary residencies from which sleep medicine fellows are drawn, as well as 1 subspecialty.

METHODS

Study design

This was a prospective, cross-sectional survey study of US ACGME training program directors in 2016–2017. An 18-question Survey Monkey survey sent to training program directors for a total of 5 requests over 2 months per specialty. Although responses were de-identified, respondents could opt to provide an email address; if they did, we removed them from further survey requests during the study period. If they provided an email address, respondents were also emailed a Starbucks coupon for $5 as a thank you for taking the survey, even if they did not complete it.

Participants

Target respondents were program directors of family medicine, otolaryngology, psychiatry, neurology, pediatrics, and PCCM training programs in the United States. Email addresses of training program directors were compiled using publicly available information.

Data collected

The data are presented in descriptive form. The survey tool was based on the previously published Sleep Education Survey,¹² created by the American Academy of Neurology Sleep Section and modified to reflect whether a sleep medicine fellowship or accredited sleep center existed at the respondent’s home institution (supplemental material ^{(96.3KB, pdf)} ). This survey asked questions about the size of the residency or training program, number of faculty with sleep medicine specialization and board certification, and affiliation with a sleep clinic or sleep laboratory. Several questions focused on the nature of sleep education including required vs elective rotations, didactics, and exposure to sleep clinic or sleep laboratory, as well as sleep-related research. Finally, the survey asked questions about trainees who pursued sleep medicine fellowship in the last 5 years. The only mandatory question was program type; all other questions could be skipped by the respondent.

RESULTS

Survey responses

A total of 1228 programs were contacted, and a total of 479 responses were received for an overall response rate of 39% (Table 1). PCCM and neurology specialties had the highest return results with 46% and 53%, respectively. Psychiatry and family medicine had the lowest response rates at 33% and 33.3%, respectively. The time to complete the questionnaire ranged between 0 and 2 months.

Table 1.

Survey response by specialty.

	Programs Emailed	Total Completed	Response Rate
Family medicine	457	152	33.3%
Otolaryngology	103	45	43.7%
Pediatrics	200	84	42.0%
Psychiatry	200	66	33.0%
Pulmonary and critical care medicine	142	66	46.2%
Neurology	126	66	52.4%
Total	1,228	479	39.0%

Programs associated with a sleep medicine fellowship program

There was a wide range in reported affiliation with a sleep medicine fellowship program at the same institution. The sleep medicine fellowship program could be located in the same or a different department within the same institution (eg, otolaryngology program reporting a sleep medicine fellowship is within the Department of Neurology). Neurology and PCCM programs reported the highest percentages of association with an ACGME-accredited sleep medicine fellowship program within its institution, followed by otolaryngology, pediatrics, family medicine, and psychiatry (52.4%, 46.3%, 43.7%, 42.0%, 33.3%, and 33.0%, respectively; Figure 1). The sleep medicine fellowship program was housed under the Division of Pulmonary and Critical Care Medicine or the Department of Neurology for most respondents.

Figure 1. Program directors indicating institution has an accredited sleep medicine fellowship program.

FM = family medicine, ENT = otolaryngology, Peds = pediatrics, Psych = psychiatry, PCCM = pulmonary and critical care medicine, Neuro = neurology.

Elective and required sleep medicine rotations

A required sleep medicine rotation varied widely among specialties (0–73.8%) with PCCM reporting the highest number of programs at 75.4% (Figure 2). At least some programs in all specialties reported offering sleep medicine electives to their trainees, ranging from 18.2% (otolaryngology) to greater than 90% (neurology) (Figure 3). PCCM and neurology reported the highest percentages of sleep medicine rotation as an option for housestaff (85.7% and 90.8%, respectively). Overall, the percentages of programs with a required sleep medicine rotation were much lower compared with an elective rotation. Of the programs that required a sleep medicine rotation, the average time spent was between 2 and 4 weeks.

Figure 2. Training programs requiring a sleep medicine rotation.

FM = family medicine, ENT = otolaryngology, Peds = pediatrics, Psych = psychiatry, PCCM = pulmonary and critical care medicine, Neuro = neurology.

Figure 3. Training programs with a sleep medicine elective.

FM = family medicine, ENT = otolaryngology, Peds = pediatrics, Psych = psychiatry, PCCM = pulmonary and critical care medicine, Neuro = neurology.

Affiliation with sleep medicine center and/or sleep laboratory

At least some programs in all specialties reported affiliation with a sleep center (12.3–87.9%) or a sleep laboratory (13.7–90.8%) within its own institution. The affiliation does not translate to housestaff rotation through the center or laboratory, but rather that a sleep center or sleep laboratory exists within the medical institution. PCCM programs reported the highest percentage of association with a sleep clinic and sleep laboratory.

Faculty with sleep medicine expertise

The number of faculty with sleep medicine expertise within the program varied across specialties, with most PCCM and neurology programs having at least 2 sleep medicine faculty (Figure 4). More than half of family medicine, psychiatry, and otolaryngology programs reported having no faculty with sleep medicine expertise.

Figure 4. Number of faculty specializing in sleep medicine.

FM = family medicine, ENT = otolaryngology, Peds = pediatrics, Psych = psychiatry, PCCM = pulmonary and critical care medicine, Neuro = neurology.

Type of sleep medicine education

Sleep medicine teaching format was a mixture of didactic lectures, sleep center and/or sleep laboratory exposure, and case reports. Overall, lectures were the most commonly used teaching format reported by all specialties. The mean duration of didactic lectures was 4.75 h/y for all respondent programs, with PCCM and neurology reporting the highest hours at 7.4 and 5.8 h/y, respectively, and pediatrics with lowest at 3 h/y.

Trainees entering a sleep medicine fellowship

Of 479 programs (responded), 236 trainees entered sleep medicine fellowships over the 5 years surveyed, with the highest being PCCM reporting 114 trainees (from 41 programs), followed by neurology with 41 trainees (from 33 programs).

Housestaff pursuing sleep medicine–related research or grants

There was wide variation among program directors responding to the question, but an overall minority of programs had at least 1 trainee who participated in a sleep-focused scholarly project (poster or slide presentation) at a professional meeting within the 5 years surveyed (Figure 5). Among responding programs, a striking minority of programs reported trainees pursuing grant funding related to sleep medicine at any time within the 5 years surveyed. However, responses were too few to be analyzed; for example, in otolaryngology, 5 program directors answered the question, with 5 trainees total reported. In a few cases, there appeared to be “super-producer” programs, such as family medicine, from which 3 programs reported a total of 7 trainees who applied for grants in sleep research. This could reflect an institutional expertise or the existence of a multiyear training grant housed at the institution.

Figure 5. Responding “yes” to the question: “In the past 5 years, have any of your trainees participated in sleep-focused research?”.

This question was answered by a subset of respondents in each specialty area. “Yes” responses are expressed as a proportion of the total respondents for this question, in each specialty. FM = family medicine, ENT = otolaryngology, Peds = pediatrics, Psych = psychiatry, PCCM = pulmonary and critical care medicine, Neuro = neurology.

DISCUSSION

This is the first study to simultaneously evaluate the current sleep medicine exposure and content across 5 ACGME-accredited primary parent specialties and 1 subspecialty, PCCM, with a stake in sleep medicine education. Results of this study emphasize the gap that exists regarding sleep medicine education across 5 primary parent specialties that offer and oversee sleep medicine board certification at the ACGME level. There is high variability on multiple levels, such as access to sleep medicine faculty, sleep center, and/or laboratory; the amount and type of sleep medicine education being offered; and the relatively low percentage of trainees pursuing a career in sleep medicine, including research. Recent data from the National Residency Matching Program reported an increase in the number of sleep medicine fellowship positions from 2016 to 2020 (142–180, respectively); however, an average of 18% slots were left unfilled.¹³ The potential impact to our field includes thinning of the pipeline of sleep medicine providers and researchers, despite identification of a growing sleep disorder burden.^14,15 Although our second aim was to identify whether certain exposure and educational characteristics might be associated with trainees choosing to engage in sleep-related research projects, grant applications, or sleep medicine fellowship training, we were unable assess this given the overall low numbers of trainees reported to pursue these activities. Given the limits of this type of survey, this could reflect low sleep medicine education engagement among trainees or substantial recall and/or response bias.

The question of how to maintain an adequate pipeline of future sleep medicine providers starts long before sleep fellowship. Salas et al¹⁶ presented an evidence-based rationale for including sleep medicine education and methods of incorporating contents across a 4-year medical school curriculum, despite the “already packed” docket of required items. Residency training (and specific fellowships such as PCCM) is a time when postgraduate physicians are often first given in-depth exposure to the specialty areas that will become their future. Therefore, understanding exposure to sleep medicine training in core training programs is important for the future growth of the field.

A number of specialties and groups have attempted to address the gaps in sleep medicine education in their current training curriculum.¹⁷ Schulman et al¹⁸ developed a multisociety (American Thoracic Society, American College of Chest Physicians, Association of Pulmonary and Critical Care Medicine Program Directors) consensus-based sleep medicine curriculum competencies for pulmonary and PCCM fellowships in an effort to address the paucity and variability of sleep medicine exposure and education across training programs. This consensus was a recommendation rather than a mandate, because the committee was sensitive to limitations in various programs including an already packed curriculum, lack of sleep medicine board-certified faculty, and lack of access to a sleep center or sleep laboratory. Cass et al¹⁹ conducted a survey among academic seep otolaryngologists to determine key sleep-related topics pertinent to training and to subsequently develop an online curriculum to supplement resident education. Although the response rate was <25%, results of the survey reported that sleep-disordered breathing and related content including upper airway anatomy, sleep study interpretation, and surgical techniques were considered most important to otolaryngology residents. Although it is commendable and encouraging to see that various specialties are taking on the development of sleep medicine curricula within their own fields, unless a unified curriculum can be implemented across primary parent specialties that are responsible for sleep medicine education and board certification, the delivery of sleep medicine education will remain variable and fragmented.

Primary residencies have different requirements in terms of what, if any, sleep medicine exposure is mandatory or elective in training. Elective exposure to sleep medicine is mentioned in the program requirements for neurology and pediatrics, as well as internal medicine (internal medicine was not a surveyed group of program directors in the current study). Of the 6 specialties examined in this study, only neurology residency training programs were required to have faculty with specialized training in sleep medicine, and only PCCM fellowship training programs and otolaryngology residency training programs had any kind of required sleep medicine exposure in their curriculum requirements; in both cases, requirements surrounded exposure to sleep-related breathing disorders and not other sleep disorders or normal sleep. For example, ACGME requires PCCM programs to ensure that graduating fellows demonstrate competence in the prevention, evaluation, and management of both inpatients and outpatients with sleep-disordered breathing.²⁰ Schulman et al¹⁸ conducted a survey of PCCM program directors and recent PCCM graduates (2–5 years from fellowship) to assess the current state of education of pulmonary and PCCM trainees in the recognition and management of patients with a wide range of sleep pathology, as well as the current scope of practice of pulmonary and PCCM specialists after graduation. Interestingly, results showed that program directors felt that graduates could diagnose a wide range of sleep disorders including nonrespiratory conditions; a discrepancy from graduates who are expected to manage a wide range of sleep disorders but did not feel comfortable doing so, particularly with nonrespiratory conditions. The discordance between program directors’ perception of sleep medicine exposure provided during pulmonary and PCCM training and the level of discomfort of recent graduates in practice may be attributed to a lack of a uniformly integrated sleep medicine competencies for trainees in programs that oversee sleep medicine education, in this particular case, pulmonary and PCCM programs.

The strengths of this study include that it is the first attempt to assess current sleep medicine exposure and content across 5 ACGME-accredited primary parent specialties and 1 internal medicine subspecialty (PCCM) with a stake in sleep medicine education. Prior studies have focused on a single specialty at a time rather than cross-sectionally across multiple programs funneling trainees to sleep medicine. In addition, the use of a validated refined tool, previously used to assess neurology programs directors, is a strength and allows for longitudinal assessment in this specialty in particular.

Weaknesses of this study include the relatively low overall response rate of 39%, which is expected for this type of study, in which respondents were contacted by email and without prior knowledge of the study and for whom responses were anonymous. Response bias can be a particular concern, especially for low-response programs such as psychiatry and family medicine, where only a third of program directors responded. Interestingly, these are the 2 parent specialties with no mention of sleep medicine in their ACGME curriculum requirements (Table 2). Caution should therefore be exercised when interpreting results for these 2 specialties in particular.

Table 2.

ACGME program requirements for residencies: sleep medicine.

	Neurology	Pediatrics	PCCM	Internal Medicine	Family Medicine	ENT	Psychiatry
Faculty present	+	−	−	−	−	−	−
Required exposure	−	−	Lab available; +SDB	−	−	+; sleep disorders and PSG	−
Elective exposure	+	+	−	+	−	–	−

ENT = otolaryngology, PCCM = pulmonary and critical care medicine, PSG = polysomnography, SDB = sleep-disordered breathing.

Another weakness of this survey of parent training program directors is that 2 parent residencies, anesthesia and internal medicine, were not included. At a high level, this was because of resource limitation; we contacted 1228 programs up to 3 times, and these 2 additional programs represented nearly 700 additional distinct program directors that surpassed available resources. The decision to remove anesthesia programs from the study was based on overall low numbers of anesthesia residents pursuing sleep medicine trajectories including fellowship training. The decision to remove internal medicine was more challenging. Family medicine and internal medicine have the largest and second largest number of training programs of all the parent programs, respectively, with family medicine having slightly more. In balancing budget and breadth of sample, we felt we could capture, to a degree, a subset of internal medicine–trained individuals by sampling PCCM programs. We felt this internal medicine subset might have exposure to sleep medicine education, because sleep medicine is a requirement of the fellowship curriculum and would be an appropriate subgroup to assess within the broader internal medicine universe.

We would expect that many factors are involved in trainee choice of career path: exposure to a specialty area during training is just 1 possible influence. Others include compensation, personal interest and/or passion, mentorship, enthusiasm and engagement among educators, and available opportunity. We did not sample program directors’ attitudes about sleep medicine, which could have provided additional insight at the training program level. For example, if a program does not have much sleep medicine content but the program director believes sleep medicine education is important, then possibly the curriculum may change to include more sleep medicine content in future years. On the other hand, if the program director believes sleep medicine education is elective rather than mandatory, then there may be little to no change in the program’s curriculum. We did review program requirements by specialty for sleep medicine–related required or elective exposure, which may in a general way reflect opportunities for exposure during residency.

In conclusion, this study demonstrates that large differences exist with respect to sleep medicine education and exposure across 5 parent specialties that offer and oversee sleep medicine board certification at the ACGME level, as well as one internal medicine–based subspecialty (PCCM). In addition to great variability in exposure and content between specialties, exposure to sleep medicine is generally quite limited across the board. This could arguably influence the low percentages of trainees reported to pursuing further training in sleep medicine specialty. More work is needed to understand how exposure and content in early training years may directly or indirectly affect specialty choice and career trajectories, but it is possible that this may have important implications for the pipeline of the future sleep medicine clinical and research workforce. Although others have called for promoting the field to potential future trainees,²¹ it is possible that exposure and content are so limited and/or variable among parent training programs that such efforts may not find adequate homes.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. Work for this study was performed at Stanford University School of Medicine. This study was funded by an American Sleep Medicine Foundation Focused Projects Award. The authors report no conflicts of interest.

ABBREVIATIONS

ACGME

Accreditation Council for Graduate Medical Education

PCCM

pulmonary and critical care medicine