Terminal Decline?
Academic and clinical fields have their booms and busts just like economies. Sleep Medicine is no exception. A field that took off from the 1990s until the 2010s is now in palpable decline. This year a total of 112 sleep fellowships were filled in the nationwide medical match. America is presently training one potentially certifiable board eligible sleep MD per three million people per year. Subtract out those who will return to their other fields; those who will do full time research; those who figure out that hedge funds or running hospitals is a more princely living, and the numbers look worse. Rather abruptly, one third of human life may be losing its perch in clinical medicine. So how did this happen?
The Gold Rush
In the 1970s sleep researchers realized that sleep apnea was a major public health problem. It dawned on people that at least 10% of the population had pretty severe sleep apnea, which meant more heart disease, strokes, hypertension, depression, accidents, and vast losses in economic activity. In 1981, Colin Sullivan perfected – along with many others who did not get credit – a simple, effective solution for sleep apnea, continuous positive airway pressure, or CPAP. After testing overnight, people would be fitted with devices relatively similar in appearance to Darth Vader’s mask, have it tried at different pressures, and get sent home. CPAP worked.
The rush began.
Sleep laboratories started popping up pretty much everywhere in America. Accreditation bodies followed suit, requiring certified sleep physicians and sleep technologists, most of whom were already working other jobs as they trained in a variety of apprentice-like settings. That’s how folks like me got accredited; I had the good fortune to learn how to read sleep studies from Mary Carskadon and Richard Millman while I was teaching at Brown. Many labs were set up without any accreditation whatsover, including “national” outfits with “flying” sleep technologists, their studies read by algorithmic programs. The money flowed in, though not to everybody – psychologists, critical to sleep research and practice, were actively sidelined. Yet the boom kept going. At one point my little town of Sarasota had nine separate sleep labs.
Then came the crash.
Rise and Fall
The reasons for decline were multiple. In America, where public health is generally an afterthought of health care, sleep medicine deeply identified itself with sleep apnea. Effectively, many centers, including many university based ones, turned sleep medicine into the “sleep apnea testing service.” The critical role of sleep in regenerating human beings, and its importance in community, physical, and economic health, was deemphasized or quite consciously overlooked as the dollars kept rolling in.
Insurance wondered what they were getting for their billions. So did Medicare. Eventually it became understood that many folks who went on the protocol train of sleep testing and CPAP equipping were not using their machines. Then new technology came in – home testing. A lot cheaper than laboratory studies – though as providing vastly less usable information – it seemed a reasonable approximation for some clinical diagnoses. Next, automatic positive airway pressure (APAP) machines appeared. At least for insurance company bottom lines, this appeared a cheaper alternative to sleep lab testing gauging CPAP pressures. Voila! Get a night or two home test, have it read by a program, give the person an APAP machine: financial problem solved.
That the majority of sleep apnea sufferers have insomnia, that many have major daytime sleepiness following CPAP, that there are a host of other sleep disorders, ranging from narcolepsy to insomnia, all with major impacts on people’s lives, insurance carriers and others recognized here was a way to cut costs.
Sleep labs started closing everywhere. With them, many sleep medicine departments downsized or disappeared. Which leads to training one sleep medicine specialist per three million Americans per year.
Fixing the Problem
The public now recognizes sleep is a critical part of life, akin to food. If you don’t sleep, you don’t live. It’s time for medical schools and health care funders to recognize the same.
Home sleep studies and APAP machines will help a lot of people, but not most of the population. Sleep is critical to life. Sleep is important to all of medicine.
It’s time for people to recognize the centrality of sleep to human health. Medicine for a long time has considered “homeostasis” to be the normal physiologic condition. This idea recognizes the body as a machine. The metaphor is both wrong and dangerous. Bodies are not machines. They are organisms. They remake themselves, rebuild themselves, or die. Illness is not a “machine” breaking down; it’s a living organism failing to properly remake itself. Sleep is necessary for that process to occur.
So it is time for a paradigm shift, not just for sleep medicine, but medicine in general. Seeing the body as a machine is to inaccurately see all of life’s growth – from fertilized egg to maturation and death – as the simple result of the “machine breaking down.” Bodies don’t break down. They build up. We survive by learning. The environment always changes. So must we. If we don’t adapt, as for example to mutating AIDS and hepatitus viruses, we die. Much of that process of rebuilding and remaking occurs through a remarkably specialized process – what we call sleep.
In trying to save itself, sleep medicine may help bring medicine back to health. People naturally see our bodies as similar to our most complicated machines. In the eighteenth century it was clocks (thus “homeostasis”); in the nineteenth the steam engine; today it is IT, computers and software.
Yet even if we accept our time’s inaccurate metaphor, we know that software has to constantly learn and update if it is not to fail. The same is true for the body. Learn, or die. Remake yourself properly or face the prospect of illness. Without proper sleep, that does not happen.
Things go better with proper sleep – for everybody.
