The current state of sleep medicine and research
The field of sleep medicine has dramatically expanded since the first sleep clinic in the world opened in 1972 at Stanford University, and more health care providers than ever are interested in the practice of sleep medicine. This field is truly multidisciplinary, with providers having education and training in diverse areas of medicine, including family medicine, internal medicine, neurology, otolaryngology, pediatrics, psychiatry, and pulmonary medicine.
This attraction of providers with diverse backgrounds to sleep medicine translates to better care for patients with sleep problems in general, since sleep problems are commonly associated with other medical and psychiatric disorders, such as pain syndromes, depression, chronic obstructive pulmonary disease, metabolic syndrome, and cancer.
The growth of this field has also produced changes in the financial aspects of sleep medicine, which coincide with the general shift of medical care to become more efficient, cost-effective, and patient-centered. In particular, the criteria for insurer reimbursement of the in-laboratory sleep study (polysomnogram), considered the primary sleep medicine test, have become more selective and restricted to patients who have significant co-morbid illnesses.
This in turn has resulted in a shift toward out-of-center sleep tests, which have their advantages (they can be conducted at home and are less expensive) and disadvantages (the most frequent types of home testing typically include measures of breathing but not parameters of sleep, such as sleep length and stages of sleep). With this shift, some sleep centers have had to shut their doors, primarily those centers that had an exclusive reliance on the income generated from in-laboratory sleep studies. However, the majority of sleep centers have adapted to this challenge with a more diversified and comprehensive portfolio of treatment options for their patients.
There have been breakthroughs in our basic understanding of sleep, sleep disorders, and their relationships, such as studies highlighting increased clearance of brain metabolites during sleep, identification of genetic markers for some sleep disorders, and the association of obstructive sleep apnea with high blood pressure. Financial support for sleep research in terms of grants from the federal government, industry, and foundations have ebbed and flowed over the years. This is largely due to cyclic variation in federal spending and shifting priorities for sleep-related industries, leading to some decline in the pipeline of young investigators pursuing sleep research.
Those who decide to pursue research in sleep currently face a number of challenges: physician-scientists need extensive and lengthy training that involves medical residency training, a 1-year sleep medicine fellowship, and perhaps further research training; federal institutional research training grants are also not always available for additional sleep research training.
Why is this an exciting time to study sleep?
Given the challenges described above, there are unlimited opportunities to talented and resourceful sleep medicine practitioners and researchers. For those in the sleep medicine field, the increased practice diversification of most sleep centers offers practitioners the opportunity to develop subspecialty “niches” or clinics.
…there are unlimited opportunities to talented and resourceful sleep medicine practitioners and researchers.
For example, psychologists can receive training in cognitive behavioral treatment for insomnia so that they can manage the multitude of patients with chronic insomnia. Physicians with an interest in restless legs syndrome can develop subspecialty clinics focused on sleep-related movement disorders. Clinicians with expertise in obstructive sleep apnea can work with bariatric medicine providers as part of a team approach to comprehensively address the needs and comorbidities of significantly overweight patients. Sleep research is almost unique in this respect.
As in-laboratory sleep studies become increasingly more reserved for patients with complex medical conditions and those who need devices delivering advanced positive pressure and ventilatory modalities, there will be expanding opportunities for those with background and training in these conditions (e.g., obesity-hypoventilation syndrome, neuromuscular disease) and treatment modalities.
Digital analysis and automated scoring of in-laboratory sleep studies will also provide the opportunity for finer-grained analyses of these studies, with the potential for uncovering other sleep and medical disorders that otherwise might not be detectable in the current state of sleep study review, scoring, and analyses. A recent article in Sleep Science and Practice explores this in more depth.
This also couldn’t be a better time for basic and clinical investigation into sleep and its disorders. In many respects, sleep research is only just getting started, since the discovery of rapid-eye-movement (REM) sleep, which initiated the organized scientific study of sleep, only occurred in 1953. This fact poses significant opportunities for those interested in and currently involved in sleep research, since there a multitude of questions to be answered, including what is considered the holy grail of sleep research: why do we sleep?