A Look Into Sleep Medicine with a Fellowship Program Director


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SS 157: A Look Into Sleep Medicine with a Fellowship Program Director

Session 157

Dr. Anita V. Shelgikar is a sleep medicine specialist and the Director of the University of Michigan Sleep Medicine Fellowship program. they talk about training pathways, lifestyle, and more! If you’re interested in sleep medicine, go check out the American Academy of Sleep Medicine.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:10] Interest in Sleep Medicine

Anita went to medical school with the intention of being a pediatrician. She did her first rotation on her third year of medical school in pediatrics. She realized very quickly that she could not be a pediatrician because she had a hard time seeing sick children.

Then she went through the rest of her core rotations as they all did in medical school. She did neurology because it was a required experience and ended up falling in love with it. She fell in love with the neurological exam, the localization, and the neuroanatomy.

Anita went into medical school aspiring to be a pediatrician and came out of medical school ready to start a residency in adult neurology.

Anita did her neurology residency at Emory University in Atlanta and loved it. One of the attendings she worked with when she was a senior resident on the inpatient service was a sleep medicine specialist. She and her colleagues initially found it odd for the specialist to ask about their sleep.

But sure enough, you start asking people about their sleep and you start to realize how many people don’t sleep well. It’s something you can take for granted, especially when you’re in a sleep-deprived existence.

Then as a resident, you recognize the value of sleep to your own well being. She also started to see patients struggling with sleep, sometimes to an extent that interferes with the very disease process they’re trying to treat. Or it interferes with their quality of life or both. This really opens your eyes to this whole other dimension of their existence that she previously wasn’t even aware of.

So in her own continuity clinic, she started asking more about it. The more she asked, the more fascinated she became with the whole idea of sleep wake disorders and the role that these have on her patients who have comorbid neurological disease.

[04:46] The Decision to Go Back Into Fellowship

Anita ended up practicing general neurology for two years where she still kept asking her patients about their sleep and symptoms related to sleep. And at that point, she decided that she should just do the fellowship. So she did a sleep medicine fellowship. And since that time, she slowly transitioned her practice from being a mix of sleep medicine and neurology into now, 100% sleep medicine.

Anita finished residency with the knowledge of what she had been exposed to, which was a lot of inpatient neurology and some outpatient neurology. She wasn’t ready to give that up entirely to do subspecialty training. She didn’t want to lose the breadth of general neurology. She really found comfort in practicing what she had trained to practice.

But then again, as she started to see patients more longitudinally, she found that sleep could help improve their quality of life regardless of their underlying neurological disease or prognosis.

And this resonated with why she went into medicine in the first place. She also discovered that she could have that joy of travel practicing medicine, with the patients she loves, and with the discipline that she loves, which is neurology, but having a slightly different vantage point as a sleep medicine specialist.

And this was what sealed the decision for her to transition from being in practice to going back and doing a fellowship full-time.

[06:27] The Biggest Myths or Misconceptions Around Sleep Medicine

“Many people don't realize that sleep medicine is actually a viable career option.”Click To Tweet

One of the biggest myths is that you can only do it from a certain type of training. You have to be a pulmonologist, for example, is one that she hears a lot. So if you’re not a pulmonologist, you can’t be a sleep medicine specialist.

But at the core, sleep medicine is a multidisciplinary specialty. And so there actually are seven training pathways from which you can enter a sleep medicine fellowship. These are Neurology, Psychiatry, Internal Medicine, Pediatrics, Family Medicine, Anesthesiology, and Otolaryngology. There are so many ways to become a sleep medicine specialist. And that’s one of the most exciting parts about the field.

[07:48] Traits That Make a Good Sleep Medicine Specialist

One of the key things that they’re looking for when they are reviewing applications and when meeting people in person during their interviews is getting a sense of their passion for sleep medicine.

Figure out why you want to pursue a subspecialty training in sleep medicine. What are your career goals? 

And one of the exciting things about being a multidisciplinary specialty is that people have such different stories in terms of mentors or experiences, whether personal experiences or experiences with family members or patients. And those stories are what really opened their eyes to the field of sleep medicine and what has drawn them to a career in sleep medicine.

“There's not one right or wrong way to enter Sleep Medicine.”Click To Tweet

[08:58] Types of Patients

Their fellowship training encompasses patients across the entire lifespan. Your residency can be focused primarily on adult patients or pediatric patients or a mix of both. You may also treat sleep wake disorders and patients of all ages.

Once people finish fellowship training, they may choose to gear their practice towards a certain age group. But the training encompasses exposure to pediatric and adult patients. 

So they see patients with a whole variety of sleep wake disorders such as sleep-related breathing disorders, obstructive sleep apnea, or sleep related hypoventilation, and central sleep apnea. They also see parasomnias, circadian rhythm, sleep wake disorders, and sleep-related movement disorders.

In terms of patients coming to them for diagnosis or just figuring out treatment, they see a mix of those. They see some patients who are referred by their primary care physician and they have a diagnosis, for example, of obstructive sleep apnea. And they’re seeking their guidance with management. Or someone with restless leg syndrome or narcolepsy could also come in.

In other situations, they are doing the initial consultation with the patient and then pursuing the diagnosis and evaluation and then coming up with a treatment plan with the patient. 

“As part of the certification as a sleep medicine specialist, we are certified to read sleep studies for our patients and proceed with formulating a treatment plan for them as well.”Click To Tweet

[11:15] Typical Day

A typical day can be a mix of seeing patients in the clinic and reading sleep studies. For some of their colleagues, they do inpatient consults as well. Some of the inpatients they may see may have issues with their breathing during sleep that are interfering with their treatment course in the hospital. Or it’s somehow more deeply tied to their admitting diagnosis.

For an example, they have consulted before on patients who are admitted with preeclampsia. And, it turns out on screening that there is a concern about possible obstructive sleep apnea. So they will see those patients in consultation while they’re in the hospital. They do a sleep study at the patient’s bedside. And if it does show obstructive sleep apnea, they get them started on CPAP (Continuous Positive Airway Pressure) therapy. Their goal is to help facilitate better response to blood pressure management. That’s an example of a patient they might see in the inpatient setting. Otherwise, the majority of their practice is done in the outpatient setting in the clinic.

The majority of the training is outpatient, a mix of adult and pediatric sleep medicine clinics. The inpatient consultation is definitely a smaller portion of what they do overall.

Generally, sleep medicine specialists do not do invasive procedures. The procedures that they are doing is the interpretation of the sleep studies for their colleagues who are board-certified in otolaryngology, or anesthesiology, or pulmonology, and also sleep medicine. But for those of us who come from backgrounds that don’t encompass that training, then they don’t tend to do those types of procedures.

[13:57] Taking Calls and Life Outside of the Hospital

Most of their calls overnight do not come from the patients directly. They come from their technologists who are staffing because the studies are being run overnight in the sleep center.

But the biggest reason they get called by the sleep lab in the middle of the night is if the patient is having severe hypoxemia that requires some intervention. Or if there is an arrhythmia that the technologist feels that the physician on-call needs to know about.

They don’t have to go in since they have the capability of accessing the sleep study software remotely. Once in the system and credentialed, they can access that remotely.

For example, they’re able to look at a rhythm strip from the sleep study if they are concerned about a certain type of arrhythmia. Then depending on the context of the patient, they can advise the technologist to either continue running the study. And it’s flagged as a high priority study to be read first thing, upon completion of the study.

Or if it’s a dangerous arrhythmia, they may advise to terminate the study and send the patient down to the emergency department.

Additionally, Anita feels she has a life outside of the hospital. One thing that also appeals to people who pursue a career in sleep medicine is that work-life balance is attainable and is achievable.

“You can pursue a number of different career pathways within Sleep Medicine.”Click To Tweet

Being at the University of Michigan, Anita had chosen an academic medicine career path. But she also has many friends and colleagues in sleep medicine who work in a private practice setting or a group practice setting. Others do fully clinical work or fully research or a mix of both.

There’s a lot of room for advocacy as well. With all of the wearable technologies and other remote monitoring technologies that are now available directly to consumers, there’s a lot of interest in sleep and how tracking sleep and measuring sleep are being integrated into these technologies.

It’s an exciting time in the field to see where they can go with sleep science and its integration with these other interfaces and how they can best serve patients.

[17:32] What Makes a Competitive Applicant for Fellowship

Just speaking for their program, they take a holistic application review approach to looking at the entire candidate, not just piecemeal looking at certain components of the application.

They don’t have any hard stop type of things within the application. So they really are looking at the whole person and the whole application when they receive applicants for the fellowship.

Her advice to students who are considering a career in sleep medicine and considering applying for residency is to seek out an elective experience in sleep medicine.  And so it’s possible to go through a three- or four-year residency without having done a sleep medicine rotation. 

“For many residency programs, Sleep Medicine rotation is not considered core.”Click To Tweet

The best way to experience what that’s like is to do an elective in it. It can be very valuable in terms of getting an insider’s view of what the field looks like on a day-to-day basis. It can help fuel that passion.

For those who are interested in doing a residency research project, get involved in something related to sleep medicine. And again, with sleep medicine being multidisciplinary, there are so many ways to interface with other specialties. So it’s a really fun and exciting way to get more exposure to the field as well.

[19:30] Special Opportunities to Subspecialize

There’s no formal subspecialization within sleep medicine as what happens in many fields. People will sometimes develop their own niche and area of expertise.

So, at a given institution, someone may be known as the narcolepsy expert or the Restless Leg Syndrome expert, but it’s not that they’ve done a separate training or separate certification to have that designation. It’s usually people following their passion in their career interests, and seeing where that takes them. But all of them have the same training and certification in sleep medicine.

There’s a pretty good match between the number of applicants and the number of spots available in any given year. There are sometimes more spots available than there are applicants. So they are always trying to get more people into the field, especially when you look at the burden of disease overall, and the number of patients in the United States and even worldwide with undiagnosed obstructive sleep apnea, let alone all of the other diagnoses that they treat like insomnia, circadian rhythm, sleep disorders, and so on.

“There is definitely a mismatch right now between the number of sleep medicine specialists and the number of patients who would have benefited from sleep medicine specialty care.”Click To Tweet

Anita stresses the shortage of sleep medicine specialists today, especially when you look at anticipated physician shortages and the number of physicians that will be retiring in years to come. So it’s definitely a field for which there’s a need, and there are positions available for those who would like to pursue this training.

[21:42] Message to Future Primary Care Physicians

Sleep medicine specialists value their partnership with their primary care colleagues. Because they are really oftentimes the first interaction that patients have in terms of discussing the symptoms and their concerns.

So Anita wants to encourage her colleagues to ask about sleep-related symptoms. Ask about daytime energy level, daytime sleepiness, quality of life. And if they have concerns about a possible undiagnosed sleep disorder, they’re more than happy to see those patients. They’d be happy to collaborate with them towards optimal quality of life and optimizing sleep health.

[22:45] Overcoming Bias Towards Osteopathic Medical Students

Anita says they welcome DO students completely and totally. Speaking for their program, they have fellows with osteopathic degrees who will be graduating in 2022.

That being said, they don’t view DOs as a negative. They view all osteopathic and allopathic applicants the same. Anita also has friends and colleagues who are Sleep Medicine fellowship program directors who are osteopathic trained as well.

“The field is very welcoming to osteopathic and allopathic applicants.”Click To Tweet

[23:28] Other Specialties They Work the Closest With

The majority of people who are applying to sleep medicine are probably internal medicine, family medicine and neurology. And then after that, pediatrics and then psychiatry, then probably less often are anesthesiology and otolaryngology.

Anita believes there are ways in which your specialty expertise will help patients in a way that’s different from others in the field. 

They get referrals from primary care which include internal medicine, Family Medicine, pediatrics, med/peds. They also get referrals from neurology, for example, for patients with migraines. There may be a comorbid sleep disorder alongside the migraine diagnosis so they end up working a lot on that end.

They are also often referring to their surgical colleagues in otolaryngology, oral, maxillofacial surgery for non Positive Airway Pressure treatments of obstructive sleep apnea. They collaborate with their dental colleagues if they are pursuing possible dental treatment for a sleep-related breathing disorder or obstructive sleep apnea.

“There’s a lot of collaboration that crosses disciplines and that's one of the really exciting and fun parts of the field.”Click To Tweet

[26:04] The Most and Least Liked Things

Anita loves that when people sleep better, they feel better. And for me, that’s why she wanted to become a doctor in the first place. She wanted to help people feel better. It’s very gratifying to see her patients improve their quality of life.

In her role as Program Director, she absolutely loves mentoring colleagues who are coming into the field and seeing their career aspirations and helping them get there.

Although she loves charting, what she likes the least about sleep medicine is having to have prior authorization process for getting sleep studies and for prescribing certain medications for their patients. And so, there can be some frustrations either on behalf of, the clinicians or on behalf of the patients about those processes. 

They do their best to streamline those and to come up with standardized workflows so that they can minimize any potential time delays. That way they can get diagnostic testing and treatment initiated for their patients.

[28:04] Major Changes Coming into the Field of Obesity Medicine

Anita says they’re on the cusp of really exciting things. The clinical evaluation is always going to be there. Right now, they study patients in the sleep lab. They do home sleep apnea testing.

They are talking more and more about wearable technology and what is the role for that in the diagnosis and long-term management of their patients. 

There’s also the role of artificial intelligence in terms of what other information can be gleaned from polysomnography. Those will provide new insights and potentially new treatment options too.

“The field will evolve as these technologies evolve.”Click To Tweet

[29:27] Advice to Premeds and Med Students

If she had to do it all over again, Anita would still have chosen the same field 100%.

Finally, if this is something you’re interested in, Anita recommends getting a rotation in your local sleep clinic. This will give you some exposure to seeing patients in the clinic and also to reading sleep studies.

And if you do have an income to do research, or you have a requirement to do research, then try to get involved with a project, however large or small in scope. Get to know other people who practice sleep medicine. 

Finally, regardless of what field you’re going into, or field you’re considering right now, ask your patients about their sleep because it’s oftentimes something that patients won’t readily talk about unless they are asked about it.

“Ask your patients about their sleep because it's oftentimes something that patients won't readily talk about unless they are asked about it.”Click To Tweet

And once they are asked about it, you will be amazed at how many times disordered sleep or sub-optimal sleep really influences their patient’s overall health and their quality of life.

[31:30] Observing Sleep Hygiene

'Optimal sleep health starts with ourselves.'Click To Tweet

We often have to recenter even those of us that practice this day in, day out. Sometimes, you have to take a hard and fast look at your own habits and your own behaviors, and be able to recenter.

In order to achieve optimal sleep hygiene and improve overall health, Anita recommends these practices:

Minimize the use of electronics at least an hour prior to bedtime. 

Use an electronic device that has a blue light filter on it so that it’s emanating warmer color wavelength light rather than the blue wavelength which is the most alerting to the brain.

Have a consistent sleep/wake schedule. Try to go to bed at the same time and wake up at the same time as much as possible. This may not be possible for those who do work shifts, but try to get as much consistency as you can.

Keep caffeine intake at earlier times of the day, and not too close to bedtime. And try to have your last alcohol drink about three hours before bedtime.

“Prioritize your own sleep health and to ask your patients about their sleep.”Click To Tweet

If you start to raise symptoms, or your bed partner starts to raise concerns that you would like to pursue further, please consult or refer them on to a sleep medicine specialist.

[34:18] Getting the Sleep Conversation Going

Some questions you can ask your patients to start the sleep conversation would be: How is your sleep? Or how well do you sleep? Do you feel rested after a night’s sleep?

Just by starting there with an open-ended question, you’d get to see what the patient says. And if they say they’re tired, then you can start to ask some more probing questions. Ask them about their nighttime routine and some other behaviors. Then go from there.

'We're talking about many sleep-related disorders. But it's important to ask about weight-related symptoms as well.'Click To Tweet

For example, excessive daytime sleepiness, someone who may have frequent fragmentation of their sleep may actually have subsequent daytime sleepiness. So to ask about things like functioning at work, functioning at school, what types of grades are they getting? Are they getting reprimanded for their job performance? What are their interpersonal relationships like? Are they noticing any mood effects from not sleeping? Well, depending on their job, or even if they’re driving a car, do they feel sleepy while driving. Because then you go from having an individual health concern to a public health concern. 

“If someone is sharing the roadways with somebody who's sleepy, that can be a real problem if someone's in a very sensitive occupation, like medicine or, first responders.”Click To Tweet

That can have a lot of implications in terms of overall performance. So asking about not only sleep related symptoms, but even how well someone’s functioning during the day is very important.

Links:

Meded Media

American Academy of Sleep Medicine

Mappd.com

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