Session 87

Dr. Jairo Barrantes joins Ryan to talk about Academic Sleep Medicine including what he loves about it, what call looks like, and why he chose academia.

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[01:24] Interest in Sleep Medicine

Jairo’s interest in sleep medicine sparked during his pulmonary critical care fellowship, where their director was the head of the American Academy of Sleep Medicine. That being said, a pulmonary physician has too little exposure to what sleep medicine really is including the different diseases you come across. Sleep medicine involves 80%-90% of sleep apnea. While the training you get as a pulmonologist is the sleep apnea part and not so much exposure to all other diseases that sleep medicine entails. This opened up different doors such as narcolepsy, parasomnia, and insomnia, which may up the main problems of sleep medicine today– but there are more others apparently, especially in children. Jairo describes sleep medicine as a very fine specialty where you get the opportunity to see all patients.

[03:31] Traits that Lead to Being a Good Sleep Medicine Specialist

Jairo says that most people choose this specialty for being gentle in terms of not having any calls and you only get to work from Monday to Friday. You infrequently get phone calls from the sleep lab at night time. So many people choose this because of the lifestyle. However, what makes you a good physician is to have a good understanding of the pulmonary and brain physiology. We sleep 33% of our life so we sleep for many years. And that’s part of the time that no one really cares about. That period of time, a lot of changes happen during our sleep. Metabolism slows down as well as your brain function and this has that recovery and immunology component.

Jairo explains that the reason many people die during their sleep is due to surges of stress once your metabolism goes down and when your body is already deconditioned, this can cause a heart attack.

[05:40] Types of Patients

You may choose to do only adults or only pediatrics, or both as what Jairo does. For the children, the most common concern would be sleeping difficulties. Childhood insomnia composes 80% of his consults. The rest would be children with sleep apnea. Interestingly, sleep apnea in children is often misdiagnosed as ADHD by primary care physicians and pediatricians and they prescribe the medication like stimulants to keep them awake and focused during the day. But the reality is that these kids are sleep-deprived and have got poor quality of sleep. That could be sleep apnea that hasn’t been treated for years and have been in medication to keep them awake. Suddenly, you go ahead to treat the sleep apnea and the kid’s behavior improves. In fact, about 40% of children that have been diagnosed with ADHD were actually suffering sleep apnea. The rest of the patients would then be dealing with parasomnias, which are irregular behaviors during sleep time such as banging of the head or entire body during sleep.

Obesity and narrow airways may cause sleep apnea and this is easier to notice among adults. However, there are other multiple solutions for this such as medication to help them sleep. Jairo also likes to use common devices like fitness trackers to help patients with insomnia so they can develop better sleep patterns. The key is to sleep right at the wrong time. For instance, teens go to sleep at around 1-2 am and wake up at 11 am. People think they’re lazy, but they just have a different sleep pattern. Unfortunately, this is causing disrupting in schools. In fact, in Minnesota, people are having their children start school later at 9am-10am and they scored better in their standardized test because they perform better when not sleep-deprived.

Some people with parasomnia may act their dreams and they think they’re playing karate in the middle of the night. That can be dangerous for the bed partner, or they can injure themselves since they’re pretty much asleep when they’re acting their dreams. And they could hurt themselves with sharp objects in the house, or fall off the mattress. Hence, these disorders should be treated.

[10:55] Taking Calls and the Golden Age of Sleep Medicine

Jairo admits to never having been back to the lab. The only time he needed was during their pulmonary fellowship. Most of the centers are outpatient sleep facilities. This makes it very convenient for people. In pediatric medicine, most of the fellowship are three years. So it’s very attractive for them to have a one-year fellowship. Moreover, Jairo describes the salary is not bad at all for the amount of extra training you do after your internal medicine, pediatrics, or psychiatry, so it’s very similar to primary specialties.

Depending on where you work, they bill time for sleep interpretation and you have your schedule close for a couple of hours so you can do the sleep studies for the night. Jairo also points out that many people stay away from sleep medicines due to economical reimbursement. It was better during its golden years some 20 years ago but Medicare adjusted the prices and now, you get a glorified internist salary without calls. Not bad at all, however, it wasn’t as good as it used to be back then. That being said, still, it’s a very mellow specialty to go through and the number of diseases is limited with about 20-25 conditions with different subdivisions compared to doing general internal medicine where you have to treat thousands of conditions.

[13:30] Typical Day and Work-Life Balance

Jairo would usually go to the office and most of the patients prefer to schedule their sleep studies early in the morning. So you do a sleep study interpretation from 8-11am. Then after the clinic from 11-12 for lunch, you go back to the clinic and finish at about 4 pm. You wrap up and then go home. This happens Monday to Friday. He still has enough time for his family as he still gets to take his daughter to ballet classes and other activities.

[14:55] Academic vs Community Setting

As to why he chose the academic setting, there are opportunities for research available. This is one area in the specialty where you can develop your career. And there are also plenty of areas to do research. Alternatively, you don’t get the opportunity to do research in the private sector and you focus more on sleep apnea as that’s where money is generated. So you need to be linked to an academy to be able to develop sleep research.

There is plenty of themes or areas that you can do it, but in order to develop that, you need a little bit of protected time, access to key people doing statistics and interpretation. You also need people to help coach you how to write articles properly. While the academic centers get more complicated cases. Hence, case reports are easier for them to make when from the academic side.

Additionally, Jairo loves to teach. He finds being attached to a center that has Sleep Fellowship as very gratifying.

[16:35] The Training Path and Getting Getting Monetary Compensation

There are different ways down the Sleep Medicine path. Initially, you have to have a base specialty and then you can apply for sleep medicine from there. You can become a sleep physician from being a general internalist or from general pediatrics. You can also come from pulmonary critical care, psychiatry, psychology, and neurology. So finish your basic specialty then do sleep medicine fellowship thereafter. You take the board for sleep medicine and become a Diplomate.

Jairo says that it’s easy to find a job in sleep medicine because, in the last ten years, the doctors who were practicing sleep medicine weren’t board-certified. Hence, they didn’t have any formal training. And when the boards came, it was very difficult for those physicians practicing without formal training to pass the board. Those people shied away and they haven’t studied again to be able to take the boards. Nevertheless, people don’t realize it’s a good specialty since it’s easy to work with the schedule because it gives you a lot of flexibility. Plus, he gets to have weekends off.  Also, the amount of RVU they can generate from the sleep is significantly higher than what you can generate from being a primary pulmonologist. This means they give you more forgiveness in time and still receive the same expectations from the hospital without working extended hours. Or if you’re paid by incentive and reach a certain amount of RVUs a year, you’re able to reach those RVUs with the sleep part which you will never reach just with the pulmonary part alone or psychiatry work, whichever specialty you have.

Matching into sleep medicine is not competitive at all. People don’t even know what sleep medicine is. But Jairo thinks it’s going to surge once people getting paid with these RVUs. There are about 60 programs that are eligible and out of those, about 60% get filled.

[21:00] Special Opportunities to Subspecialize

There isn’t much opportunity to subspecialize once you get into sleep medicine. You basically choose your niche of practice usually depending on your background. For instance, if your background is neurology, you usually focus on circadian rhythm disorders, seizures, and movement disorders during the sleep compared to doing sleep apnea. In Jairo’s case, he does mostly sleep apnea and uses of non-invasive positive pressure ventilation at night. He also does what he calls as special populations like children who have facial malformations or other conditions that leave them with very narrow airways and have severe sleep apnea that requires tracheostomies, advanced ventilators, or non-invasive positive pressure ventilation at nighttime, especially patients with APS who become dependent on those during both nighttime and daytime.

[22:25] Working with Primary Care and Other Specialties

Jairo wishes primary care physicians would realize that sleep medicine is more than a sleep apnea. But that’s not what just the sleep medicine entails. It’s more than just prescribing the CPAP or the BIPAP. A lot of knowledge is involved and a lot of different opportunities to treat the patient better. Additionally, there are many diseases that are preventable or better treated when you have a better sleep pattern at night. For example, if you have diabetes and your sleep apnea is controlled thereby giving you good sleep, your insulin requirements go down by 30-40%. The same happens to people with hypertension where they notice some drop in the amount of medication required for hypertension when they’re treated for sleep apnea or insomnia. If they’re able to understand this, primary care physicians would be more enticed to know more about sleep medicine so they can do basic practice in their practice, says Jairo. As a general internist, you can prescribe the CPAP and sleep study. But if you have the basic knowledge and interest in that, then you won’t have to refer to a sleep specialist, which can be very difficult to find these days. In fact, it may take up to 6-8 months to get a sleep specialist available. This actually discourages patients to pursue any longer since they can’t find anybody to see them.

Other specialties they work the closest with are mostly pulmonologist, bariatric surgeons, psychiatrists, and child psychiatrists. They also work with neurologists for patients with ALS or spinal trauma. They do work with cardiologists as well as endocrinology. They’re trying to get better control of irregular heartbeat at nighttime or daytime and this decreases the frequency of relapses of atrial fibrillation after ablation when sleep apnea is being treated.

[25:22] Special Opportunities Outside of Clinical Medicine

One area would be commercial devices. They’re looking for people developing new technologies. If you get to work with one of the companies that develop non-invasive positive pressure ventilation, there are opportunities to go into the commercial or research side. You would now be part of the protocol. But if your center is standardized and needs to forfeit all of the conditions of the American Academy of Sleep Medicine, you will be able to get research going on in your lab. There are private doctors who decide to devote all of their time or 80% of their practice to do the case being paid by the research study.

[26:26] Most and Least Liked About Sleep Medicine

When he did his residency in internal medicine as an intern, one of the sleep doctors gave them a talk about sleep medicine and didn’t mention about it and he was making good money at that time. Today, the population they work with include patients that are very gratifying as it enhanced their quality of life. Although there are some that complain, the majority are still grateful for what you do for them. Interestingly, you don’t need to see your sleep patients very frequently. You may only seem them every year and they can do very well with that.

What he likes the most about his specialty is the schedule. Interestingly, Jairo doesn’t find anything that he doesn’t like about his specialty. He enjoys every single minute he’s at work. Maybe, having patient with insomnia that is very difficult to treat can be upsetting for him so you can end up being a dispenser of control medications for them. But as far as you do your job right, most of your patients get well.

[29:20] Major Changes in Sleep Medicine

People are becoming more aware of the wellness and lifestyle so sleep medicine is going to start growing more and more. And perhaps in the next 10-20 years, physicians are going to be very aware of the benefits of having a good quality of sleep. Hopefully, there will be more physicians coming to learn what sleep medicine is and practice it. This will lead to better reimbursement and more opportunity to treat other people.

If he had to do it all over again, he’d still do it. In fact, he would even do it first over the pulmonary part if he’d just have to take sleep medicine. Although he loves pulmonary, he finds sleep medicine as more gratifying.

[30:33] Final Words of Wisdom

Jairo says that sleep medicine is a wonderful field where you can achieve many personal goals in relation to your career. Career is significantly easier when you do it from the sleep part because there is a blank canvas to be painted compared to other specialties. So this is a fine specialty to pursue.

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