Sleep Disorders Clinic |
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Q: Sleep medicine as a subspecialty is just a few decades old. Are sleep disorders a new problem, or is it that physicians have only recently recognized them?
CLERK: There is also a macho mentality [about not needing sleep].
ADORNATO: Also, there is a certain regard for hard work and long hours. Henry Ford frequently boasted he slept only four hours a night, but after his death his housekeeper disclosed that he usually fell asleep at his desk in the afternoon. Q: If sleep disorders are so ubiquitous today, why do sleep problems so often go unrecognized?
CLERK: Part of the lack of attention to sleep problems involves lack of physician education, although this is improving. Most of us never received any training in sleep medicine in medical school. We picked it up later.
Q: Is the sleep program having an impact on helping area physicians understand sleep medicine? LIDDELL: Judging by our referral patterns, the physicians in the Palo Alto area are pretty sensitive to the need to refer patients with sleep difficulties. In San Francisco, the Brown & Toland group is aware of the need to refer patients promptly, but otherwise the understanding of sleep medicine appears to be a bit less widespread there than it is down here. ADORNATO: Awareness among the public, however, is high. Patients tell me that they sought out the sleep lab after reading in Time magazine, for example, that falling asleep at 2 o'clock in the afternoon is not normal. Q: When somebody comes to a sleep lab as a patient, what do you do? CLERK: Our paradigm is no different from that of any other medical clinic. At the core, we use histories and physicals to make a diagnosis and then confirm the diagnosis with tests. In our case, the gold standard is a polysomnogram. From there we go to other tests as needed. Q: Can you describe what happens when a typical evaluation patient comes here? CLERK: The patient is admitted as in any other clinic. The patient will meet with an attending physician - and sometimes with a fellow as well - to obtain a history and physical exam. We pride ourselves on making decisions with the patient on possible treatment options. This is also the point at which we would discuss overnight testing options. If warranted, the patient arrives back on the scheduled date at 7 p.m. He or she is finished at 7 the next morning. If we do the test at home, the patient is fitted with electrodes, given a device and then sent home. The patient returns the device the next morning for downloading the data. Next, reports are sent to the patient and to the referring physician, and a treatment plan is started. Q: What's new on the treatment front? ADORNATO: Radiofrequency treatment for snoring. It shrinks tissue relatively painlessly, and the procedure is available on an outpatient basis. Q: If the polysomnogram is the centerpiece of what you do, why shouldn't patients from afar simply send test results to you for reading? ADORNATO: That happens frequently, but there is a significant value added when a physician who knows the patient is interpreting the test. GUILLEMINAULT: And, of course, there are the benefits of a full-service clinic that takes care of patients from infancy through seniority. We can develop a treatment plan, but before we can even do that, we clearly explain the results and treatment options to the patient. CLERK: We offer more detailed testing by highly skilled technologists. I really think that is a quality advantage. Our detailed testing helps diagnose and treat sleep disorders that can be easily missed. LIDDELL: Like much of the rest of Stanford, we're a tertiary center, and we get referrals from other sites where results have been inconclusive. Q: Are all your studies performed on site? ADORNATO: No, we're doing more and more in-home studies. This option is attractive to patients who have anxiety about spending a night in an unfamiliar location. Q: What should primary care physicians do before they consider referring a patient? CLERK: There are simple things that with a little education the primary care physician can easily do. And more complicated patients can be referred to us. There are patients who suffer from insomnia because they drink too much coffee, and all they need is advice to get off the coffee. Other patients need to be told to stop watching the 11 o'clock news or exercising late at night. There are many other examples. ADORNATO: My advice to the primary care physician is to read about sleep disorders and perhaps take a course in sleep medicine. And we need to offer more courses in sleep medicine for primary physicians. The AMA, the American Family Practice Association and others have courses in which we've participated. GUILLEMINAULT: I do think early referral is preferable, and in many cases it can be cost-effective if you weigh the cost of an evaluation against the consequences of long-term health difficulties. ADORNATO: Sleep disorders are generally lifelong issues. Primary care physicians should be quick to determine a chronic pattern vs. an acute, stress-related episode of insomnia that might be effectively treated with short-term medication. That being said, if a patient experiences chest pain or headache as a once-a-week occurrence, no one would have any hesitation about referring the patient to a specialist in those areas. The analogy here is slightly different in that acute symptoms - "I haven't been able to sleep" - don't sound as ominous to most physicians, but the underlying problem and its sequelae can be devastating - and expensive. The cost of a consultation is relatively small, and not all patients will require polysomnography. Q: Specifically, what sort of symptoms should physicians look for and when should they consider sending a patient to you for evaluation and possible treatment? GUILLEMINAULT: Daytime sleepiness, complaints of not sleeping well at night for no obvious reason, snoring, abnormal behavior during sleep, such as sleepwalking, violence, confusion during sleep, nocturnal tumescence and pain. Anything "wrong" during sleep, we see and try to handle. CLERK: We recognize that sleep problems may be part of a larger context. There are very few areas of medicine where you have the opportunity to look at so many different parameters at the same time. For example, patients with COPD [chronic obstructive pulmonary disease] often have problems with insomnia, which can become complicated beyond the normal scope of the pulmonary physician. We can deal with the sleep problem while the pulmonary physician continues to treat COPD. Or if the patient is referred to us, we can often coordinate his or her pulmonary care with the appropriate clinic. Q: Speaking of cost, what has managed care done to your referral process? ADORNATO: The same thing it has done to everyone else - made life more complicated. In San Francisco we have had to add a second office person to handle authorizations and related phone calls. And with reduced reimbursement, we find it increasingly hard to provide pro bono treatment. Q: With the advent of UCSF Stanford Health Care, what is the relationship between your clinic and another San Francisco sleep clinic operated by UCSF faculty? ADORNATO: Preliminary talks are under way to collaborate and perhaps integrate services. This is an opportunity to benefit from the merger and consolidate the only two accredited sleep labs in San Francisco. Q: How did each of you get into sleep medicine? GUILLEMINAULT: When I started, there was no sleep medicine. We were intrigued with the observation that some patient symptoms became worse during sleep, and that led to the notion that the controls of the vital functions are different during awakeness and during the two different states of sleep. If a patient is examined only while awake, we found that we couldn't diagnose sleep-specific conditions. CLERK: As a psychiatrist in a VA hospital, I treated many Vietnam veterans with recurring nightmares. At that time, we as psychiatrists really didn't know what to do for them. I saw that the small sleep lab at the VA hospital was monitoring EEG, EMG, eyes, breathing. Intuitively, I thought this monitoring might be useful. And eventually, we found a number of patients suffering from REM sleep difficulties who might have been misdiagnosed as depressed or suffering from PTSD (posttraumatic stress disorder). I was fascinated, so I asked how to get specialized training in this. I applied and was accepted for a fellowship. ADORNATO: Trained in neurology, I was seeing patients with narcolepsy. I was impressed by the tale of a woman who for 12 years had been treated for depression, when her complaint was actually daytime sleepiness. We found she had cataplexy and undiagnosed narcolepsy. After treatment, her career flourished and I realized there was a need for more emphasis on sleep disorders. Q: We understand you must have a prior specialty. GUILLEMINAULT: Yes, pulmonary specialists represent about 60 percent of the nation's sleep specialists. Internal medicine, neurology, pediatrics, psychiatry are, in declining order, the specialties that feed sleep specialists.
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GUILLEMINAULT: It's largely a phenomenon of modern industrialized societies. One interesting study in Europe showed that people are sacrificing sleep because they are starved for free time as they juggle commuting, work and household tasks in two-income families. They don't realize they are paying a price.
ADORNATO: Part of the reason is that when people go to sleep at night, their thinking, judgment and memory are impaired. They don't know that they snore or have sleep apnea, or that they turn over 12 times an hour, or that they talk in their sleep. Insomniacs tend to spend too many hours in bed, which is maladaptive. Long times in bed perpetuate poor sleep efficiency and lead to more fragmented sleep. There are many other examples.
LIDDELL: Dr. Dement has been particularly active here at Stanford in ensuring that sleep medicine is incorporated in the curriculum. And he initiated primary care pilot projects in sleep medicine in Walla Walla, Wash., Moscow, Idaho, and Alamo in the East Bay. He's helping to provide training to primary care doctors who can either gain the additional education to become a sleep specialist or, at least, gain the expertise to refer patients quickly to a specialist.
