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Conundrums in Sleep Medicine FREE TO VIEW

Nancy A. Collop, MD, FCCP
Author and Funding Information

Affiliations: Charleston, SC 
 ,  Associate Professor of Medicine, Medical University of South Carolina; Associate Editor, CHEST, and Chair, ACCP Sleep Section.

Correspondence to: Nancy A. Collop, MD, FCCP, Associate Professor of Medicine, Deputy Editor, CHEST, CSB 812, 171 Ashley Avenue, Medical University of South Carolina, Charleston, SC 29425

Chest. 1999;115(3):607-608. doi:10.1378/chest.115.3.607
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All of us who have spent a night without sleep know it is an important bodily function. Sleep disorders are common; insomnia affects one third of the population1and half of patients with chronic medical conditions such as diabetes, hypertension, and heart disease.2 Additionally, obstructive sleep apnea syndrome may afflict up to 5% of the adult male population.

Because of statistics like these, sleep medicine is a burgeoning field. It is unique in that it encompasses both physicians and PhDs in a variety of medical specialties. Pulmonologists pioneered much of the early research in sleep medicine because of their interest in sleep-related breathing disorders. Subsequently, many pulmonologists were involved in developing the standards for accreditation and certification now available for both sleep laboratories and physicians in this field.

There are many controversies regarding sleep medicine, and several of these directly affect the pulmonologist members of the American College of Chest Physicians (ACCP). Sleep laboratories are opening regularly in this country. What is required to set up a sleep laboratory? Money and a building! Anyone can open a sleep laboratory, and it seems that just about everyone is. In the small city of Charleston where I reside, there are at least seven sleep laboratories run by a variety of specialists, including ear, nose, and throat; pulmonologists; and neurologists. Many of these physicians do not have any specific training in sleep medicine. There is also a lack of quality control in sleep laboratories. In some labs, technicians “score” the sleep study, and the physician never actually reviews the study, but only develops an interpretation based on the scores. Portable sleep studies are also being performed with even less quality control. What is the reason for the popularity of sleep laboratories? Patients and income. The significance to the pulmonologist is many of these labs are being run by us or are in direct competition with us.

Should there be better controls? I say yes. The American Sleep Disorders Association (ASDA) was established to promote and improve the practice of sleep medicine. The ASDA has an accreditation process for sleep laboratories. This accreditation, however, is currently not required by most states, or more importantly, by most insurance carriers for reimbursements. The ASDA standards are quite high, and many laboratories cannot attain those standards for a variety of reasons, including money, space, time commitment to the process, or personnel requirements. There is also an American Board of Sleep Medicine (ABSM) that certifies individuals as sleep specialists. This certification presumably makes those individuals more qualified to run a sleep laboratory; however, the certification is not required to run a laboratory or to read sleep studies.

The ABSM certification process currently has a waiver in which physicians in practice can be “grandfathered” (or“ grandmothered”) in to sit for the board. Most physicians currently sit for the board using this avenue, but this route is gradually being phased out. There are also 1-year sleep medicine fellowships and a pathway for current pulmonary fellows to receive separate training in“ nonpulmonary sleep disorders” for 6 months, which will qualify them to sit for the board (level 2 training).

Level 1 training is what pulmonary fellows should obtain during their fellowship, enabling them to adequately diagnose and treat patients with sleep-related breathing disorders. Consistently, each spring, the fellows in our program become acutely interested in reading sleep studies. It is at that time, they have begun to look at practices and find that “experience in sleep medicine” is a desirable and marketable skill. Many practices want these pulmonologists to set up a sleep laboratory and read sleep studies. Talking to other pulmonary colleagues who practice sleep medicine in an academic setting, I know my experience is not unique. The problem is, in my opinion, level 1 training does not sufficiently train a fellow to run a sleep laboratory. Not all patients with hypersomnia have sleep apnea, and other diagnoses may be missed if the physician is only trained to diagnose and treat sleep apnea. Also, when a physician runs a sleep laboratory, they are “assumed” to be a sleep expert and are asked to evaluate and treat all types of sleep disorders when they are not adequately trained to do so.

Should every sleep laboratory be ASDA accredited? Should every sleep laboratory have at least one board-certified sleep specialist? Does every city or town in the United States need a sleep laboratory? Could there be “sleep apnea laboratories” run by pulmonologists who have received adequate level 1 training devoted to the diagnosis and treatment of sleep-related breathing disorders? Should there be“ tertiary care sleep laboratories” to study all aspects of sleep medicine? I don’t think the latter is feasible because our patients do not know how to characterize themselves; they only know that they cannot stay awake behind the steering wheel of a car or cannot fall asleep at night! Another long-term solution being advocated is to teach more sleep medicine during medical school, residency, and fellowship programs so there is a broader base of knowledge. If this was done, primary care doctors could better diagnose and manage sleep disorders, allowing the sleep specialist to concentrate on the more difficult diagnostic and management issues. Unfortunately, medical schools are trying to cope with an exploding amount of information for their students, and sleep medicine is often seen as a low priority. Pulmonary fellowship programs, in order to accommodate critical care training, are already 3 years long, and if meaningful research is to be done during that time, there are not many months left to devote to teaching sleep medicine. A 4th year could be added, but the money for this type of training is shrinking, not expanding. Even the 6 months of“ nonpulmonary sleep” required to complete level 2 training is difficult to fit into most current fellowship programs.

I believe the ASDA and the ABSM are trying to raise the standards, but are their current standards too difficult for many practicing pulmonologists and training programs to attain? Is there a middle ground where we can assure improved quality in sleep laboratories, without the high accreditation standard that the ASDA requires? After the grandfather clause is no longer available, will there be enough sleep specialists trained?

The ACCP recently initiated discussions with the American Board of Internal Medicine (ABIM) regarding an Institute for Clinical Evaluation for sleep. Groups represented at this meeting included: ACCP, ASDA, ABSM, American Thoracic Society, and ABIM. The ABIM is currently setting up an Institute for Clinical Evaluation for ECG interpretation in which a physician can take a test administered by the ABIM and obtain a “certificate of proficiency.” In the scenario of sleep medicine, we discussed a certificate available to physicians who demonstrate proficiency in reading polysomnograms. This idea was ultimately considered not feasible because polysomnography interpretation alone is not adequate to demonstrate proficiency in the field of sleep medicine. Currently, other individuals and groups also are proposing other means of accrediting professionals to run laboratories. Most, to date, have not “caught on.”

I think these issues must be critically evaluated by all those involved, including the ASDA, the ABSM, the ACCP, the American Thoracic Society, and other societies whose members are running sleep laboratories or practicing sleep medicine. My concern is that if we, the sleep specialists, do not impose better quality control on sleep laboratories, either the government, or worse yet, the insurance companies, will force our hand to do so. As the majority of sleep specialists are pulmonologists, we must take the lead in resolving some of these issues.


Mellinger, G, Balter, M, Uhlenhuth, E (1985) Insomnia and its treatment: prevalence and correlates.Arch Gen Psychiatry42,225-232. [PubMed] [CrossRef]
Katz, D, McHorney, C Clinical correlates of insomnia in patients with chronic illness.Arch Intern Med1998;158,1099-1107. [PubMed]




Mellinger, G, Balter, M, Uhlenhuth, E (1985) Insomnia and its treatment: prevalence and correlates.Arch Gen Psychiatry42,225-232. [PubMed] [CrossRef]
Katz, D, McHorney, C Clinical correlates of insomnia in patients with chronic illness.Arch Intern Med1998;158,1099-1107. [PubMed]
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