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Point/Counterpoint Editorials |

Rebuttal From Dr Fleishman et alRebuttal From Dr Fleishman et al FREE TO VIEW

Sam A. Fleishman, MD; Nancy A. Collop, MD, FCCP; Amy J. Aronsky, DO, FCCP; Kathleen M. McCann
Author and Funding Information

From the American Academy of Sleep Medicine (Drs Fleishman, Collop, and Aronsky and Ms McCann); The Sleep Center (Dr Fleishman), Cape Fear Valley Health System; Emory University (Dr Collop); and Comprehensive Sleep Associates (Dr Aronsky).

Correspondence to: Sam A. Fleishman, MD, Cape Fear Valley Health System, Fayetteville, NC 28304; e-mail: safleishman@capfearvalley.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(1):13-14. doi:10.1378/chest.13-0361
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The concept that primary care providers and physicians trained in other specialties with limited sleep medicine training possess the expertise to diagnose and treat patients suffering with sleep disorders merely because they are common is very alarming and based on a weak premise. As Dr Simon1 acknowledges, the interpretation of sleep studies is complicated and requires intensive training. Less than 2 hours of total teaching time in US medical schools, however, is allocated to sleep and sleep disorders on average.2 As reported by Rosen and colleagues,2 37 of 126 surveyed medical schools indicated no structured teaching time related to sleep. And although sleep medicine is included as part of the curriculum for fellowship training programs in neurology, otolaryngology, pediatrics, psychiatry, and pulmonary medicine, the exposure resident physicians receive is extremely limited. This limited knowledge of the pathophysiology of sleep disorders, diagnostic tools for patient testing, interpretation of sleep studies, and long-term management of patients is not sufficient to qualify as “expertise.” The training program proposed by Dr Simon is also lacking in sufficient education and training. Although he states that a recent study suggests competency in interpretation is obtained after scoring 20 to 30 tests, he does not include the full finding of the study, which also calls for 4 months of dedicated training in sleep medicine.3 Furthermore, it is unclear how his program defines appropriate training as category 1 continuing medical education in sleep disorders. Is training in the interpretation of polysomnographic data or the pathophysiology of sleep disorders required training?

Dr Simon also charges there are no empirical data available to demonstrate the value of board certification with regard to test interpretation or improvement of patient outcome. Parthasarathy and colleagues4 reported that “accreditation or certification status of sleep centers and physicians were associated with better indexes of clinical management in patients with OSA.” In addition, there is increasing evidence that demonstrates the overall care management, including interpretation of the diagnostic test, by a board-certified sleep medicine physician (BCSMP) promotes improved patient outcomes.5 A recent Australian inferiority study suggested that some of the uncomplicated cases of OSA with limited comorbidities can be managed as effectively in a primary care setting as in a sleep center.6 It is interesting to note that there was a higher withdrawal rate in the primary care group, and the costs applied are misleading, as the majority of these patients would have been evaluated by out-of-center sleep testing as opposed to polysomnography. Furthermore, there are now >1,000 sleep centers in the United States that have out-of-center accreditation by the American Academy of Sleep Medicine and are using all of the available modalities to treat patients with obstructive sleep apnea.

The clinical practice of sleep medicine goes far beyond diagnostic testing—BCSMPs provide longitudinal care for their patients with sleep disorders by coordination with an expert team at a sleep center as well as primary care physicians in the medical home. We welcome the role of working together with our noncertified health-care professionals to screen for sleep disorders and correctly refer patients to BCSMPs for assistance and care; however, please leave the diagnosis and management of sleep disorders to the experts trained in that specialty.

References

Simon RD Jr. Counterpoint: should board certification be required for sleep test interpretation? No.Chest. 2013;144(1):11-13.
 
Rosen RC, Rosekind M, Rosevear C, Cole WE, Dement WC. Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep. 1993;16(3):249-254. [PubMed]
 
Chediak A, Esparis B, Isaacson R, et al. How many polysomnograms must sleep fellows score before becoming proficient at scoring sleep? J Clin Sleep Med. 2006;2(4):427-430. [PubMed]
 
Parthasarathy S, Haynes PL, Budhiraja R, Habib MP, Quan SF. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea. J Clin Sleep Med. 2006;2(2):133-142. [PubMed]
 
Chung SA, Jairam S, Hussain MR, Shapiro CM. Knowledge of sleep apnea in a sample grouping of primary care physicians. Sleep Breath. 2001;5(3):115-121. [CrossRef] [PubMed]
 
Chai-Coetzer DL, Antic NA, Rowland LS, et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life. JAMA. 2013;309(10):997-1004. [CrossRef] [PubMed]
 

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References

Simon RD Jr. Counterpoint: should board certification be required for sleep test interpretation? No.Chest. 2013;144(1):11-13.
 
Rosen RC, Rosekind M, Rosevear C, Cole WE, Dement WC. Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep. 1993;16(3):249-254. [PubMed]
 
Chediak A, Esparis B, Isaacson R, et al. How many polysomnograms must sleep fellows score before becoming proficient at scoring sleep? J Clin Sleep Med. 2006;2(4):427-430. [PubMed]
 
Parthasarathy S, Haynes PL, Budhiraja R, Habib MP, Quan SF. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea. J Clin Sleep Med. 2006;2(2):133-142. [PubMed]
 
Chung SA, Jairam S, Hussain MR, Shapiro CM. Knowledge of sleep apnea in a sample grouping of primary care physicians. Sleep Breath. 2001;5(3):115-121. [CrossRef] [PubMed]
 
Chai-Coetzer DL, Antic NA, Rowland LS, et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life. JAMA. 2013;309(10):997-1004. [CrossRef] [PubMed]
 
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