Rebuttal From Dr Simon

Abstract

I find myself in agreement with many of the points made by my colleagues on the “Pro” side of this discussion.1Fleishman SA Collop NA Aronsky AJ McCann KM Point: should board certification be required for sleep test interpretation? Yes.Chest. 2013; 144: 9-11Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar I agree that board-certified sleep medicine physicians (BCSMPs) possess the training and competence in sleep medicine to provide reliable interpretation of diagnostic tests, but I do not agree that this competence is unique to BCSMPs. For example, the performance of polysomnography (PSG) and PSG interpretation is a core competency in neurology fellowships.2American Board of Psychiatry & Neurology Psychiatry and Neurology Core Competencies Version 4.1. American Board of Psychiatry & Neurology website.http://www.abpn.com/downloads/core_comp_outlines/core_psych_neuro_v4.1.pdfGoogle Scholar And as we have demonstrated with the Walla Walla Project, referred to in my “Con” argument,3Simon Jr, RD Counterpoint: should board certification be required for sleep test interpretation?.No. Chest. 2013; 144: 11-13Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar others can be trained to successfully interpret sleep studies. Why should these trained physicians be denied the ability to read sleep studies? My fundamental utilitarian argument is that the number of patients with significant sleep disorders vastly exceeds the capacity of our medical system to care for them if only BCSMPs are permitted to read studies and care for such patients. My colleagues from the American Academy of Sleep Medicine (AASM) do not address this issue in their statement. They do bring up an argument that BCSMP consultation prior to PSG improves CPAP usage by 58 min a night in a cohort study,4Pamidi S Knutson KL Ghods F Mokhlesi B The impact of sleep consultation prior to a diagnostic polysomnogram on continuous positive airway pressure adherence.Chest. 2012; 141: 51-57Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar but they do not address the fact that if consultations were required, the cohort that did not undergo consultation would likely have received no care for their OSA. A recent study from Australia suggests that OSA can be effectively managed in primary care with similar outcomes to those obtained in formal sleep centers.5Chai-Coetzer CL Antic NA Rowland LS et al.Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial.JAMA. 2013; 309: 997-1004Crossref PubMed Scopus (143) Google Scholar I find myself in absolute agreement that formal education in sleep physiology and sleep disorders medicine is woefully inadequate in medical schools, residency programs, and fellowship programs.6Gamaldo CE Salas RE Sleep medicine education: are medical schools and residency programs napping on the job?.Nat Clin Pract Neurol. 2008; 4: 344-345Crossref PubMed Scopus (9) Google Scholar The AASM has worked to address this serious fault in academia,7Silber MH Academic sleep centers of the future: an achievable vision.Sleep. 2007; 30: 244-245PubMed Google Scholar but much more needs to be done both for health-care providers in training and health providers in practice. Humans spend 30% of their life sleeping; there are physiologic differences in nearly all systems between wake, non-rapid eye movement sleep, and rapid eye movement sleep, and there are serious sleep disorders that result in untold human suffering, disability, and premature death. It is absolutely unconscionable that extensive formal sleep physiology and sleep disorders medicine curricula are not an integral part of medical school training. A fundamental understanding of the physiology of sleep and of sleep-disorders medicine should be core competencies for all health-care providers. Rather that limiting the number of patients who have access to sleep-disorders medicine, which is what surely will happen if only BCSMPs can interpret sleep studies, it would seem to me that a better strategy would be to encourage health-care providers to obtain the knowledge that it takes to diagnose and treat patients with uncomplicated sleep disorders and to learn to refer those who either do not respond to therapy or who have complicated sleep studies to BCSMPs. Academic and clinical sleep centers should be cooperative in these efforts, and continued educational efforts should be supported by the American Academy of Sleep Medicine for health-care providers in training as well as those currently in practice so that the enormous number of patients with sleep disorders can be effectively diagnosed and treated.