Medical literature documenting human sleep disturbances dates back centuries, usually in the form of self-reported experiences from patients and their sleep mates. However, the recognition of sleep medicine as its own field is generally traced to the not-so-distant past: the 1970s, when disorders such as obstructive sleep apnea (OSA) first became clearly defined, and polysomnography became the standard clinical test.
Explore This IssueDecember 2020
The conversation about which medical specialists are best suited to treat patients with sleep disorders evolved even more recently. Sleep medicine was initially considered the purview of pulmonologists, to whom patients were referred by their general medicine practitioners. Over the years, however, as the complexities of sleep disorder cases became more apparent, so too did the multidisciplinary nature of sleep medicine as a practice. In 2007, the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) launched a conjoint American Board of Sleep Medicine (ABSM) that included the American Boards of Internal Medicine, Family Practice, Pediatrics, Psychiatry and Neurology, Anesthesiology, and Otolaryngology (changed in 2017 to “Otolaryngology–Head and Neck Surgery”).
Requirements for otolaryngologists who wish to become dual boarded in sleep medicine have become more stringent in recent years. The American Board of Otolaryngology–Head and Neck Surgery (ABOHNS) dictates that otolaryngologists with a valid certificate and license in otolaryngology who wish to achieve certification in sleep medicine must complete 12 months of sleep medicine fellowship training in an ACGME-accredited program, wherein they achieve ACGME-established training experience that includes clinical performance and ability to interpret a range of sleep-related diagnostic tests. Finally, candidates must also perform successfully on the ABOHNS Sleep Medicine Certification Examination. (It should be noted that, because the ACGME-accredited, 12-month fellowship requirement was enacted in 2012, many of today’s dual-boarded otolaryngologists earned their sleep medicine certification through previously accepted paths.)
Given the considerable commitment that current requirements for subcertification represent, how worthwhile is it for otolaryngologists to dual board in sleep medicine? So far, those who have chosen this path are few and far between. However, given that an estimated 50 to 70 million people in the U.S. are reported to have some type of sleep disorder—and that number is expected to increase—the personal and professional rewards of doubling up might be worth the investment.
Determining how surgery may be part of an integrated treatment isn’t something you can easily do with just one of those two hats on. It comes down to knowing how to integrate the care of the complex patient. —B. Tucker Woodson, MD
The Draw of Sleep Medicine
Otolaryngologists who dual board in sleep medicine arrived at their decision at different points in their careers. Christine H. Heubi, MD, assistant professor in the department of otolaryngology–head and neck surgery at the University of Cincinnati College of Medicine and a dual-boarded otolaryngologist who practices in the divisions of pediatric otolaryngology–head and neck surgery and pulmonary medicine at the Sleep Disorders Center at Cincinnati Children’s Hospital Medical Center (CCHMC), solidified her career trajectory prior to medical school while serving as a research assistant.
“I worked on a project entitled, ‘ENT manifestations of children with Down syndrome,’ with Dr. Sally Shott. I participated in an informal multidisciplinary group of specialists where we reviewed complex cases of obstructive sleep apnea in children and was fascinated by the different approaches to care and the variety of management modalities,” she said.
Following her one-year sleep medicine fellowship, Dr. Heubi completed a two-year fellowship in pediatric otolaryngology at CCHMC. “As I went through my ENT training, I found that my experience had an impact on how I approached patients with sleep abnormalities, and I pursued sleep training so that I could offer patients medical and surgical management not only of OSA, but of other sleep disorders,” she said.
Mas Takashima, MD, professor and chair of the department of otolaryngology–head and neck surgery for Houston Methodist Hospital System at Texas Medical Center, was first drawn to sleep medicine during his residency. “There was nothing more dissatisfying than operating on OSA patients,” he recalled. “We didn’t have good diagnostic tests identifying the site of obstruction. The surgery that we performed was just a uvulopalatopharyngoplasty (UPPP), which was effective only 40% of the time.” Dr. Takashima wanted to learn more. “Even though I was an otolaryngologist, I never felt that it was appropriate that I was considered an ‘expert’ in the field of sleep surgery,” he said. “I wanted to immerse myself in the medicine of sleep disorders, along with the potential nonsurgical and surgical cures.”
Long recognized in the field of OSA, dual-boarded otolaryngologist and sleep medicine specialist B. Tucker Woodson, MD, professor and chief of the division of sleep medicine and surgery, department of otolaryngology, at the Medical College of Wisconsin in Milwaukee, started out in the early 1990s, before board certification was available. “I’d come out of [Detroit-based] Henry Ford Hospital, which had one of the early programs involving sleep apnea and sleep medicine,” he said. Over time, Dr. Woodson realized that he was seeing a lot of patients who “really needed people with an orientation and understanding of the upper airway anatomy and physiology, and different modalities of treatment. I found that having that double level of expertise was really necessary,” he explained. “I didn’t start out deciding to be board-certified; it just sort of evolved.”
One practical aspect to becoming subcertified in sleep medicine is the addition of reimbursement for reading sleep studies, which Dr. Woodson acknowledges is a benefit of board certification. “It’s still a part—I had around 15 or 20 studies that I read today,” he said. “But for me, the advantage is more about integrating all of the information I gained from the clinical care experience.”
“Your practice goals and interests will determine whether achieving subcertification in sleep medicine will advance your career,” added Pell Ann Wardrop, MD, who began seeing sleep patients at a local hospital sleep clinic in 1999 as part of her general otolaryngology practice. “I entered private practice at a multispecialty clinic and was drawn to adult and pediatric patients with sleep-disordered breathing,” she said. Dr. Wardrop became dual boarded in 2003 and is currently medical director at CHI Saint Joseph Health Sleep Care Center in Lexington, Ky. “A certification in sleep medicine allows you serve as a medical director, to read sleep studies, and to practice within an accredited sleep center,” she explained.
Eric J. Kezirian, MD, MPH, professor and vice chair at the University of Southern California Caruso Department of Otolaryngology–Head and Neck Surgery at the Keck School of Medicine of USC in Los Angeles, who became dual boarded in 2009, cited two main categories of benefits to sleep medicine board certification: clinical scope of practice and the simple certification itself. “Sleep medicine board allows one to practice sleep medicine—especially activities such as interpretation of sleep studies—in a sleep center certified by the American Academy of Sleep Medicine, without any questions raised,” he said. “In my own career, I never really wanted to be reading sleep studies. However, I did want to indicate that I possessed a similar core body of knowledge as my colleagues in sleep medicine.”