The Science and Hucksters of Sleep

By Brandon Peters, MD

Sleep medicine has an image problem. It can be traced back to its earliest history, and it is perpetuated by practitioners who value personal gains over public interests. Changes must be made for the field to finally gain the respect that it rightly deserves.

There are giants in the field of sleep medicine. It has been my great fortune to work and train with many of these individuals. One such giant is William C. Dement, MD, PhD, professor at Stanford University, and widely regarded as one of the founders of contemporary sleep medicine. His pioneering work led to the discovery of sleep stages, including rapid eye movement (REM) sleep. With Christian Guilleminault, MD, he helped to found the world's first sleep clinic at Stanford. Dr. Dement was also integral in securing reimbursement for this valuable work from insurance providers.

I have heard Dr. Dement recount one of the early meetings he had with a group of insurance administrators. As he shared the basic procedure, findings, and purpose of sleep testing with a diagnostic polysomnogram (a term he likewise coined), one of the men in the room became infuriated. He denounced his work as a fraud, and him as a huckster, and stormed out of the room. Fortunately, cooler heads prevailed, and the diagnosis of sleep became reimbursable and a new field of clinical medicine was born.

In the past 5 decades, since sleep clinics were first established, the field of sleep medicine has thrived. Even today, it is difficult to meet the extraordinary demand for evaluation, testing, and treatment. Though sleep apnea and insomnia predominate, there are dozens of sleep disorders that require expert management. It became important to recognize those with proper training and education, to designate those with expertise.

To meet these needs, and to integrate a diverse collection of experts, the board certification in the specialty of sleep medicine was previously extended not only to physicians but also to dentists, psychologists, and researchers. Once achieved, through passing an examination, the recognition conferred was lifelong.

Insurers began to use this designation alone as a criterion for selecting who could interpret sleep studies and manage sleep patients. As a result, non-physicians could be board-certified in sleep and might run a sleep clinic or even a testing facility. This raised some concerns. For example, how can a psychologist best manage someone with heart failure? Since 2007, only physicians who complete medical school, residency training, and a fellowship in sleep medicine may become board-certified in sleep.

Unfortunately, everyone who previously simply sat for an exam and passed it are still out there. It is upsetting to encounter, via second-hand patient reports, the suboptimal care that is being delivered. I see the books they write, the articles they post, and the interviews they give; it is unnerving. Until these practitioners retire, which could be 50 years from now, the quality of care as a whole suffers. Moreover, as the financial incentives grew, the business of sleep drew others into the fold who are simply out to make a fast buck. 

Everyone deserves a quality night of sleep. Society benefits in measures of safety, health, and happiness. Unfortunately, the good science - based on careful experiments, well-designed clinical trials, and thoughtful interpretation - can be drowned out by junk science, unsubstantiated opinions, and novice pronouncements. These hucksters, those most feared by the angry insurance man, have crept into a field with a sound foundation and imperative ongoing need.

It will prove nearly impossible to rid ourselves of those who rightly claim board certification in sleep without proper training. The best we can do is review someone's credentials before accepting their opinions. Did they complete a sleep fellowship? Does their message smack of astrology, horoscopes, and unscientific musings? Or do they back up what they say with academic and scientific support? Are they out to make money through relentless testing or book sales? Or do they honestly seem concerned about making a diagnosis and initiating treatment?

We need to clear our ranks of those who bring down our collective reputation. Those with the credentials and expertise must take a more prominent role in leading the public discourse. We must do it to build on the hard-won gains made by sleep medicine's foremost mentors and champions.

Brandon Peters, MD, is the writer on sleep for Verywell.com, a neurology-trained sleep medicine specialist at Pulmonary and Sleep Associates of Marin in Novato, Calif., and consulting assistant professor at the Stanford Center for Sleep Sciences and Medicine.