Medical Training with a Side of Sleep Medicine

A fast-growing medical subspecialty, sleep is one that also uniquely affects patients and health care workers alike.

And that personal connection drives the passion for physicians who decide to help others improve their lives through better sleep.

"It was not until residency, under work-related sleep deprivation from night shifts and the on-call schedule, when I realized that sleep was the biggest quality of life factor for me personally, and that sleep was also a large quality of life factor for my patients and their whole families," says Lisa Matlen, M.D., a pediatric neurologist and sleep specialist with the C.S. Mott Children's Hospital and the Michigan Medicine Sleep Disorders Centers.

Matlen worked on sleep-related research as an undergraduate, as a medical student and while studying pediatric neurology during her residency, then continued with a sleep medicine fellowship at Michigan Medicine before joining the faculty.

Sajeer Bhura, M.D., did his residency in internal medicine and decided sleep medicine would complement his primary specialty. Upon graduation from his one-year sleep medicine fellowship at Michigan Medicine, Bhura will continue to another institution for a pulmonary/critical care medicine fellowship.

Bhura and Matlen reflect on their experience studying sleep medicine at Michigan Medicine, which is the second largest sleep medicine fellowship program in the country, and share what others should know about their subspecialty.

What appealed to you about a sleep fellowship?

Matlen: Although I love what I do as a general pediatric neurologist, I was also excited to train to become an expert in such an interesting field, which has broad quality of life implications and combines what I learned in fellowship to use between the two practices of pediatric neurology and sleep medicine.

There is extensive overlap between pediatric neurology and pediatric sleep medicine clinical practices, particularly in the management of epilepsy and headache disorders. I also found the electroencephalography (EEG) portion of my pediatric neurology training to be fascinating, relying on visual pattern recognition and allowing for variety of practice.

I enjoyed the ability of this field to combine clinical outpatient work with electrophysiologic testing, as polysomnography reading is an important part of sleep medicine.

Bhura: I wanted to study sleep medicine first before going into pulmonology and critical care.

Obstructive sleep apnea is the bread and butter for sleep medicine – many of the patients we see suffer from this disease. And it complements pulmonary medicine in the sense that pulmonologists often treat patients with OSA. I am getting a good perspective about how the devices for OSA are used while I'm here.

Working in sleep, pulmonology, and critical care means my career will have a lot of variety. I'll be able to care for both inpatients and outpatients, in both more stressful and in less stressful situations. Sleep medicine is a good field in the sense that it gives you a good work-life balance and there's a lot of demand.

What makes the sleep field unique?

Matlen: Sleep medicine is uniquely multidisciplinary. There are pathways from multiple clinical specialties into sleep medicine, and those from each field have a unique perspective and approach. We are constantly learning from each other.

For example, I have worked with fellows and faculty spanning disciplines ranging from general pediatrics and internal medicine, family medicine, neurology and pediatric neurology, pulmonology and pediatric pulmonoloy, otolaryngology, oral maxillofacial surgery, dentistry, psychiatry, developmental behavioral pediatrics, psychology, and with respiratory therapists and sleep technologists.

Bhura: Seven specialties are eligible to continue to a sleep subspecialty: neurology, psychiatry, internal medicine, pediatrics, family medicine, anesthesiology and otolaryngology. My fellowship classmates are from family medicine, internal medicine and pediatric pulmonology training programs.

The best thing about this diversity is the easygoing environment and discussions. For example, from my internal medicine residency, I have rich experience in cardiology, so my classmates sometimes ask me questions about EKG findings. And if I have a question about pediatric sleep, I don't have a pediatric background, but I have two classmates with pediatric expertise who I could ask.

What stands out to you about your experience?

Matlen: Though I have trained at University of Michigan since college, I was unaware until I applied to the sleep medicine program how large and well-established our program is, and the amazing depth and breadth of expertise within the faculty, several of whom are world-renowned experts. The faculty are incredibly humble and excellent, approachable teachers.

I have seen some of the rarest disorders, like congenital central hypoventilation syndrome and highly complex cases of narcolepsy. I've learned how to read seizure montage polysomnography, and about the practice of behavioral sleep medicine. I've also participated in reading numerous neonatal polysomnograms and relevant case management, which are performed at relatively few centers across the country.

Bhura: The sleep medicine faculty: they are friendly and they want to teach. They're never in a hurry, and they respond to feedback. We brought some ideas for changes to the fellowship to the table, and they are already being implemented.

For example, the first months of the fellowship were a challenge for me at times. From studying for my internal medicine boards to hosting my family visiting from Pakistan to applying for my next fellowship for next year, I was really busy outside of work. I was also working some extra hours to finish everything I needed to do. We proposed changes to our schedules to protect time for protocoling sleep studies so we wouldn't have to squeeze that in on the weekends, and to protect academic time. I appreciated that the fellowship program leadership took our feedback and made changes to improve the experience.

What makes a good sleep medicine training program?

Matlen: I think a good sleep training program will provide sufficient patient volume to learn from both bread-and-butter and complex cases.

Polysomnography reading should also be prioritized: it takes a combination of in-depth evaluation into the many technical components and high volume to learn and understand the scoring criteria and accurate interpretation. In pediatrics especially, our interpretations guide whether or not a child will proceed with invasive surgery.

Finally, faculty should be invested in fellow education. There should be faculty representation among multiple specialties.

Bhura: It's important to me to gain a lot of experience. Our patient population is very diverse, because we get referrals from all over the state, and sometimes from out of state. I'm expected to see a lot of patients, but that expectation is a strength of the program, in my opinion, because we gain so much confidence in treating patients and understanding their disease processes.

And U-M's alumni base is strong and widespread across the country, and even internationally, which is another positive.

What does the future of sleep medicine look like?

Matlen: I think telemedicine is here to stay and many of our evaluations will continue to include use of virtual care, which was new to most of us prior to March 2020. I also hope to see more pediatric providers enter the field as there are relatively few of us compared to the high patient need for pediatric sleep medicine evaluations.

Bhura: The field of sleep medicine is growing by the day as the medical community realizes the impact of sleep. For example, we know OSA affects heart health and blood pressure control. We see more referrals for sleep medicine evaluation than in the past, and I expect the demand to keep growing.

What are you glad you've learned about sleep on a personal level?

Matlen: I have always prioritized sleep: my personal high sleep need is one of the reasons I went into sleep medicine to begin with!

However, after sleep medicine fellowship, I am even more attentive to my sleep habits including going to bed early, avoiding staying up too late or sleeping in too much on weekends, and use of blue light-filtering technology when needed.

I am frequently asked about sleep from friends and family; interest in sleep is not only a personal niche, but it's a common one throughout society. I am humbled by how much we still do not know in sleep medicine and there are many clinical questions that remain unanswered. For instance, I can't explain the meaning of your dreams (yet).

Bhura: Although we spend one-third of our life sleeping, people don't always realize the importance of it. Not being able to sleep for the required number of hours affects our performance during the day and our energy levels.

During my fellowship, I realized that if I can understand how sleep works and what my own body needs, then I can deal with it. For example, if I don't sleep well for one day, I can carry on the next day, but make sure I get the sleep I need the following night. When you understand a process and what is normal physiology, you're able to deal with problems that arise as well.