Primary Care Physician vs. Sleep Specialist: Who Knows Best?
Sleep problems can predispose individuals to many medical conditions. Conversely, medical disorders can lead to sleep disturbance. In fact, sleep disturbance represents one of the most challenging, yet exceptionally common problems faced in the primary care practice today.But if doctors aren’t asking, and patients aren’t telling, how is anyone going to know what’s really going on? A recent study found that only 43 percent of primary care physicians routinely inquire about sleep. To put that into perspective, 80 percent discuss exercise and 79 percent address healthy diet with patients on a regular basis. Despite this discrepancy, only 16 percent believed that counseling patients on sleep is not as important doing so with regards to diet and exercise. Oftentimes, patients end up on sleeping aids for long-term use when all along it was restless legs or sleep apnea that was the root cause of their poor sleep.
What if rather than addressing sleep concerns with a "Band-Aid approach" like a sleeping pill, they instead look for the real cause of poor sleep? Many patients end up on high blood pressure meds, sleeping aids and anti-anxiety medications when all along it was sleep apnea causing the issues.
Sleep as a Vital Sign
Sleep is one of our most basic human needs, but it’s rarely discussed during a typical primary care visit. Sleep habits should be considered a vital sign. It should be something that is questioned at every visit. When sleep is poor, chances are extremely good it’s due to an undetected or untreated health problem. It might be an undiagnosed medical condition, an underlying sleep disorder, medication problems or even mental health concerns.
A patient is told they stop breathing multiple times an hour each night. Their heart is feeling the consequences and they are being warned that they are three times more likely to suffer a stroke or, even worse, if their condition is left untreated. That’s scary and quite overwhelming!
When we think about the complexity of sleep apnea and then about the finite amount of time a primary care physician has to spend with the patient (sometimes only 15 minutes), it’s simply not enough to make an accurate diagnosis.
The main treatment for sleep apnea is continuous positive airway pressure (CPAP). The national average adherence to CPAP is 47 percent. Only 47 percent? Why? We need more sleep specialists and care teams tackling the barriers to treatment and inconveniences of CPAP. A primary care physician is very limited on time and is not kept up to date with all the different types of treatment options for sleep apnea.
Oftentimes, the only follow up the patients get in most primary care settings is the “compliance check” at 31 days after therapy. This is due to the fact that insurance companies want to know that they machine is actually being put to use. The medical equipment company will request the primary care doctor to follow up with the patient to make a note of how many hours the patient is using the CPAP. But who is actually checking to see if the CPAP is clinically working? Is the patient still having apneas?
At times I have seen sleep apnea patients who are placed on a CPAP and end up with worsening conditions. It’s important to have a sleep specialist check the effectiveness of the treatment not just for hours of usage, but also for a decrease in apneas, comfort, decreased fatigue and increased quality of life.
When we say “sleep apnea” it undervalues the true meaning. After all, sleep apnea is not a sleep problem. In fact, the patient may be suffering from heart disease, irregular heart rhythms, uncontrolled high blood pressure, uncontrolled diabetes or severe depression. The sleep apnea or, shall we call it “nocturnal severe hypoxemia” or “nocturnal respiratory cessation”, is the underlying cause of their primary health problems.
Approximately 50 to 70 million Americans experience disorders of sleep and wakefulness, and a significant majority of these people are undiagnosed. Regarding common sleep disorders, it is estimated that in the United States, chronic insomnia affects 30 million individuals, while obstructive sleep apnea syndrome affects 8 million; and restless legs syndrome affects 6 million.
Why would you ask a cardiac doctor to treat your broken leg? The same goes for your sleep. You sleep a third of your life, which means that it plays a big role into your overall health. Knowing this, wouldn’t more patients want to be treated by a sleep specialist? Particularly one with a savvy sleep educator on staff? We need to spread the word!
Kristina Weaver, RPSGT, is neurodiagnostic manager for Parrish Healthcare's Sleep Disorders Center. Kristina has been involved in sleep medicine for 13 years. Prior to that, she was a paramedic. Kristina has established many programs, which include Sleep Navigator, COPD Navigator and Corporate Sleep Navigator programs within her community. Kristina is also the coordinator for the Brevard AWAKE group and serves as the past president for the Florida Association of Sleep Technologists.