Sleep and addiction?

[tenesmus-x]

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Short version: is it in any realistic way to do both addiction and sleep fellowship despite their overall disconnect, and have a viable practice where you get to use skills from both.

Long version:
I have waffled between sleep, pain, and addiction all of residnecy, and had finally settled on doing an addiction fellowship. I love where pain And addiction cross and while I don’t think I will do a fellowship I would enjoy being the “pain whisperer/ addiction guy”.

That all being said I just recently was diagnosed with OSA (non obese) which has rekindled a strong Interest in sleep, I would love to sniff out the other people out there like me who arnt you classic OSA. I recognize I can just refer to sleep which I do on probably 50% of my patients.

If I was to do both sleep and addiction would there be anyway I could reasonably find a job doing both? I fully recognize it’s an odd pair for fellowship choices but I know that sleep is typically is never 100% of a docs time so I would have to be doing something else when not doing sleep anyway.

* to answer the comment before it comes: Yes I know you don’t HAVE to do an addictions fellowship, however I feel like it would make me way more confident in my decision making. I also hope to use the year to really “polish” my practice in an environment where I can still make mistakes and have tons of people to ask questions of.

 

[whopper]

IMHO yes cause guess what?
Most people I've seen with addiction problems can't sleep. So you'd have plenty of patients where combined knowledge in these areas will be especially helpful.

 

[clausewitz2]

OP, do you want to be interpreting sleep studies or do you want to be treating people with sleep disorders?

You 100% need a fellowship for the first one.

You 100% do not need a fellowship for the second. The insomniacs shall ye always have with you.

In seriousness, if you got reasonable training in sleep during residency and know how to take a good sleep history/glean patterns from sleep diaries, you can do a pretty good job treating a lot of sleep problems. I do this all the time. For rare stuff or really treatment refractory things, sure, i will refer to sleep medicine, but as i have posted about before i have caught at least a handful of (MSLT-confirmed) cases of narcolepsy masquerading as a primary psychiatric problem and continue to treat them, all in the last couple of years. I am not going to be publishing case series of Kleine-Levin syndrome anytime soon but I still get to treat sleep disorders.

If, or course, you did not get a chance to do any sleep rotations or get appropriate training in residency, i understand your interest in a fellowship, but there are lots of good resources for learning CBT-I, AASM publishes practice guidelines, and between those two things you can do better by @ substantial majority of your patients with sleep problems than the average psychiatrist.

 

[singasongofjoy]

I'd think that anywhere that sees a lot of patients with either would love to have you on staff - that would be a huge asset.

 

[TexasPhysician]

You could get 1099 jobs for both a sleep center and an addictions center. It is highly unlikely that you will find one place that will pay you well to do both. These are typically different departments that will have their own incentives. From what I’ve seen in my area, sleep centers are seeing decreasing reimbursement and significant midlevel encroachment. It is easy to develop a relationship with a company that will provide all of the equipment for a fee and send reports to sleep medicine in the middle of nowhere. You bill insurance and train on the equipment. Any specialty can thus incorporate sleep now.

 

[singasongofjoy]

You could get 1099 jobs for both a sleep center and an addictions center. It is highly unlikely that you will find one place that will pay you well to do both. These are typically different departments that will have their own incentives. From what I’ve seen in my area, sleep centers are seeing decreasing reimbursement and significant midlevel encroachment. It is easy to develop a relationship with a company that will provide all of the equipment for a fee and send reports to sleep medicine in the middle of nowhere. You bill insurance and train on the equipment. Any specialty can thus incorporate sleep now.

^^sounds like a good approach- make connections with sleep clinics / specialists so they'll refer patients to you. Worked in a sleep clinic for a while and such a connection to refer folks to would have been super appreciated (did have a psychiatrist specializing in geriatrics that we referred to often)

 

[dl2dp2]

You won't find a job doing both. They have little in terms of overlap on a practical level, especially at a facility.

However, it is possible to set up a practice that has a dual focus, especially as a consultative service for people with refractory sleep issues of a psychiatric/substance use origin. I can see the market appeal if things are set up/marketed correctly. But this is not a facility driven job.

 

[tenesmus-x]

Good questions. One of the major reasons I have struggled with committing to addiction or sleep by way of fellowship is I know you can do a MASSIVE amount of either specialty without doing the fellowship/board cert. However if I want to be expert at something I fell like I really want the expertise that further training can provide.

To answer the questions.
1. Defiantly would like to be treating people with sleep disorders/everyone in the world could use better sleep so its a great skillset to have. Do I have a burning passion and my life wont be fulfilled if I don't read sleep studies? Probably not. Do I envision sleep studies to be an enjoyable way to still be do clinical practice without needing to sit across from a patient for X hours a week, and something I could probably do long into my aged "retirement years"? Yeah (it would kind of be my "radiologist life").

I have also only been able to rotate with sleep medicine, a handful of times during residency, so feel that I would defiantly have plenty to learn from fellowship (recognizing it would be possible to teach myself a lot of it).

--
Overall what I am hearing is, it is possible to pull off doing both (probably overkill but possible).

 

[romanticscience]

On this topic, what are the opportunities for outpatient psychiatrists to get involved with home sleep-study testing and interpretation? I know PCPs do it.

 

[bGMx]

Bump, would like to hear new perspectives on being triple boarded in General Psychiatry, Addiction Psychiatry, and Sleep Medicine-- I could imagine a very fun practice with this kind of training

 

[Sushirolls]

Waste of time. If one will do a fellowship, pick addiction or sleep but don't waste your time doing both, thinking somehow you will have a fancy blend.

 

[Cath Up]

The sleep clinic at my institution seem to mostly be OSA/sleep study doctors. They don't even manage the KLS patients when they are hospitalized. I'd guess they get some non-OSA consults as well obviously. As someone who is super interested in sleep, diagnosing OSA seems profoundly boring to me, but if one enjoys it I echo that a fellowship seems important. For me the most interesting any enjoyable part of sleep treatment consists of CBTI, which you can get training in during residency.

 

[comp1]

Just no. Formal schooling has to end some time and a general psychiatry residency is a great place for it to do so.

 

[Stagg737]

This also honestly sounds like a largely redundant plan. Patients with significant SUDs are going to have sleep issues and the treatment is to address their SUD. Patients with insomnia may develop sedative use disorders and the recommendation is going to be to address their insomnia with non-addictive meds and therapy. If you really have an interest in one of these areas and want to make this the bulk of your practice then 1 fellowship is enough. Fellowships are for people who want those sub-specialties to be their primary area of practice. Even then it's not always necessary.

 

[FlowRate]

Bump, would like to hear new perspectives on being triple boarded in General Psychiatry, Addiction Psychiatry, and Sleep Medicine-- I could imagine a very fun practice with this kind of training

What most interests you about each of those fields? I'd just echo what everyone else said--you can do 100% of addiction and 50-75% of sleep without a fellowship.

 

[bGMx]

For me it's the intersection, and what I imagine I could be for patients who have sleep / mood / SUD. The imagined patient is as follows: chief complaint: insomnia, utilizing substances to cope-- mood is the primary driver but the patient with low insight. Keep the polysomnography in house, rule out and/or treat organic sleep disorders (OSA); if ruled out, use gen-psych to treat and addiction psych to address SUD. Essentially, once sleep is corrected, focus on mood and SUD.

 

[FlowRate]

For me it's the intersection, and what I imagine I could be for patients who have sleep / mood / SUD. The imagined patient is as follows: chief complaint: insomnia, utilizing substances to cope-- mood is the primary driver but the patient with low insight. Keep the polysomnography in house, rule out and/or treat organic sleep disorders (OSA); if ruled out, use gen-psych to treat and addiction psych to address SUD. Essentially, once sleep is corrected, focus on mood and SUD.

You can do 100% of this without any fellowships as long as you're okay with sending out the sleep study/OSA treatment (you can do basically the rest of the sleep workup minus the sleep study yourself.) No one needs you to be one stop shop for the OSA treatment part but lots of people will benefit from having one person addressing both MH and addictions piece.

In our system, insomnia is 95% psychiatry's domain anyway. Sleep med doesn't see them unless we've already seen and tried various interventions and determined there's something actually complex/unusual going on.

 

[bGMx]

I'm thinking specifically about doing the sleep study myself. How many patients do you have where you refer them to Sleep Med for a sleep study but there is either a) no availability or b) they don't follow up?

Being the person who does the sleep study allows me to say definitively "no sleep meds, use this CPAP and work on hygiene" because they slept like a baby in the lab.

Then there would be no credibility to: "I smoke / drink to fall asleep."

 

[Stagg737]

For me it's the intersection, and what I imagine I could be for patients who have sleep / mood / SUD. The imagined patient is as follows: chief complaint: insomnia, utilizing substances to cope-- mood is the primary driver but the patient with low insight. Keep the polysomnography in house, rule out and/or treat organic sleep disorders (OSA); if ruled out, use gen-psych to treat and addiction psych to address SUD. Essentially, once sleep is corrected, focus on mood and SUD.

Sounds like sleep medicine fellowship could be worthwhile if you're wanting to perform and interpret sleep testing in house. You don't need an addictions fellowship for what you're talking about as it sounds like primary driving factor is mood d/o -> insomnia -> sedative/hypnotic abuse. Primary psych should have no problems treating that almost ever.

I'm thinking specifically about doing the sleep study myself. How many patients do you have where you refer them to Sleep Med for a sleep study but there is either a) no availability or b) they don't follow up?

Availability of testing is abundant where I am. Even in the half of the state where I do telehealth and there are no psychiatrists and specialists are sparse there are an abundance of sleep testing centers. There's even a Ivy trained sleep specialist in one BFE town. Strangely sleep medicine is not in short supply there at all...

Follow-up/not scheduling is fairly common. I have a handful of patients I've been telling to get a sleep study for 6+ months and they either have excuses for why they won't do it or say insurance won't cover it (which is only true about 50% of the time).

You can do 100% of this without any fellowships as long as you're okay with sending out the sleep study/OSA treatment (you can do basically the rest of the sleep workup minus the sleep study yourself.) No one needs you to be one stop shop for the OSA treatment part but lots of people will benefit from having one person addressing both MH and addictions piece.

In our system, insomnia is 95% psychiatry's domain anyway. Sleep med doesn't see them unless we've already seen and tried various interventions and determined there's something actually complex/unusual going on.

Agree, but our system does sleep medicine a bit differently. We see most of the general sleep complaints, but we don't do any OSA testing or treatment, 100% deferred to sleep/pulm. If we suspect narcolepsy, REM/non-REM disorders, etc and they need polysomnography or MSLT type stuff it goes to sleep/neuro. We sometimes manage those meds after neuro-sleep has gotten them stable, but they often just continue to see them every 6-12 months. If those tests are negative or it's not a medical insomnia or another disorder like OSA we manage most of those through psych though.

 

[FlowRate]

I'm thinking specifically about doing the sleep study myself. How many patients do you have where you refer them to Sleep Med for a sleep study but there is either a) no availability or b) they don't follow up?

Being the person who does the sleep study allows me to say definitively "no sleep meds, use this CPAP and work on hygiene" because they slept like a baby in the lab.

Then there would be no credibility to: "I smoke / drink to fall asleep."

No follow-up happens, but that's true of any test or recommendation you might make. Whether or not you are interpreting the sleep study yourself doesn't change a whole lot about whether you require that they do it as part of your treatment plan.

Never run into lack of availability. I actually order the home sleep apnea test myself. Our sleep docs officially interpret them but I think 90%+ of the interpretation is automated anyway. And I certainly understand the result data without needing their read of the home sleep apnea tests.

In lab sleep studies are primarily for rare dx workup and the occasional OSA fitment/titration.

 

[TexasPhysician]

Sleep medicine has become much less lucrative. I believe this results in less demand for intelligent, caring people to enter the field. The result is more big box shops that essentially ship sleep study supplies to patients. I don’t go a week without an online sleep doctor sending me an email, calling the office, or something to pitch their convenient, online sleep solution to me. Getting a sleep study is now super easy for patients. Appointments are easy to get and the equipment is shipped conveniently like patients ordering from Amazon.

I’m not sure that an addictions fellowship is needed here unless you plan to do a significant amount of detox, work in rehabs, etc. Learning CBTi and other counseling strategies to naturally improve sleep would be more valuable to improve sleep quality.

 

[michaelrack]

I'm thinking specifically about doing the sleep study myself. How many patients do you have where you refer them to Sleep Med for a sleep study but there is either a) no availability or b) they don't follow up?

Being the person who does the sleep study allows me to say definitively "no sleep meds, use this CPAP and work on hygiene" because they slept like a baby in the lab.

Then there would be no credibility to: "I smoke / drink to fall asleep."

You won't be able to do full-scale sleep and addictions in a single job. And these days it wouldn't be cost effective to do in a private practice either- it costs a lot of $ to set up a sleep lab.... and the sleep lab needs to be oriented towards churning out cpap machines to be able to hope to make any $. And home sleep testing (without the backup of a sleep lab) isn't going to allow you to "to say definitively "no sleep meds, use this CPAP and work on hygiene"

I do a little work at a private sleep lab to keep up my skills, but the days of me starting up sleep labs are far gone.

But anyways, if you want to primarily treat sleep-disordered breathing, go ahead and do a sleep fellowship. You can do some psychiatry on the side, perhaps at a sleep lab. But it only makes sense to do a sleep fellowship if you plan on focusing on treating sleep-disordered breathing.

 

[mistafab]

Bump, would like to hear new perspectives on being triple boarded in General Psychiatry, Addiction Psychiatry, and Sleep Medicine-- I could imagine a very fun practice with this kind of training

I highly recommend you do not do multiple fellowships. You would be hard pressed to hear me recommend doing a single fellowship, let alone two. The only fellowships I really understand in many cases are CAP, and forensics (if they want to do criminal forensic work).

Get out of the mindset of collecting paperwork. Get in the mindset of PRACTICE of psychiatry. Want to do more addiction? Go PRACTICE addiction. Want to do more sleep? Besides reading sleep studies - go practice! Stop looking for excuses to put your real career off any longer.