Sleeping with Neurologist and Internists?

[GOINGDUMB]

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Hi everyone!

I don't know a lot about neurology. I am doing a 'check-it-out' rotation on neurology this month.

I want to ask a question that might sound totally noob but I gotta ask...

Sleep medicine sounds super cool and like a way you can really change lives.

These neurology guys are blowing my mind. One of the neurologists was talking about Parkinson's and how you can see RBD and treat it with clonazepam. So it got me thinking - you guys are the brain guys - Aren't you guys the best suited to do sleep medicine?

I have been eyeing sleep medicine through IM but don't know enough (read: nearly nothing) about it

So I ask, Do the neurologists who do sleep vs internist/pulm guys who do sleep have a difference in knowledge?

If you had a sleep disorder would you prefer one over the other?

Just asking...

Thanks for your input!

 

[bustbones26]

Hi everyone!

I don't know a lot about neurology. I am doing a 'check-it-out' rotation on neurology this month.

I want to ask a question that might sound totally noob but I gotta ask...

Sleep medicine sounds super cool and like a way you can really change lives.

These neurology guys are blowing my mind. One of the neurologists was talking about Parkinson's and how you can see RBD and treat it with clonazepam. So it got me thinking - you guys are the brain guys - Aren't you guys the best suited to do sleep medicine?

I have been eyeing sleep medicine through IM but don't know enough (read: nearly nothing) about it

So I ask, Do the neurologists who do sleep vs internist/pulm guys who do sleep have a difference in knowledge?

If you had a sleep disorder would you prefer one over the other?

Just asking...

Thanks for your input!

A neurologist is going to tell you that they are better at sleep. An Interist/Pulmonologist is going to tell you that they are better at sleep.

Here is the low down, sleep is trending toward multidisciplinary medicine.

There is a lot of good neurophysiology involved with sleep, hence, they neurologist get into this. But there is always the "airway" issues, hence why pulmonologists stake their claim too.

We are what we all are, so knowledge difference will exist, but there is a common goal at the end of the day.

 

[danielmd06]

Fellowship training is standardized so specific backgrounds matter less than previously.

The major people in sleep right now are pulmonary, neurology, and psychiatry. IM, FP, ENT, and others (including even anesthesia) can apply. The idea of who is "best" is highly debatable and often inconsequential. One of the strengths of sleep medicine is its multidiciplinary nature.

Of the major three current background branches there are some basic truisms (with individual variability) that follow logic. Pulmonary people are more comfortable with COPD and OSA (overlap syndrome), hypoventilatory disease, supplemental oxygen, etc. Neurology people are more comfortable with nocturnal seziures, parasomnias, restless legs syndrome, movement disorders of sleep, etc. Psychiatrists are most comfortable with insomnia and nightmares. Everyone manages the standard sleep disordered breathing stuff fine. Sometimes psychiatrists are less than thrilled to be goat-roped into seeing insomnia patients, though.

In my experience, pulmonary and neurology are the most sought after in private practice. I have no idea what an academic center would most prefer. Probably whatever gap they feel they need to have filled. Pulmonary people will be involved in sleep less than previously in my opinion due to the disinterest in completing a second fellowship for sleep medicine which is now required (previously, they could "grandfather" into it by documenting enough work in the dicipline during their Pulm/CCM years). The extra year is a big drawback for them.

It's a great field. Good luck.

 

[GOINGDUMB]

Thanks guys for the insight.

I hear the multidisciplinary part, and how pulm brings something to the table in terms of airway stuff.

But what about just a general internist or fp who does a sleep fellowship - Will they be able to bring something to the table/know enough after fellowship beyond 'a dangerous little bit of information'?

Also,

there are some basic truisms (with individual variability) that follow logic... Sometimes psychiatrists are less than thrilled to be goat-roped into seeing insomnia patients, though.

1. I like the way you neurologists talk. In another life, I would do this neurology just to be as sophisticated and intellectual sounding as you guys.

2. Can you elaborate on what you mean psychiatrists aren't thrilled about insomnia?

Thanks again!

 

[danielmd06]

But what about just a general internist or fp who does a sleep fellowship - Will they be able to bring something to the table/know enough after fellowship beyond 'a dangerous little bit of information'?

Can you elaborate on what you mean psychiatrists aren't thrilled about insomnia?

IM or FP are in less demand than neurology or pulm in my experience. They know basic management of alleriges, PFT's, and bring more knowledge about general medicine to the table than most neurologists, but the pulmonologists know this stuff too, and frankly it's not that hard to pick up for the level a sleep specialist needs. But they certainly get sleep fellowships and become great sleep specialists. In general, I think it's fair to say that more training usually makes for better hiring material.

The insomnia comment? Just my opinion. Nothing more. Insomnia patients often have alot of overlap with anxiety/depression, and are "sticky" interviewees. Most doctors prefer the straightforward objective stuff. So the psychiatrists are not always ecstatic about getting a disproportionate percentage of "difficult" patients (even though this is technically solidly within their purview and they should arguably be the best at managing the concomitant disease).

 

[michaelrack]

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2. Can you elaborate on what you mean psychiatrists aren't thrilled about insomnia?

!

Interesting thread title.

The cash in sleep medicine doesn't come from insomnia (although they can be interesting patients). Sleep apnea pays the bills.

I personally get the most professional satisfaction from successfully treating a case of narcolepsy. BTW, my background is IM/psych/sleep.

 

[Hank Rearden]

I've never understood why pulmonologists would want to go into sleep medicine. You've just spent 3 years in IM residency, 2-3 years in Pulm/Critical Care. You are incredibly skilled at taking care of the sickest patients on the planet, and now you want to spend 90% of you day diagnosing and treating sleep apnea? What an utter waste of training. I think most pulm folks who go into sleep medicine at some point just got burned out and want the cushy lifestyle because they have families, etc.

Sleep is much more interesting from the neuro / psych perspective. Narcolepsy, insomnia, RBD, RLS, etc. Still an incredible amount to learn research wise - we still don't even know why people need to sleep!

 

[michaelrack]

I've never understood why pulmonologists would want to go into sleep medicine. You've just spent 3 years in IM residency, 2-3 years in Pulm/Critical Care. You are incredibly skilled at taking care of the sickest patients on the planet, and now you want to spend 90% of you day diagnosing and treating sleep apnea? What an utter waste of training. I think most pulm folks who go into sleep medicine at some point just got burned out and want the cushy lifestyle because they have families, etc.
!

A lot of the pulms with sleep training make sleep a minority of their practice- 25% or so and spend the rest of their time doing traditional pulm.

Back in the old days (early 2000's) sleep was seen as a way to ease into retirement for some pulms.

 

[danielmd06]

I've never understood why pulmonologists would want to go into sleep medicine. You've just spent 3 years in IM residency, 2-3 years in Pulm/Critical Care. You are incredibly skilled at taking care of the sickest patients on the planet, and now you want to spend 90% of you day diagnosing and treating sleep apnea? What an utter waste of training. I think most pulm folks who go into sleep medicine at some point just got burned out and want the cushy lifestyle because they have families, etc.

Sleep is much more interesting from the neuro / psych perspective. Narcolepsy, insomnia, RBD, RLS, etc. Still an incredible amount to learn research wise - we still don't even know why people need to sleep!

Well, you can actually make the same argument about people from neurology or psychiatry who also both practice "pure" sleep medicine after their own residencies (like me).

I suppose you can also make s similar case of people from IM who do 3-4 years of IM and then 1-X years of fellowship and practice exclusively within the purview of the fellowship.

 

[GOINGDUMB]

I've never understood why pulmonologists would want to go into sleep medicine. You've just spent 3 years in IM residency, 2-3 years in Pulm/Critical Care. You are incredibly skilled at taking care of the sickest patients on the planet, and now you want to spend 90% of you day diagnosing and treating sleep apnea? What an utter waste of training. I think most pulm folks who go into sleep medicine at some point just got burned out and want the cushy lifestyle because they have families, etc.

Interestingly the guy I slept with today told me he did 3 years of pulm research, a couple years of general doctoring overseas, produced some hardcore basic science papers at a big name university (I saw them, they were legit), bleeds surfactant, IM--> Pulm/CCM.

Now in his last year as a sleep fellow, hair 50% grey, he told me he started med school in 1993, and has finally reached his final year of "training" as a sleep fellow this year.

Painfully. long. road.

 

[GOINGDUMB]

Back in the old days (early 2000's) sleep was seen as a way to ease into retirement for some pulms.

This inability to do this now, is this a reimbursement cut issue or something else?

 

[danielmd06]

This inability to do this now, is this a reimbursement cut issue or something else?

Reimbursement cuts are projected for diagnostic polysomnograms by progressively greater numbers of insurance companies. Obviously, this will have financial ramifications for the specialty, but in my opinion we'll still be fine.

I presume Mike is just pointing out that this sub-specialty was once thought of (and commonly used) as a bit of a hobby area for pulmonologists to steadily drift away into the sunset with (from ICU, and then even outpatient pulmonary medicine). Sort of an end stage to a successful medical practice if you will. Like a red giant phase for a star. Or, perhaps more relevant to this forum, an epileptologist who only reads EEG's in the twilight of her career.

Now, you have people fresh out of ACGME-accredited training programs who burst out of the starting gate angling for a large percentage of sleep patients.

 

[michaelrack]

I presume Mike is just pointing out that this sub-specialty was once thought of (and commonly used) as a bit of a hobby area for pulmonologists to steadily drift away into the sunset with (from ICU, and then even outpatient pulmonary medicine)..

yes. There used to be multiple ways for pulms to get into sleep. The "old" (ABSM) boards had several grandfather periods/waivers that made it easy for pulmonologists to do sleep- often late in their careers. Now a full year of sleep fellowship is required.

 

[Mattchiavelli]

Just throwing this out there- I expected this thread to be something entirely different based on the title. Might want to work on communication skills 😛

 

[GOINGDUMB]

Just throwing this out there- I expected this thread to be something entirely different based on the title. Might want to work on communication skills 😛

LOL. But seriously Internists and Neurologists... No. I'm talking about that NSFW thread called:

"Sleeping with Dermatologists and Pediatricians (with forays into on call OB/GYN's and Urologists)"

I joke, I joke.

 

[GOINGDUMB]

yes. There used to be multiple ways for pulms to get into sleep. The "old" (ABSM) boards had several grandfather periods/waivers that made it easy for pulmonologists to do sleep- often late in their careers. Now a full year of sleep fellowship is required.

Thanks. I guess that's good the field is getting more robust and organized. It's funny after hanging out with the sleep guys and my GF telling me she sees me stop breathing and subsequently shaking at night, I went shopping for a Sleep doctor today. I made it a point not to go to an Pulm/CCM Based sleep doctor... No offense, just my bias from what I saw in our sleep lab... Just like how some people bias Carotid Stenting over CEA perhaps...

Just throwing this out there- I expected this thread to be something entirely different based on the title. Might want to work on communication skills 😛

LOL. But seriously Internists and Neurologists... No. I'm talking about that NSFW thread called:

"Sleeping with Dermatologists and Pediatricians (with forays into on call OB/GYN's and Urologists)"

I joke, I joke.