Starting a Sleep/Fatigue Clinic

[peiyueng]

Hey friends:

Just wanted to share a little brain child of mine:

I just Thought of a cool little niche market. One of the local psychiatrists who happens to be a heck of a businessman has open saturday 1/2 day office spots. I am thinking about opening a sleep/fatigue clinic using his office space 1/2 day a saturday. Normally, I am a state hospital psychiatrist, but I have 1/2 day free on Saturdays and I think it would be fun to run such a clinic. I have insomnia myself and I have been learning a lot of the sleep wake architecture.

I think this would be a fun little project, as I have a psychopharmacology fellowship under my belt and one of my mentors of the fellowhsip is a world renowned psychiatrist who did more than a bit of the consultation for the newly approved Merck orexin antagonists, suvorexant. Of course, I will be using a full compliment of meds and behavioral techniques to get pts the most restful sleep they can have.

I think I will be marketing this clinic to many of the local psychs and gen pract. doctors. I really think that there is a huge need for such a clinic. Eventually I can probably do pharmaceutical lectures when I get a large samples of patients who benefit from this new mechanism. Btw: here is the mechanism of action of orexon: Orexin goes up steadily during the day. Then, by 9pm, physiologically, there is supposed to be a sharp drop off. This is what kicks normal physiologic sleep into gear. With an orexin antagonis, you are mimicking this physiologic drop off, giving you a sleep architecture that looks like the sleep seen in normal controls. So, this is a new exciting class of med for those patients who have chronic and refractory insomnia and day time fatigue.

:- ).

Cheers.

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[michaelrack]

will the malpractice policy u have at the state hospital cover the clinic? Are u set up for billing?

 

[birchswing]

Hey friends:

Just wanted to share a little brain child of mine:

I just Thought of a cool little niche market. One of the local psychiatrists who happens to be a heck of a businessman has open saturday 1/2 day office spots. I am thinking about opening a sleep/fatigue clinic using his office space 1/2 day a saturday. Normally, I am a state hospital psychiatrist, but I have 1/2 day free on Saturdays and I think it would be fun to run such a clinic. I have insomnia myself and I have been learning a lot of the sleep wake architecture.

I think this would be a fun little project, as I have a psychopharmacology fellowship under my belt and one of my mentors of the fellowhsip is a world renowned psychiatrist who did more than a bit of the consultation for the newly approved Merck orexin antagonists, suvorexant. Of course, I will be using a full compliment of meds and behavioral techniques to get pts the most restful sleep they can have.

I think I will be marketing this clinic to many of the local psychs and gen pract. doctors. I really think that there is a huge need for such a clinic. Eventually I can probably do pharmaceutical lectures when I get a large samples of patients who benefit from this new mechanism. Btw: here is the mechanism of action of orexon: Orexin goes up steadily during the day. Then, by 9pm, physiologically, there is supposed to be a sharp drop off. This is what kicks normal physiologic sleep into gear. With an orexin antagonis, you are mimicking this physiologic drop off, giving you a sleep architecture that looks like the sleep seen in normal controls. So, this is a new exciting class of med for those patients who have chronic and refractory insomnia and day time fatigue.

:- ).

Cheers.

As an aside, I've seen the very juvenile commercials for this recently. I have to say as a patient, I find the commercials a bit insulting to one's intelligence. They don't actually market the product to avoid having to list the side effects and instead direct you to an "educational" web-site, which if you dig around eventually leads you to the product web-site. I finally found the name of the drug and could then read about it on Wikipedia. The fact that there is actually a new class of drug is somewhat remarkable and I feel that the drug should be sold to customers (if such marketing is to be allowed at all) on it own merits—and inventing a new class of drug is worthy of merit and interest. I'm guessing the dumbed down marketing technique is known to be effective because there's no way that it doesn't come off as a parody of itself. Consumers have been seeing these cartoons for prescription drugs back to the days of Prozac's introduction (frowny face on one side of the magazine insert, smiley face on the other). I'm not impressed when people hide what they are selling. It actually would make me less likely to trust the company. I know that when they list all of the deadly side effects in commercials that there is always a benefit/risk ratio, and it would be nice if the companies trusted consumers enough to know that as well when marketing to them rather than skirting FTC regulations.

That aside aside, I'm also curious as to whether this product helps with delayed sleep phase disorder, which currently has very little treatment.

EDIT: I should add that your description of the drug and hearing about from a different perspective mitigated my initial negative feelings that this was a drug with something to hide.

 

[Shikima]

Good 'ol CBTI.

 

[peiyueng]

No, the hospital will have no involvement with the private side. So, I will be getting mal.pra. on my own. I will have to talk to the psychiatrist who owns that office space and see what needs to be done (this guy has a large number of psychiatirsts working for him. He also keeps on opening new offices in our county. As I said, this guy does quite well on the business side of medicine, beside being a psychiatrist himself. I;ll need to ask him. I know that billing is no a problem becasue he has the infrastructure. I ill have to find out aobut mal. prac.

And to our patient above: yes! I am generally very skeptical of drug rep claims and even pharmaceutical talks given by doctors are to be taken with some amount of grain of salt. I have seen lots of people try to over sell new meds as the be all and end all. But, when one looks at the research and when one understands the mechanism of action and pathophysiology, there is no reason that many of theses new meds would be any more superior.

The most recent example I can think of is this one female Family Practice doc who some how got the drug company to pay her to speak on Brilltellex (sp?). She way oversold this thing as though it is more efficacious than anything we have ever had before! SHAME! When you look at the mechanism, this is no more than an SSRI/ and a 5HT1A partial agonist. and a 5HT3 antagoinist. NONE of these mechanisms are new. We have been at this thing long enough to have heard the conclusions of STAR-D and KATIE: ie really, it would be rare that one similar med is superior to another similar med. {STAR D said no one antidepressant is superior; and KATIE and other studies found that no one antipsychotic is superior (save for Clozapine, which is a med on to itself in terms of real efficacy!) than any other one--first gen or second gen! I mean there is even doubtful difference in efficacy betw 1st gen and 2nd gen antipsychotics). So, my point is that when Britellix brings nothing new to the table, one just has to be soo skeptical of any wild claims.

[Sorry to get so worked up. I just can't get over how these charlatan FP docs who practice such poor science gets to be out there looking like an expert, spreading highly biased false info!!] [really gets me angry!]

But. you know what she does? She is very enthusiastic. She puts her female depressed patients on it. Then, two weeks later, she personally calls the patients and OF COURSE her patients are going to report good news. This is well known in the mass marketing world. Ever watch faith healing? Only people who have had postitive experience will endorse the experience. Imagine if you are a patient and your good doctor personally calls you two weeks after starting a med? All the reporting are going to be biased towards positive reviews. Patients will heavily bias towards telling the doctor what they think the doctor wants to hear. And onces she gathers enough of these anecdotally and ill gotten result, she stands up in front of fellow FP docs and hard sell this run of the mill me-too med.

You know what? She also did this bs with Pristique. She has the same modus apparentus for all new meds and is duping herself and her fp colleagues and hurting patients (ie pointing them to expensivie meds that have no justification as being first line). The next time if I ever hear her talk again, I am going to open up on her and rip her a new one for being a piss poor scientist who has no business giving pharm talks.!!!! [I am righteously very angry when pts can be hurt!]

So, thusly, what I am saying is she is heavily biasing her sampling and trying to tell the audience that this brittellix should be the new and go to med! WTF!!!!

WTF is a FP doing doing talks like this? And WTF is she doing with that kind of junk science? It borders on unethical! Makes me so angry!


I know this is off topic from my original Suvorexant post, but I dislike and despise poor science whereever it is practice or touted. I think we, as psychiatrist should do all we can to weed out junk science--whether it be the anti-immunization craze crowd or these drug reps who way over sell their products. And when we see fellow doctors spreading junk science, we need to snuff that crap out, HARD! This profession needs integrity and inscrutable ethics. we have to be beyond reproach if we are to keep our good names as profession!!!

[I stand tall, soap box'd!] thank you!


Cheers.

 

[peiyueng]

Good 'ol CBTI.

Where could a guy like me find resources on this? I would love ot learn to become proficient in this area. Some time ago, I signed up on some website that was trying to do this online. I didn't pursue it further. Basically, you pay a fee, and they try to do CBTI online with you.

But, maybe you can endorse some good resources towards me here. I am an existential psychotherapist (ie Yalom through and through); I have only cracked open the beck book, on the other hand, a handful of times. But, hey if cbt works, let's do it!

cheers.

 

[watto]

Cognitive Behavioral Treatment of Insomnia
A Session by session guide
Perlis, et al

 

[clusterF]

Please get back to us after a few weeks or months at this. I'm not saying you won't succeed, you may succeed more than you want to. Insomnia patients are tough. I have tried belsomra a few times. It is no magic pill. Most people find ambien to work better and it has its own side effects.

Also, if insomnia was really a great market, all the sleep docs would be doing it. Notice that almost none of them treat insomnia in private practice. There is a reason. The pay sucks and the time requirements are intense.

 

[Shikima]

I dunno, I get pretty good results with Insomnia Pt's. The trick is to teach them that the 'Michael Jackson Treatment' isn't an option and explore what is their driving factor for going to sleep. The downside is that it does eat up a lot of time and productivity will go down - I guess you could bill a 90833 for the work.

 

[clusterF]

I dunno, I get pretty good results with Insomnia Pt's. The trick is to teach them that the 'Michael Jackson Treatment' isn't an option and explore what is their driving factor for going to sleep. The downside is that it does eat up a lot of time and productivity will go down - I guess you could bill a 90833 for the work.

I think you can be successful using purely behavioral techniques but you are right, it takes time with insomnia. Productivity will go down with pure insomnia, hence it is no cash cow. Which is why the sleep guys rarely have insomnia clinics. For example Stanford devotes significantly more time to OSA than insomnia even though there are a lot more people with insomnia.

I gathered that OP was implying using quite a bit of psychopharmacology which I have never found to work for any extended period of time. It doesn't look like, at least currently, he has a lot of knowledge about treating insomnia behaviorally although to be fair he did mention that he is interested in learning.

This is not to discourage the OP. I think an insomnia clinic, run by a physician who knows what they are doing is a fantastic idea. But pharmacology is only one (very important) part of it. I find it is more about learning which medications disrupt sleep as much as which ones cause sedation. The behavioral aspect is equally important. You can't just tell someone to not watch TV and have that be only intervention. I would imagine in a true insomnia clinic you would want to invest in actigraphy although I don't know anyone that gets paid for this.

 

[Shikima]

@clusterF - To make it more financially feasible, I work in bite sized pieces with edcuation and med management strategies with 30 minute appointments billing at a 99214.

 

[clusterF]

@Shikima I imagine you are doing individual therapy but how about groups, actigraphy etc.

 

[Shikima]

No real time or good reimbursement in doing actigraphy. I've considered doing group but tbh, I haven't checked to see how billing would be done for it and if it is financially worth it.

 

[clusterF]

Yeah. That was kind of my brief experience. I still work with patients on insomnia but when I envisioned an insomnia clinic I realized I would basically be losing money doing it the way I wanted.

I wonder what the data shows on actigraphy vs. smartwatches, fit bands etc. A lot of my patients already use that tech, I wonder how helpful it could be and how it can be incorporated into a clinical practice. Also, what are the malpractice risks of using that data and making recommendations based on it.

 

[Shikima]

No real significant malpractice impact. The nice thing is if you do interpret it, you can demonstrate to the Pt the times when they are 'sleeping' vs 'awake'; Very helpful with the proverbial claim, "I never sleep at night." Caveat, only works with someone who has good insight and has a willingness to learn. It has even greater value if you complete sleep diaries to coincide with the actigraphy because you now have something physical to hang your hat on and you can also track what medications have the best impact on sleep latency.

 

[heyjack70]

I think advertising to FP docs that you are a sleep specialist would get lots of referrals. So many patients complain of poor sleep it would be one less headache they could refer to you.

 

[heyjack70]

No real time or good reimbursement in doing actigraphy. I've considered doing group but tbh, I haven't checked to see how billing would be done for it and if it is financially worth it.

Cash $35/hour x 10 people per group = $350 without insurance hassles. Or plug in your own numbers.

 

[Shikima]

Cash $35/hour x 10 people per group = $350 without insurance hassles. Or plug in your own numbers.

That's a good thought. I had considered that, but the area where I am practicing doesn't allow for a lot of 'loose cash' due to the ecomony collapse. Things are slowly improving, but there are a lot of people still living paycheck to paycheck.