Editor, Journal of Clinical Sleep Medicine, Boston, MA and Tucson, AZ
The lifeblood of a medical specialty is the pipeline of trainees entering its field. As exemplified by our own specialty's recent application,1 it is for this reason that the admission ticket for recognition as a new medical specialty by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties includes a sufficient number of active training programs and trainees in the prospective specialty. Because without practitioners, there is no specialty. In the most recent Sleep Medicine fellowship match, 64 programs offered 129 positions to start in July 2013. Thus, it is alarming that 31 positions or ~25% went unfilled. It is possible that in some cases programs deliberately did not rank any candidates leading to seemingly unfilled positions on the match list. Conversely, candidates may have perceived that some programs were of insufficient quality. However, given the openings in some prestigious programs, it is likely that there is a paucity of demand. This begs several questions. Is this the beginning of a trend, i.e., the proverbial “Canary in the coal mine”? And if so, why?
Unfortunately, it is impossible to know if this past year's match is a blip in the radar or a harbinger of future results. However, if these results portend the outcome of future matches, several explanations are possible. First, potential trainees have become aware that there is decline in polysomnography use and reimbursement, thus making specialization in Sleep Medicine less financially attractive. Second, many trainees enter the field after having already completed 4 to 6 years of post graduate medical training. Thus, some may view the extra year of training required for Sleep Medicine as neither intellectually nor financially worthwhile. Third, and perhaps the most potentially worriesome, Sleep Medicine may not be perceived as intellectually stimulating with most patients being evaluated and treated for sleep disordered breathing problems.
What can be done? Obviously, there must be increased efforts to develop new practice paradigms to make Sleep Medicine financially viable and not completely dependent on performing laboratory polysomnography. More importantly, we as Sleep Medicine practitioners need to promote our field to potential trainees. Large numbers of the general populace suffer from sleep disorders and thus the potential to improve the quality of life for many is great. Furthermore, there is diversity to the field. It is not just about treating sleep disordered breathing although some believe this to be the case. Moreover, there are few disciplines where medical devices, pharmaceuticals and behavioral modalities are all used as primary treatments for patients. We should be communicating to potential trainees that Sleep Medicine is a diverse and complex specialty with the potential to help many patients. If we can do this, our field will have a promising future. If not, there will be uncertainty.
Quan SF. Graduate medical education in sleep medicine: did the canary just die? J Clin Sleep Med 2013;9(2):101.
Shepard JW, Buysse DJ, Chesson AL, et al., authors. History of the development of Sleep Medicine in the United States. J Clin Sleep Med. 2005;1:61–82. [PubMed Central][PubMed]