Residents and Medical Students

Choosing Sleep Medicine

James A. Rowley, MD
Program Director
Pulmonary and Critical Care Medicine Fellowship
Wayne State University

Why go into Sleep Medicine?

The decision of whether to sub-specialize is individual and complex. However, most residents pondering fellowships have certain considerations in common. They center on the nature of subsequent practice, employment opportunities and lifestyle. In addition, those considering an academic career may be drawn to specific research topics or questions.

Nature of Practice

Sleep medicine is a broad, multidisciplinary field that encompasses a broad number of disorders. While the majority of patients in many sleep practices have sleep apnea, the sleep physician will also evaluate patients with insomnia, restless leg syndrome, narcolepsy, circadian rhythm disorders (such as sleep phase delay) and parasomnias (such as sleepwalking). Depending upon the clinical interests of the sleep physician, the relative percentage of patients evaluated in these varied areas may differ.  For instance, many psychiatrists who enter the sleep field may see a predominance of insomnia patients while pediatricians may see a large number of parasomnias, which are more common in children.

Sleep medicine is primarily an outpatient practice that comprises two major activities: consultative/management outpatient visits and reading/interpreting sleep studies. A large portion of a sleep physician’s time is spent seeing patients in consultation for the variety of sleep disorders mentioned above. These consultations are key as many patients present with signs/symptoms of multiple sleep disorders.  Providing follow-up care, particularly for sleep apnea patients on positive airway pressure therapy, is also a major portion of the practice for most sleep physicians as outcomes clearly improve with regular follow-up.  In addition, sleep physicians are responsible for reading/interpreting sleep studies (diagnostic polysomnography, PAP titrations, multiple sleep latency tests and maintenance of wakefulness tests).  The number of sleep studies interpreted each week is dependent upon a number of factors, primarily the percentage of sleep medicine in the physician’s overall patient mix.

Employment Opportunities

Sleep has been a growing field over the last two decades with a large expansion of sleep centers across the United States.  This expansion is expected to slow due to a number of reasons, including recent reductions in Medicare reimbursement, increasing use of home sleep testing, and increased regulatory requirements for sleep centers (for instance, several states now require a sleep center to be accredited by the American Academy of Sleep Medicine (AASM) in order to receive insurance reimbursement).  However, there are still a wide variety of employment opportunities in the field as board certified sleep physicians are still in demand for their broad expertise in sleep (not all sleep medicine is OSA!) and because only certified physicians can serve as medical directors of AASM accredited centers.  Most sleep physicians are generally associated with group practices, generally comprised of other physicians in their primary field (pulmonary, neurology, etc.).  These practices may own their own freestanding sleep laboratories or are affiliated with laboratories center in and owned by a hospital.

Lifestyle

Because sleep medicine is multidisciplinary, the lifestyle of physicians trained in sleep medicine varies greatly depending upon the mix of sleep practice with the practice of their primary specialty. Sleep medicine itself is primarily an outpatient based practice. In theory, if a physician practices only sleep medicine, his/her practice would be primarily office-based, with few night or weekend responsibilities.  However, the majority of sleep specialists practice sleep as one part of their overall specialty.  For instance, a pulmonary/critical care physician would likely continue to round in the ICU and include pulmonary and sleep as part of their outpatient practice.  A neurologist would likely continue to see inpatient and outpatient consults for other neurological disorders and might continue to also read EEGs and other neurologic studies. Thus, the lifestyle balance could be quite different depending upon the mix of inpatient and outpatient medicine and the type of primary specialty.

What Pathways Exist for Training in Sleep Medicine?

At present, to achieve board certification in sleep medicine, a one year fellowship is required.  The major requirement for fellowship is successful completion of a residency in one of the following specialties: Internal Medicine, Pediatrics, Neurology, Psychiatry, Family Medicine, Otolaryngology or Anesthesiology.

For internists, sleep medicine training often follows the traditional 3 year pulmonary/critical care fellowship.  However, increasingly, internists are choosing to do a sleep fellowship immediately after residency training.

More information on the requirements for sitting for the Board exams in sleep medicine, visit the website of your primary board (Internal Medicine, Pediatrics, etc). General information on the sleep board examination can is available from the American Board of Internal Medicine, the administrative board for the exam (www.abim.org).

How Do I Apply for a Fellowship in Sleep Medicine?

Most Sleep Medicine Fellowship Programs participate in the National Residency Matching Program, www.nrmp.org/fellow/ and use the Electronic Residency Application Service (www.aamc.org/students/medstudents/eras/). Even within ERAS, individual programs may still have specific application requirements, but in general will ask candidates for basic information about education and accomplishments, a personal statement of career objectives and several letters of reference, often including a letter from their residency program director. Upon receipt of completed applications, most programs will invite particular individuals to visit for interviews. The cost of these interviews is borne by the applicant. After interviews are completed, both applicants and programs submit rank lists. The Match takes place in the November prior to the July starting date.

A general timeline for the application process appears below. It is important to remember that each program will have its own deadline for completed applications.

July:

Complete ERAS application, including all letters of reference.

August:

Programs review applications and start inviting applicants

September-October:

Interviews take place.

Late October:

Match Rank Lists due.

Early November:

Match Day.

July, following year:

Begin fellowship.

How Should I Go about Choosing a Fellowship Program?

There are 75 fellowship programs in Sleep Medicine. Because of the multidisciplinary nature of the field, a sleep medicine fellowship program can be based in a department of internal medicine (pulmonary), neurology, psychiatry, pediatrics or family medicine. While, the department in which a program is based should not make a difference in sleep training (all are required to provide a well-rounded education in sleep medicine), sleep specialists do often approach the practice of sleep medicine differently based upon the specialty of their primary training.

An applicant must narrow down his or her choices, if not initially, at least when the time to interview comes around. Exploring options in advance will help minimize costs associated with interviewing and maximize the chances of matching with the program that is best for you.

First, it is important to identify what you want from a training program. Are you planning an academic career or a future in community practice? Do you want a large program with multiple hospitals or a smaller or single-institution program? Do want a program that has all faculty members from one specialty or would you prefer a program with a true multidisciplinary approach? What type of research do you want to do? Are you willing to go anywhere if the training is excellent or are you limited in terms of where you are willing to live?

Once you have identified the type of program that fits your needs, begin to research your options.

Ask sleep faculty in your residency training program. You can get a sense of the overall quality of training programs by asking faculty which programs they believe are best and why. Start with the faculty you will be asking for letters of reference. If you are interested in a particular program, try to speak with someone who trained there. Remember that you will be sampling local opinions.

Ask current fellows. If you are at an institution with its own sleep fellowship program, the fellows will have recently completed the process you are just now embarking on. Ask them where they interviewed and what their impressions were.

Ask what other applicants were saying about particular programs.

Request information. When you contact programs for applications, you will generally receive additional information about the institution and training program. If you have specific questions, contact the program director.

Visit the division or program website. This site provides direct links to many Division and program websites.

Programs will invite only candidates that they feel have a reasonable chance of matching with them. The interview process offers candidates a chance to directly assess individual programs.

What Should I Expect From the Interview?

The interview process is vital to finding a fellowship that not only provides you with the kind of training you are seeking but is also a place you are glad to be working. During the interview you should meet not only with faculty members but with one or more current fellows. Here are some tips for an effective interview:

  1. Do some research before you visit a program. If there are faculty members doing clinical work or research of particular interest to you, ask specifically to meet with them.

  2. If you know of fellows who came from your residency program, contact them.

  3. Ask about the variety of sleep disorders seen in the program (make sure it’s not just all sleep apnea).  How many patients are seen each week?  How many sleep studies will you read during the year? Is there an insomnia program? What is the pediatric experience?  Will you interact with dentists, ENT physicians, behavioral psychologists?

  4. In addition to asking specific questions, also try to get a general feel for the program and whether you think you would fit in. Remember, you will spending a years in a program and you should feel comfortable working with the people there.

How Should I Decide on my Rank List?

After you have interviewed at all of the programs you are considering, you will need to complete your rank list and submit it to the National Residency Matching Program. The relative weight you give to the various strengths and weaknesses of individual programs will depend on what is most important to you. It is important for applicants not to ignore their overall gestalt about a program when they are formulating their Pro/Con lists. At times, questions or concerns may arise after the interview process, and it is perfectly appropriate for you to contact the program director to gather more information. This is a good time to talk again with those trusted faculty members at your own institution about your impressions.

For the match to work well, it is necessary that all parties respect the integrity of the match process. While it is perfectly appropriate to express a high degree of interest in a program and to let the program director know of your interest, all parties should avoid making explicit comments about rank order. Communication between programs and applicants after the interview varies greatly between programs. A lack of contact should not lead you to believe that a program is not going to rank you highly. From an applicant’s perspective, there is no disadvantage to ranking programs in order of your preference, even if you think the likelihood of matching with your first choice is not high. You should also rank all programs that you would be willing to join. Listing only one program because you are under the impression that you are sure to match there may result in you not matching at all.

What Happens after the Match?

Applicants that do not match and programs that do not fill are notified the day prior to the Match. Applicants who match will be contacted by the training program to sign a letter of commitment. In the spring before the fellowship begins, more communication with the training program will take place in order to facilitate licensing, credentialing and other transitional issues. Many programs will provide an orientation prior to the start of clinical responsibilities. But sometime after July 1, it will be time to get down to the business of learning Sleep Medicine.

 

 

Last reviewed: February 2015