Rip Van Winkle: Will Academic Pulmonary Programs Ever Wake up to Sleep?

ALLAN I. PACK

University of Pennsylvania, Philadelphia, Pennsylvania

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There is an imbalance between patient need, research opportunities, public and congressional support of research on sleep and its disorders, and the relative lack of interest in academic pulmonary programs, at least in the United States. This is true for both adult and pediatric areas. I explore various reasons for this apparent lack of interest. I propose that current academic pulmonary structures are out of date, and cannot meet the academic needs of the ever-expanding scope of the various components of pulmonary medicine. This essay is focused on academic needs and not on issues about certification for the clinical practice of sleep disorder therapy. It is based on data from a membership survey of the American Thoracic Society (ATS) and an informal survey of pulmonary academic programs conducted by the author, as well as information from the National Institutes of Health about the numbers of K23 and K08 grants for the study of sleep and its disorders. I argue that many clinical pulmonologists have recognized the opportunities and needs presented by sleep medicine, but that our pulmonary academic programs, for the most part, have not. If pulmonary medicine is to play a major role in this area, it must commit not only to provision of clinical services, but also to development of clinical training programs, research training, and support of the exciting and growing research agenda of this field.

Over the last decade, the number of patients seeking help for a variety of sleep disorders has grown rapidly. The number of pulmonologists involved has also grown, as even a casual perusal of the advertisements in the Journal would indicate. Currently, about half of the diplomates of the American Board of Sleep Medicine are pulmonologists and the number of pulmonologists sitting for the board (certificate of competence in sleep medicine) has doubled over the last five years, from 120 in 1996 to 240 in 2000 (source: American Board of Sleep Medicine). A survey of the membership of the ATS showed that 45.9% of the respondents were involved in the clinical practice of sleep disorder treatment for less than 25% of their time, whereas 10.3% devoted more than 25% of their time. (The balance was not involved in clinical therapy of sleep disorders.) Whereas our clinical colleagues have recognized the enormous needs, our academic programs have not. Thus, there has been limited development of formal training programs in sleep and little development of research programs and even fewer research training programs.

Sleep is unlike almost any other area of medicine, in that the structure for sleep medicine varies greatly from academic institution to institution. This is largely driven by the local conditions, that is, who got there first, and hence, controls the resources. In two institutionsthe University of Pennsylvania and Harvardthere is now a Sleep Division. These divisions recognize the inherent multidisciplinary nature of this field, with faculty from Pulmonary Medicine, Neurology, and Psychiatry involved. In an increasing number of institutions the sleep laboratory comes under the control of the pulmonary division, but these programs may not be multidisciplinary. In some institutions the pulmonary division is not involved and the sleep center is under the control of the Department of Neurology or Department of Psychiatry. Some academic institutions have two sleep programs that may be in direct competition! The current structures often do not acknowledge the multidisciplinary nature of the field; they often do not provide mechanisms for training individuals from different relevant disciplines; there is limited organized clinical training; there is almost no organized research training; there is no commitment to the breadth of research that is required; there is no clear path to leadership for individuals entering this field. In short, the current system is seriously broken!

Within academic institutions, there are few leaders of pulmonary divisions whose major interest is sleep-disordered breathing, and almost none in our major research universities. It seems likely that the lack of role models and support by division chiefs will inhibit young academic pulmonologists from becoming involved in sleep medicine. This lack of academic leadership in the area of sleep medicine is associated with the few individuals obtaining young investigator career development grants in patient-oriented research (K23) or basic research (K08) in sleep. Given the importance that the U.S. Congress has placed on research in sleep and its disorders with the establishment of the National Center for Sleep Disorders Research, and the National Plan for Sleep Research, the relative paucity of young investigators can be viewed as a crisis.

This raises the following question: Why is there so little academic activity in pulmonary divisions in sleep-disordered breathing given the high prevalence of the disorder, the explosive clinical growth in the field, the strong support of the lay public and government, and the incredible opportunities for scientific discovery in a relatively new area of medicine?

A first possible explanation is that these programs have no interest in sleep. Data would argue against this. In a survey of major academic programs I conducted, I found that more than 75% of the respondent programs had a sleep laboratory as part of their division and that the average number of sleep studies performed per year was more than 1,000. This would suggest that sleep studies may be among the most common procedures in many divisions, and that sleep activities in these divisions are generating resources, but these are not being reinvested into the academic development of sleep research. This is a short-sighted strategy.

A second possibility is that the division chiefs have a commitment to developing sleep research but have no means to accomplish this goal, given the paucity of investigators in this area. They may not have the faculty to mentor fellows and junior faculty and hence cannot develop the discipline. This is a distinct possibility and, if so, will require new strategies such as a national mentorship program for fellows and faculty at sites without sufficient current mentorship to allow the research program in sleep-disordered breathing to develop "seeds" at different institutions.

A third possibility is that pulmonologists by nature are not excited about neuroscience. The fundamental discipline of sleep research is neuroscience, one of the fastest moving and exciting areas of modern science. Although this may currently be true, pulmonologists have been willing to get into other cross-cutting, fast-moving disciplines such as immunology. Thus, with appropriate education it might be possible to see neurobiological research programs flourish in pulmonary divisions. If, however, pulmonologists are not interested in pursuing neurobiological research, then sleep medicine needs to develop in other ways and the role of pulmonologists will, of necessity, be minimized. We must not be in a position where the groups taking the lead in providing clinical services in our major academic institutions are not committed to developing the science of the field.

A final possibility is that the modern academic pulmonary division is an out-of-date structure and not able to meet the broad demands of the ever-expanding horizon of the pulmonologist. Over the last decade we have seen adult pulmonary medicine in the United States assume critical care and, most recently in many institutions, provision of clinical sleep medicine services. (This assumption of critical care by pulmonary medicine did not occur outside the United States and did not take place in pediatric pulmonary programs within the United States.) These changes have impacted positively on the cash flow to pulmonary divisions, but have they impacted positively on the academic development of these areas? It is reasonable to ask whether development of research in critical care, particularly in nonpulmonary aspects, has been helped or hindered by the co-opting of critical care by pulmonary medicine. Currently, most of our adult pulmonary academic structures are not built to have a balanced development of all aspects of pulmonary medicine because the focus has been primarily on lung cell/molecular biology. Many divisions structured around the interest of the division chief, and fellows, etc., are actively encouraged to follow the path of research that is the division chief's interest. Although laudable, in that the division can aspire to being outstanding in at least one area, it unfortunately puts both critical care and sleep-disordered breathing research in a position where academic development of these aspects of the discipline cannot occur. Given the high prevalence of, and public interest in, sleep-disordered breathing, this is not a sustainable position. Rather, the modern academic pulmonary division might see itself as a small department of medicine with balanced development of all three major components and an appropriate structure to achieve this.

The ATS, our major professional organization, has also taken little interest in sleep and its disorders. The Respiratory, Neurobiology and Sleep Assembly was established as a Section in 1988, becoming an Assembly in 1991. The assembly has been vibrant and taken the lead within the ATS in developing new approaches such as travel awards to encourage young basic scientists to attend the annual meeting of the ATS. Since the inception of this assembly, the ATS has supported a number of workshops on specific topics in sleep, and one of these (intermittent hypoxia) led to a request for grants from the National Institutes of Health. During the same time period, the other major professional organization, the American Academy of Sleep Medicine (AASM), has done the following: facilitated development of the National Commission of Sleep Disorders Research (Wake Up America); facilitated development of the National Center for Sleep Disorders Research (this led to a national plan for sleep research and major infusion of targeted research dollars); developed accreditation procedures for sleep centers; developed mechanisms for sleep fellowship accreditation; developed a certification procedure for sleep disorders medicine; took the lead in development of evidence-based clinical practice guidelines for sleep disorders; funded grants to facilitate research groups to develop large grants for multicenter clinical trials of treatment of sleep apnea; developed the Sleep Medicine Education Research Foundation, which is currently spending $400,000 per year in research grants in sleep, particularly for young investigators.

In conclusion, this is an exciting time for work on sleep disorders and sleep-disordered breathing. As a discipline, this young field has accomplished much in the last decade. If pulmonary medicine wishes to maintain playing an important role in the provision of sleep medicine services, it has the responsibility to contribute its part to the development of the academic discipline. The millions of Americans with sleep disorders have the right, I believe, to expect no less of us. New strategies to develop the academic component that this new discipline so urgently needs will need to be evolved. It will require collaboration with colleagues in other important and necessary clinical disciplines, in particular neurology and psychiatry.

It would help if this essay stimulated a debate within the pages of the Journal so that we can come to some consensus as to how to move this important and yet nascent field forward. I look forward to a vigorous debate in the Letters to the Editor section. The fundamental question is whether academic pulmonary medicine is more than lung cell/molecular biology and whether the academic leadership has the breadth of vision to recognize the incredible opportunity presented to them by sleep-related breathing disorders. To date, they have not done so. Will they finally wake up to sleep?

	Footnotes

Correspondence and requests for reprints should be addressed to Allan I. Pack, M.B., Ch.B., Ph.D., University of Pennsylvania, 991 Maloney Bldg., 3600 Spruce Street, Philadelphia, PA 19104. E-mail: pack{at}mail.med.upenn.edu

(Received in original form October 22, 2001 and accepted in revised form November 6, 2001).