National Sleep Disorders Research Plan
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Section 7 Content:
Public and Patient Education
Scientific Training


Clinical Education and Training


Education and training are integral to meeting the goals of Sleep Medicine in improving clinical practice and patient-oriented outcomes. Successful educational interventions require the development, implementation, and dissemination of materials covering a wide range of topics, including the basic neurobiology of sleep and circadian rhythms, clinical sleep disorders and evidenced-based treatment, the consequences of sleep deprivation, and the role of sleep in health and disease. Education and training must be targeted toward all relevant professional and public audiences, and must include evaluation of the impact of such programs on public health.

Physician Education and Training

The practice of sleep medicine is inherently multidisciplinary, drawing physicians from many areas such as geriatrics, neurology, internal medicine and pediatrics (including pulmonology, neonatology, critical care), psychiatry, and surgery. Because of this diversity, the field of sleep medicine continues to evolve standards, practices, and training opportunities. In April 2002, for example, the American Academy of Sleep Medicine submitted an application to the Accreditation Council on Graduate Medical Education requesting the establishment of a Residency Review Committee approval of fellowship training programs in sleep medicine. Despite advances in defining sleep medicine as a specialty and in formalizing training infrastructure to sustain sufficient growth in the field, empirical data from survey and clinical outcome studies indicate that, in general, physician education regarding the recognition, diagnosis, management, and prevention of clinical sleep disorders in both adults and children is inadequate. Substantial knowledge deficits exist at the medical school level, as well as at the post-graduate training and continuing education levels.

There are important public health implications to the large gaps existing between scientific knowledge, clinical teaching and practice. For example, it is known that physicians outside sleep medicine significantly under-diagnose or misdiagnose sleep disorders, leading to increased morbidity and decreased quality of life. Furthermore, early intervention efforts to detect and prevent sleep disorders are likely to be significantly compromised by this lack of education and training.

To address these concerns, we need to further define a knowledge base in sleep medicine and circadian biology, develop a basic sleep curriculum for medical schools, and create appropriate educational tools as a foundation for enhanced learning at all levels. Current medical education activities are involved with curriculum development, and will require application of rigorous methodological criteria for outcome measures and demonstration of efficacy of teaching methods and tools. Knowledge, competence, and behavioral change objectives involve different methods of assessment. Specific knowledge acquisition, for example, is usually measured with standard written tests, skills acquisition with performance-based assessment, and behavioral changes with self-report or structured observational methods.

Assessment of impact on clinical practice may depend upon a variety of health outcome measures, including quality of life and disease prevalence data, tracking of health care utilization, and cost-benefit analyses. Thus far, however, little research in sleep education has been directed toward evaluation of these types of outcomes related to professional knowledge, attitudes, and changes in clinical practice behavior. Some evaluation tools do exist, such as knowledge surveys and standardized clinical examinations, but most are not validated and few are widely available. Although clinical care is likely to be improved by continuing medical education efforts targeted at improving knowledge and skills, and fostering behavioral change in practicing physicians, Sleep Medicine has not been included in research on effective strategies to change physician behavior. Prospective, multi-center structured trials are needed to accomplish these goals.

Education and Training of Other Health Professionals

Dentists, nurses, pharmacists and psychologists are increasingly involved in identification and treatment of sleep disorders. These disciplines should also be targeted for educational interventions. The educational needs of these various disciplines overlap with those of physicians, but additional educational resources and strategies are needed to address their unique concerns. For example, nurses have a potential key role in the identification of sleep disorders in patients being treated by other medical specialties. Psychologists have become increasingly important in the evaluation and behavioral treatment of insomnia. Dentists have become actively involved in the treatment of sleep apnea with mandibular devices. These health care initiatives would benefit from coordination of evaluation research to determine the impact on behavioral change, clinical practice, and ultimately on the quality of patient care in sleep medicine across these disciplines.

Progress In The Last 5 Years

- In a 1978 survey of sleep education in medical schools in the United States, the American Sleep Disorders Association found that less than 10% of schools offered adequate training and 46% included no sleep medicine at all in the curriculum. A decade later, in 1990, a medical education survey reported relatively little progress, with 37% of medical schools offering no sleep education. In those schools that did, the average time devoted to sleep in the 4-year curriculum was less than 2 hours. Subsequent surveys of post-graduate training programs in adult and pediatric medicine have found similar results, with lack of time in the curriculum and of qualified instructors cited as major barriers. Surveys of practicing physicians conducted in the last 5 years reveal similar gaps in knowledge and clinical practice despite increasing recognition of the importance of sleep in the health and well being of their patients.

- In 1996 the National Center on Sleep Disorders Research (NCSDR) developed the Sleep Academic Award (SAA) Program to address these educational gaps. Twenty medical schools in the U.S. were awarded 5-year grants to develop model medical school curricula in sleep medicine, to promote interdisciplinary learning environments, and to improve the quality of sleep education and education research at all levels, including the public arena. The SAA program has raised awareness of sleep education in both the sleep and general medical communities, and has laid the foundation for continued sleep education development by facilitating the creation of screening and evaluation tools such as the ASK-ME Survey of sleep knowledge, regional and national faculty development workshops, and public education programs on sleep. Development of MedSleep, a web-based repository of over 50 sleep education tools and products developed by the awardees and available to all health professional and educators, was the result of a collaborative effort between the SAA program and the American Academy of Sleep Medicine (AASM.)

- The SAA program, in collaboration with the AASM and the American Medical Association (AMA), has initiated a collaborative education and research effort to address the issue of sleep and fatigue in medical training. Several research projects, including a multi-site collaborative study, have evolved from this initiative, and a national conference was held in 2001 to define specific research goals and objectives regarding consequences of sleep loss in physicians and to develop effective interventions.

Clinical Education and Training Recommendations

- Develop sleep educational programs at the medical school, post-graduate and continuing medical education levels, and develop a coordinated, structured, and scientifically rigorous approach to evaluate the impact of sleep education programs and tools across multiple institutions and clinical settings.

> Outcome measures should include assessment of changes in:
* physician knowledge, attitudes, skills and behavior
* clinical practice
* patient health and quality of life

- Evaluate the effectiveness of strategies to address these training gaps. This should be based on a needs assessment of educational gaps in sleep training among other health professions including but not restricted to nursing, dentistry, pharmacy, clinical psychology and other mental health disciplines.

> Outcome measures should include assessment of changes in: * professional knowledge, attitudes, skills and behavior
* clinical practice
* patient health and quality of life

National Institutes of Health (NIH) Department of Health and Human Services (click here) First Gov Website (Click here)
National Heart Lung and Blood Institute (Click Here) National Center on Sleep Disorders Research (Click Here)