Sleep Education: A Narrative Review on Barriers and Opportunities to Grow a Diverse Sleep Team.

The increased recognition of sleep-wake disorders and their effects, along with the anticipated shortage of sleep medicine specialists, heralds a concomitant need to have more health care providers with dedicated training in the evaluation and management of sleep disorders across the life span. A narrative review of published literature on sleep education was conducted and identified factors related to diversity within the sleep team, barriers to implementation of sleep education, and strides in sleep education. Implementation of novel sleep education strategies will require creative navigation of barriers such as allocation of curricular time, availability of teaching faculty, and funding to train more members of the sleep team. Deliberate coordination within and across health professions programs, with efforts to share resources and leverage technology, will be instrumental to guide the next phase of growth in sleep education.

Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement.

The period of the year from spring to fall, when clocks in most parts of the United States are set one hour ahead of standard time, is called daylight saving time, and its beginning and ending dates and times are set by federal law. The human biological clock is regulated by the timing of light and darkness, which then dictates sleep and wake rhythms. In daily life, the timing of exposure to light is generally linked to the social clock. When the solar clock is misaligned with the social clock, desynchronization occurs between the internal circadian rhythm and the social clock. The yearly change between standard time and daylight saving time introduces this misalignment, which has been associated with risks to physical and mental health and safety, as well as risks to public health. In 2020, the American Academy of Sleep Medicine (AASM) published a position statement advocating for the elimination of seasonal time changes, suggesting that evidence best supports the adoption of year-round standard time. This updated statement cites new evidence and support for permanent standard time. It is the position of the AASM that the United States should eliminate seasonal time changes in favor of permanent standard time, which aligns best with human circadian biology. Evidence supports the distinct benefits of standard time for health and safety, while also underscoring the potential harms that result from seasonal time changes to and from daylight saving time. CITATION: Rishi MA, Cheng JY, Strang AR, et al. Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2024;20(1):121-125.

OMS residents' obstructive sleep apnea-related education, knowledge, and professional behavior: A national survey.

OBJECTIVES: Oral and maxillofacial surgeons (OMS) treat adult and pediatric patients with obstructive sleep apnea (OSA). Objective 1 assessed sleep apnea-related education, knowledge, and professional behavior of OMS residents in the United States. Objective 2 was to compare the responses of junior versus senior residents and residents in single- versus dual-degree programs. METHODS: OMS residents in the United States received a recruitment email with a link to an anonymous online survey; 81 residents responded. The survey included 20 questions to assess respondents' OSA-related education, knowledge, attitudes, and professional behavior. RESULTS: Respondents generally agreed that they had received OSA-related didactic-based education (5-point scale with "5" = agree strongly: mean = 3.62) and clinical training (mean = 3.75). Clinical and classroom educational gaps were identified in relation to treatment with oral appliances and hypoglossal nerve stimulation. The residents scored on average 10.38 out of 18 (58%) possible correct answer points for the knowledge questions. Findings about pediatric OSA suggest that only 43.8% of residents understand diagnostic criteria for pediatric OSA, with only 26.6% screening pediatric patients for OSA. A case analysis showed that only 1.5% of residents correctly identified an apnea-hypopnea index of 17 as moderate sleep apnea. CONCLUSION(S): This survey found knowledge gaps in several areas that can be improved upon. It identifies deficiency in objective knowledge about OSA among OMS residents and a specific lack of clinical training and confidence with hypoglossal nerve stimulation and management of pediatric patients with OSA. Junior and senior residents and single- and dual-degree residents showed no statistically significant differences in any category except senior residents in regard to surgical management of OSA, particularly with maxillomandibular advancement.

Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement.

This position statement provides guidance for age and weight considerations for using continuous positive airway pressure therapy in pediatric populations. The American Academy of Sleep Medicine commissioned a task force of experts in pediatric sleep medicine to review the medical literature and develop a position statement based on a thorough review of these studies and their clinical expertise. The American Academy of Sleep Medicine Board of Directors approved the final position statement. It is the position of the American Academy of Sleep Medicine that continuous positive airway pressure can be safe and effective for the treatment of obstructive sleep apnea for pediatric patients, even in children of younger ages and lower weights, when managed by a clinician with expertise in evaluating and treating pediatric obstructive sleep apnea. The clinician must make the ultimate judgment regarding any specific care in light of the individual circumstances presented by the patient, accessible treatment options, patient/parental preference, and resources. CITATION: Amos L, Afolabi-Brown O, Gault D, et al. Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(8):2041-2043.

Assessing changes in the quality of quantitative health educations research: a perspective from communities of practice.

BACKGROUND: As a community of practice (CoP), medical education depends on its research literature to communicate new knowledge, examine alternative perspectives, and share methodological innovations. As a key route of communication, the medical education CoP must be concerned about the rigor and validity of its research literature, but prior studies have suggested the need to improve medical education research quality. Of concern in the present study is the question of how responsive the medical education research literature is to changes in the CoP. We examine the nature and extent of changes in the quality of medical education research over a decade, using a widely cited study of research quality in the medical education research literature as a benchmark to compare more recent quality indicators. METHODS: A bibliometric analysis was conducted to examine the methodologic quality of quantitative medical education research studies published in 13 selected journals from September 2013 to December 2014. Quality scores were calculated for 482 medical education studies using a 10-item Medical Education Research Study Quality Instrument (MERSQI) that has demonstrated strong validity evidence. These data were compared with data from the original study for the same journals in the period September 2002 to December 2003. Eleven investigators representing 6 academic medical centers reviewed and scored the research studies that met inclusion and exclusion criteria. Primary outcome measures include MERSQI quality indicators for 6 domains: study design, sampling, type of data, validity, data analysis, and outcomes. RESULTS: There were statistically significant improvements in four sub-domain measures: study design, type of data, validity and outcomes. There were no changes in sampling quality or the appropriateness of data analysis methods. There was a small but significant increase in the use of patient outcomes in these studies. CONCLUSIONS: Overall, we judge this as equivocal evidence for the responsiveness of the research literature to changes in the medical education CoP. This study identified areas of strength as well as opportunities for continued development of medical education research.

Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement.

Obstructive sleep apnea (OSA) may lead to serious health, safety, and financial implications-including sleepiness-related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Evidence and expert consensus support its identification and treatment in high-risk commercial operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal has led to questions about whether efforts to identify and treat OSA are warranted. In the absence of clear directives, we urge key stakeholders, including clinicians and patients, to engage in a collaborative approach to address OSA by following, at a minimum, the 2016 guidelines issued by a Medical Review Board of the Federal Motor Carrier Safety Administration, alone or in combination with 2006 guidance by a joint task force. The current standard of care demands action to mitigate the serious health and safety risks of OSA. CITATION: Das AM, Chang JL, Berneking M, et al. Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(10):2467-2470.

Impact of the COVID-19 Pandemic on the Clinical Learning Environment: Addressing Identified Gaps and Seizing Opportunities.

The clinical learning environment (CLE) encompasses the learner's personal characteristics and experiences, social relationships, organizational culture, and the institution's physical and virtual infrastructure. During the COVID-19 pandemic, all 4 of these parts of the CLE have undergone a massive and rapid disruption. Personal and social communications have been limited to virtual interactions or shifted to unfamiliar clinical spaces because of redeployment. Rapid changes to the organizational culture required prompt adaptations from learners and educators in their complex organizational systems yet caused increased confusion and anxiety among them. A traditional reliance on a physical infrastructure for classical educational practices in the CLE was challenged when all institutions had to undergo a major transition to a virtual learning environment. However, disruptions spurred exciting innovations in the CLE. An entire cohort of physicians and learners underwent swift adjustments in their personal and professional development and identity as they rose to meet the clinical and educational challenges they faced due to COVID-19. Social networks and collaborations were expanded beyond traditional institutional walls and previously held international boundaries within multiple specialties. Specific aspects of the organizational and educational culture, including epidemiology, public health, and medical ethics, were brought to the forefront in health professions education, while the physical learning environment underwent a rapid transition to a virtual learning space. As health professions education continues in the era of COVID-19 and into a new era, educators must take advantage of these dynamic systems to identify additional gaps and implement meaningful change. In this article, health professions educators and learners from multiple institutions and specialties discuss the gaps and weaknesses exposed, opportunities revealed, and strategies developed for optimizing the CLE in the post-COVID-19 world.

Sleep is essential to health: an American Academy of Sleep Medicine position statement.

CITATION: Sleep is a biological necessity, and insufficient sleep and untreated sleep disorders are detrimental for health, well-being, and public safety. Healthy People 2030 includes several sleep-related objectives with the goal to improve health, productivity, well-being, quality of life, and safety by helping people get enough sleep. In addition to adequate sleep duration, healthy sleep requires good quality, appropriate timing, regularity, and the absence of sleep disorders. It is the position of the American Academy of Sleep Medicine (AASM) that sleep is essential to health. There is a significant need for greater emphasis on sleep health in education, clinical practice, inpatient and long-term care, public health promotion, and the workplace. More sleep and circadian research is needed to further elucidate the importance of sleep for public health and the contributions of insufficient sleep to health disparities. CITATION: Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2021;17(10):2115-2119.

New frontiers in pharmacologic obstructive sleep apnea treatment: A narrative review.

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing characterized by intermittent partial or complete closure of the upper airway during sleep. If left untreated, OSA is associated with adverse cardiovascular outcomes such as hypertension, coronary heart disease, heart failure, cardiac arrhythmia, stroke, and death. Positive airway pressure (PAP) is often considered the first-line treatment for OSA. While PAP can be very effective in reducing the number of obstructive apneas and hypopneas, its impact on prevention of adverse cardiovascular consequences remains controversial, and treatment adherence is often poor. Hence, the necessity for novel treatment options to help those who cannot adhere to positive airway pressure treatment. Different classes of medications have been tested with regards to their effect on OSA severity. This review 1) provides an update on the epidemiology and pathophysiology of OSA, 2) outlines the mechanistic rationale for medication classes tested as OSA treatment and 3) discusses the effects of these medications on OSA. Several wake-promoting medications are approved for management of persistent sleepiness despite OSA treatment; discussion of these symptomatic treatments is outside the scope of this review. Herein, the authors review the current evidence for pharmacological management of OSA and provide future directions.

Sleep Medicine Milestones 2.0: designed for our field.

NONE: The Accreditation Council for Graduate Medical Education published the first sleep medicine milestones in 2015. However, these milestones were the same among all internal medicine fellowship programs; they were not specific to the specialty. Based on stakeholder feedback, the Accreditation Council for Graduate Medical Education called for the creation of specialty-specific milestones. Herein, we outline the history of Accreditation Council for Graduate Medical Education reporting milestones; the identification of knowledge, skills, and attitudes that define the practice of sleep medicine; and the creation of the supplemental guide and sleep medicine-specific milestones (Sleep Medicine Milestones 2.0) to assess developmental progression during fellowship training.

Daylight saving time: an American Academy of Sleep Medicine position statement.

None: The last several years have seen intense debate about the issue of transitioning between standard and daylight saving time. In the United States, the annual advance to daylight saving time in spring, and fall back to standard time in autumn, is required by law (although some exceptions are allowed under the statute). An abundance of accumulated evidence indicates that the acute transition from standard time to daylight saving time incurs significant public health and safety risks, including increased risk of adverse cardiovascular events, mood disorders, and motor vehicle crashes. Although chronic effects of remaining in daylight saving time year-round have not been well studied, daylight saving time is less aligned with human circadian biology-which, due to the impacts of the delayed natural light/dark cycle on human activity, could result in circadian misalignment, which has been associated in some studies with increased cardiovascular disease risk, metabolic syndrome and other health risks. It is, therefore, the position of the American Academy of Sleep Medicine that these seasonal time changes should be abolished in favor of a fixed, national, year-round standard time.

Optimizing virtual and distance learning during an emergency and beyond.

STUDY OBJECTIVES: The novel coronavirus 2019 (COVID-19) pandemic has forced program directors of sleep medicine fellowship programs, and other clinical training programs, to immediately transition longstanding face-to-face clinical and didactic instruction to virtual formats. The effects of this sudden transition to distance learning affect multiple aspects of training, from recruitment to patient care, scholarly activity, and well-being. Clinical educators must also understand how to consider and maintain equity while implementing distance learning strategies. METHODS: Resources were collected from multiple sites that are openly accessible to sleep medicine educators. These resources are presented within their topic domains to provide guidance on how to effectively implement distance learning strategies into a clinical training program. RESULTS: Links to helpful resources are provided for each of the following topics: virtual clinical care, didactic delivery in a virtual clinical learning environment, generating scholarship via distance learning, well-being in the setting of distance learning, virtual interviews, and equity in a virtual clinical learning environment. CONCLUSIONS: Clinical training programs, including sleep medicine fellowships, can utilize virtual and distance learning methodologies to deliver, and even enhance, currently existing curricula. The widespread adoption of distance learning strategies opens new opportunities for educational innovation and collaboration among training programs.

Artificial intelligence in sleep medicine: an American Academy of Sleep Medicine position statement.

None: Sleep medicine is well positioned to benefit from advances that use big data to create artificially intelligent computer programs. One obvious initial application in the sleep disorders center is the assisted (or enhanced) scoring of sleep and associated events during polysomnography (PSG). This position statement outlines the potential opportunities and limitations of integrating artificial intelligence (AI) into the practice of sleep medicine. Additionally, although the most apparent and immediate application of AI in our field is the assisted scoring of PSG, we propose potential clinical use cases that transcend the sleep laboratory and are expected to deepen our understanding of sleep disorders, improve patient-centered sleep care, augment day-to-day clinical operations, and increase our knowledge of the role of sleep in health at a population level.

Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement.

None: Physician burnout is a serious and growing threat to the medical profession and may undermine efforts to maintain a sufficient physician workforce to care for the growing and aging patient population in the United States. Burnout involves a host of complex underlying associations and potential for risk. While prevalence is unknown, recent estimates of physician burnout are quite high, approaching 50% or more, with midcareer physicians at highest risk. Sleep deprivation due to shift-work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis and perpetuation of burnout. Maladaptive attitudes regarding sleep and endurance also may increase the risk for sleep deprivation among attending physicians. While duty-hour restrictions have been instituted to protect sleep opportunity among trainees, virtually no such effort has been made for attending physicians who have completed their training or practicing physicians in nonacademic settings. It is the position of the American Academy of Sleep Medicine that a critical need exists to evaluate the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout. Such evaluation may pave the way for the development of effective countermeasures that promote healthy sleep, with the goal of reducing burnout and its negative impacts such as a shrinking physician workforce, poor physician health and functional outcomes, lower quality of care, and compromised patient safety.

Competency-based sleep medicine fellowships: addressing workforce needs and enhancing educational quality.

None: The path for physicians to become credentialed sleep medicine specialists has changed in many ways in the last few decades. Currently, sleep medicine is recognized as an independent subspecialty with appropriately rigorous and comprehensive training required to become a board-certified sleep medicine physician. However, added time for requisite fellowship training, coupled with an aging sleep medicine physician workforce, have had the unintended consequence of decreasing the number of sleep medicine physicians at a time when the demands for sleep medicine care continue to rise. Thus, new training pathways that provide flexibility to trainees, while ensuring high-quality, comprehensive, and multidisciplinary sleep medicine training are needed to maintain a workforce that can meet the sleep health needs of the present and future. Here, we describe two pilot programs that apply principles of competency-based medical education to sleep medicine fellowship training. These novel models are likely to attract additional well-qualified physicians to the field who might otherwise not pursue a career in sleep medicine.

A Responsible Educational Handover: Improving Communication to Improve Learning.

An important tenet of competency-based medical education is that the educational continuum should be seamless. The transition from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless, however. Current practices around this transition drive students to focus on appearing to be competitively prepared for residency. A communication at the completion of UME-an educational handover-would encourage students to focus on actually preparing for the care of patients. In April 2018, the American Medical Association's Accelerating Change in Medical Education consortium meeting included a debate and discussion on providing learner performance measures as part of a responsible educational handover from UME to GME. In this Perspective, the authors describe the resulting 5 recommendations for developing such a handover: (1) The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance, (2) the process used to create an educational handover should be philosophically and practically aligned with the learner's continuous quality improvement, (3) the educational handover should be learner driven with a focus on individualized learning plans that are coproduced by the learner and a coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement. These recommendations are shared to encourage implementation of the educational handover and to generate a potential research agenda that can inform policy and best practices.

Chronic Opioid Therapy and Sleep: An American Academy of Sleep Medicine Position Statement.

None: There is a complex relationship among opioids, sleep and daytime function. Patients and medical providers should be aware that chronic opioid therapy can alter sleep architecture and sleep quality as well as contribute to daytime sleepiness. It is also important for medical providers to be cognizant of other adverse effects of chronic opioid use including the impact on respiratory function during sleep. Opioids are associated with several types of sleep-disordered breathing, including sleep-related hypoventilation, central sleep apnea (CSA), and obstructive sleep apnea (OSA). Appropriate screening, diagnostic testing, and treatment of opioid-associated sleep-disordered breathing can improve patients' health and quality of life. Collaboration among medical providers is encouraged to provide high quality, patient-centered care for people who are treated with chronic opioid therapy.

Obstructive sleep apnea and orthodontics: An American Association of Orthodontists White Paper.

The Board of Trustees of the American Association of Orthodontists asked a panel of medical and dental experts in sleep medicine and dental sleep medicine to create a document designed to offer guidance to practicing orthodontists on the suggested role of the specialty of orthodontics in the management of obstructive sleep apnea. This White Paper presents a summary of the Task Force's findings and recommendations.