By Brandon R. Peters, M.D.
Health care can be a complicated and convoluted endeavor. From the perspective of a patient, it can be downright bewildering. It's even hard to determine the role of your caregiver at times. There are a lot of credentials thrown around these days. Some health care providers seem to have more letters after their names than letters in their names. It may be difficult to sort out the training and authority of your provider, a term itself that lumps together physicians with other trained professionals. In the realm of sleep, it can be helpful to explore the meaning of some commonly used descriptors and how they have changed over the years to ensure that you get the care that you need.
Starting at the top, your physician must undergo years of training and education to become a licensed medical doctor. After obtaining a four-year undergraduate degree from a college or university, he or she went on to another four years of medical school. Depending on their area of specialization, doctors complete residency (a mix of education and on-the-job training) that lasts at least an additional three or four years. Fellowship training, which is now required to become a board-certified sleep medicine physician, lasts an additional one year (with a few academic programs tacking on a second research year) (1). If you are keeping score: That's often 12 to 15 years of training on average!
Due to the multidisciplinary nature of the practice, sleep medicine physicians can have diverse primary specialty training. Many sleep specialists train in pulmonary medicine, neurology, and psychiatry. Some are trained otorhinolaryngologists (ear, nose, and throat specialists), anesthesiologists, and even surgeons. Less commonly, physicians trained in family or internal medicine and pediatrics can also go on to complete a fellowship in sleep (1).
Prior to and up until 2011, fellowship training in sleep medicine was not required to seek board certification. Rather, interested physicians (and even psychologists) could pay a fee and sit for the examination. If they passed, they received credentialing indicating their status as "board-certified." More recently, these exams have shifted to six other medical board societies and it is now not possible for a physician to take the examination without formal fellowship training (1).
Does fellowship training make a difference? Based on the results of the 2011 sleep medicine certification exam, it would seem that it does. Only 65 percent of the 2,913 candidates who took the board examination passed. For those who completed fellowship training in sleep medicine, the new requirement for everyone entering the field, the pass rate was over 90 percent (2).
Why does fellowship training matter? Dedicating a full year of one's life to education and training in the subspecialty of sleep medicine enhances knowledge, increases experience, and ensures the quality of care provided is maximized. It provides a structured learning environment in which specific standards of care are upheld. Research time and time again has demonstrated that board-certified sleep specialists deliver a higher level of care with this additional training (3). Moreover, Medicare and other insurance providers require sleep study interpretations by these trained specialists (4).
Physicians don't do it alone, and this adds to the complexity of care in some clinics and sleep centers. Midlevel providers such as physician assistants and nurse practitioners frequently provide supervised care. Psychologists (those with Ph.D. and Psy.D. credentials) may manage insomnia with therapy. Nurses and respiratory therapists may also have a role, especially in the management of continuous positive airway pressure (CPAP) equipment. There are also medical assistants who prepare patients by taking vital signs and reviewing documentation. Within the testing facility, you may also encounter polysomnographic technologists (some of whom also pass certification exams to become registered techs) (5). It's a diverse collection of professionals, and with communication, collaboration, and proper training the experience for patients can be optimized.
How do you know if your physician completed a fellowship and board certification in sleep medicine? You can start by asking prior to scheduling your first visit. Many clinics and groups also have websites that provide detailed biographies of their providers, including relevant sleep medicine fellowship training. You can also find the diplomates of the American Board of Sleep Medicine listed online by last name, with Ph.D. diplomates listed separately (6). Keep in mind that those certified prior to 2012 may not have completed fellowship training in sleep medicine.
It is worth learning a little about the credentials of your sleep medicine specialist. If you struggle to sleep well, start by finding a board-certified sleep medicine physician with formal fellowship training near you. You want to ensure that they are well-qualified to provide you the evaluation and treatment that you deserve.
1. "Current State of the Sleep Medicine Specialty Examination for Physicians and PhDs." American Board of Sleep Medicine. Last accessed: November 24, 2014.
2. Quan, SF et al. "Development and growth of a large multispecialty certification examination: sleep medicine certification--results of the first three examinations." J Clin Sleep Med. 2012 Apr 15;8(2):221-4.
3. Parthasarathy, S et al. "A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea." J Clin Sleep Med. 2014 Mar 15;10(3):243-9.
4. "Coding FAQ." American Academy of Sleep Medicine. Last accessed: November 24, 2014.
5. "Board of Registered Polysomnographic Technologists." Last accessed: November 24, 2014.
6. "Verification of Diplomates of the American Board of Sleep Medicine." American Board of Sleep Medicine. Last accessed: November 24, 2014.
Brandon R. Peters, M.D., is the writer on sleep for About.com, a neurology-trained sleep medicine specialist in Novato, Calif., and consulting assistant professor at the Stanford Center for Sleep Sciences and Medicine. This Center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. To learn more, visit us at: sleep.stanford.edu.