The 19th-century French critic, journalist, and novelist Jean-Baptiste Alphonse Karr wrote, “Plus ça change, plus c’est la même chose,” which means “The more things change, the more they are the same.”
On the other hand, President John Fitzgerald Kennedy said, “There is nothing more certain and unchanging than uncertainty and change.”
I agree with Kennedy and disagree with Alphonse Karr, especially as the second quote seems so much more appropriate for those of us who have worked in health care for a decade or more. I set forth to you two examples:
- As a respiratory therapist, I once instilled artificial surfactant into premature babies in an experimental study to help those that had immature lungs and improve their survivability. Now, this treatment is pretty much the standard of care.
- A decade ago, when I first entered the field of sleep, a thermister or thermocouple was used to assess airflow as the gold standard. Now, the pressure transducer airflow (PTAF) is a much more sensitive and accurate tool and has all but replaced the method of using temperature gradient to detect airflow.
ADAPTABILITY IS KEY IN MEDICINE
Stagnation or status quo in health care has never been the norm, nor will it ever be. For as a cell continues to metabolize and grow, so does our field of study evolve and change the ways in which we practice.
Sleep disorders medicine has been on the radar screen only for a solid 25 years or so. While it is true that the work of Nathaniel Kleitman, PhD, William Dement, PhD, MD, and others began earlier than that, the sleep storm—based on their pioneering foundations—really started brewing in the early to mid 1980s.
Today, this storm continues to swirl and spread across the medical community. Countless studies are being published monthly, sleep services are offered at many regional centers, and the American Academy of Sleep Medicine (AASM) accredited its 1,000th sleep center this past year.
As with any good organization, to see where sleep medicine is going, you must first see where it has been. While the field has grown and changed by leaps and bounds since its inception, let us look at the past 5 years or so of change in order to better appreciate and perhaps even predict the upcoming 5 years.
LOOKING AHEAD AT SLEEP EDUCATION
When trying to anticipate future developments, it is important to keep in mind that things do not always go as planned and one should be able to adapt to the climate as needed should the winds of change shift their heading. Adaptability is particularly important in the subset of education in sleep medicine. As theories change and new practices emerge, as educators, we must readily adapt to incorporate these new parameters into our educational processes.
One fairly safe assumption is that pharmacology will continue to be a huge influence on our field. In the past 5 years we have seen the release of ropinirole (Requip) for restless legs syndrome (RLS) and sodium oxybate (Xyrem) for excessive daytime somnolence (EDS) and cataplexy in patients with narcolepsy.
In addition, many hypnotics are now frequently advertised in the media and that competition will remain fierce. What will future drug releases hold? These things are usually corporate trade secrets, but I am sure that progress will continue in the field of hypnotics and stimulants, as well as in the exciting possibilities of orexin—a chemical secreted in the hypothalamus that regulates the sleep/wake cycle—in managing either insomnia (by inhibiting it) or EDS (by synthesizing/producing it).
Of course, everyone is awaiting that “magic bullet” that targets selectively the tone of upper airway dilator muscles. Will we see it by the end of this decade? Stay tuned!
NEW SCORING RULES
The scoring interpretation of sleep studies has undergone its first revision, and deservedly so, in nearly 40 years. As a result, texts must be rewritten and adapted if these new guidelines are to take the place of the R&K (Rechtschaffen and Kales) standard that we have all operated comfortably with since the inception of our field. For me, this makes the present an exciting time to be in sleep medicine. It reminds me of when one of the larger laboratories I worked at early in my career switched from a paper process to a digital one. At first, it was quite intimidating, but it was where the field was going. If you do not stay current with technology, software upgrades, etc, you will soon find yourself in the back of the pack or needlessly playing “catch-up” and trying to make things work in an “old-fashioned” environment.
The same can be said with our educational resources. We need to be receptive to the change, or potential of change, and be able to readily implement and deploy strategies that will make learning easier. The educators of the field must stay current on the latest trends and developments in sleep medicine so that our programs can remain state-of-the-art and operate at peak efficiency to serve the needs of the sleep community and those who work within it.
Along with the revisions listed above, the technology of the field is rapidly advancing because of refinements and improvements in computer software and device miniaturization. The push is on for ambulatory studies, software scoring programs, paperless sleep laboratories, and autotitrating devices. While some may see this as an encroachment on job security, it really is part of the solution for access to care for people with sleep disorders.
In addition, while technology may make testing more efficient, that technology will still need to be operated by dedicated and competent individuals who must receive their training and continued training from institutions that meet the highest of standards. The AASM’s Accredited Sleep Technologist Education Program (A-STEP) is certainly a huge step forward into maintaining the high standards of care that the AASM sets for the facilities it accredits. A-STEP programs offer structured and detailed instruction in our field and have set the bar much higher than previous certificate programs. Along with the Board of Registered Polysomnographic Technologists (BRPT) requirement of recredentialing, the amount of qualified and continuing education credit (CEC)-level programs is sure to increase by the end of this decade in order to aid RPSGTs in maintaining their credential. The challenge to these CEC programs is to not just offer a program for the benefit of the credits, but to expand, enhance, and share the wealth of new knowledge that is going on in the field, as well as keeping tabs on the basics of our field (scoring, titrations, etc).
LICENSURE AND CREDENTIALING ISSUES
As the field continues to broaden its referral base and becomes more technology oriented, the need for state licensure most certainly will be on the rise between now and 2010. With the advent of adaptive servo-ventilation (ASV) for complex sleep apnea as a prime example, standards must be set higher so that people operating these pieces of equipment (and those yet to come) are highly trained and qualified individuals. The BRPT’s RPSGT credential and A-STEP-accredited educational programs are the first step in meeting this need. Technicians should want to be credentialed, as a way of proving their competence as well as assuring the future of their profession. For the states that have licensure, this is already paving the way for the ultimate goal in the field: attaining and keeping the RPSGT credential. It would not surprise me at all if, in the very near future, the BRPT offered specialty examinations as we expand to do more pediatrics. (It also wouldn’t surprise me if an advanced scorers exam was on the horizon).
With this being said, the last thing the field needs is a competing examination from a discipline closely related but distinctly different from sleep. The National Board for Respiratory Care (NBRC) is pursuing the creation of a competing exam that would confuse and disrupt the field when the NBRC should be embracing and recognizing our current credential. If an individual wishes to carry dual credentials in respiratory and sleep, I have no problem with it. Having come from a respiratory background myself, I was quite humbled to realize the depth of knowledge that I lacked when I first entered the field of sleep medicine. Basically, that is how I got involved in education myself. In 1996, few training options were open to me, so I created my own at the urging of my program director. Together, we created a couple of three-credit courses and tagged them into our respiratory curriculum as RPSGT preparatory classes. Just as I do not expect an RRT to be able to identify spike and wave activity, I do not expect a RPSGT to know that they intubated the esophagus. My vote is to keep the two disciplines separate. Just as REEGT techs can carry the sleep credential, so can respiratory therapists, of which I am proud to say I am one.
MORE RESEARCH NEEDED
The more we know about sleep, the more questions we need to ask. Behavioral and alternative therapies have long been whispered about, but I can see that, in the not too distant future, behavioral sleep medicine will come into the spotlight and make its presence known. Already involved in treatments for insomnia, behavioral therapies may eventually become an integral part of the overall clinical treatment of the patient. Remember, it is not obstructive sleep apnea, it is obstructive sleep apnea-hypopnea syndrome. There is a huge key difference in thinking that needs to be made to recognize that sleep apnea (like most sleep disorders) is a long-term disease, and it needs long-term follow-up just like other chronic conditions (ie, hypertension, diabetes, COPD, etc). Behavioral medicine is sure to make its mark in the field, and, with current research, I believe it will be validated and brought forward as a front-line treatment option in conjunction with other modalities.
Among all of these changes, the one that may have the biggest impact on education is the new recredentialing criteria set by the BRPT. It is the best opportunity for us involved in education to take this forum that has been handed to us and make it worth the effort. Whether it is the normal regional or national meetings, grand rounds, in-services, or workshops, we need to take the current literature and knowledge and spread it to the techs who are at the bedside with the patients. We need to give them the tools with which to excel at their responsibility. It is truly an exciting time to be involved in sleep medicine and even more exciting in the educational component. Using the power of technology, through multimedia presentations, videos, PowerPoint presentations, and other teaching aids, we can spread the knowledge more efficiently and quickly than ever before. It is the educators’ responsibility to keep the knowledge flowing and making presentations fresh and captivating enough for the target audience to walk away equally as inspired as the instructor. With all the changes that are forthcoming over the next few years, those seen and unseen, there will certainly be enough subject matter to fill 50-plus hours’ worth of CECs over the next 5 years. This is a huge opportunity for educational programs to flex their muscle and really step up and show what they have to offer. Whether it is wireless acquisitions or paperless PSG transmissions over data lines, the field can only grow and adapt as quickly as those who can spread the word and help others learn their new tasks. With teleconferences and Webinars, the sky is the limit. Someone just needs to think it up first and put a plan into place. For as patients achieve REM sleep, so do the instructors dream of the possibilities that lie in front of us.
Stephen Tarnoczy, BS, RRT, RPSGT, is clinical education specialist at SleepTech LLC, Kinnelon, NJ, and associate professor at Quinnipiac University—Respiratory Care and Polysomnography. He also serves on the education committee for the American Association of Sleep Technologists (AAST, formerly the APT). He can be reached at. SleepTech LLC, Kinnelon, NJ, offers the Resources for Expert Sleep Training (REST™) program for sleep professionals. More information can be found at www.rest-education.com or by calling (973) 838-6444.