This father and son team up at the Ohio Sleep Medicine Institute to determine sleep disorders through assessing patients’ physical and psychological conditions.

SchmidtsMarkus Schmidt, MD, PhD, (sitting), with his father, Helmut Schmidt, MD.

For Markus Schmidt, MD, PhD, following his father’s footsteps into sleep medicine was a natural path to take. “[I] never felt pressured,” he says. “I always had an interest in sleep anyway… thanks to my father. It’s just worked out that way. I think he would have been happy no matter what I did. I think he’s thrilled, obviously, that I’ve joined him.”

Markus recently joined his father, sleep medicine pioneer Helmut Schmidt, MD, at the Ohio Sleep Medicine Institute, Dublin, Ohio. The Columbus-area institute was founded by the elder Schmidt in 1990 and, until his son joined him in July, was the only physician there. The Schmidts are the only multigeneration sleep medicine team in the country.

The family involvement in the center, which Helmut calls the “Taj Mahal of sleep medicine,” does not stop with Markus. The center—including its six bedrooms—was decorated by Helmut’s wife, Angelika. Each room in the center is named after a figure in sleep medicine who inspired Helmut. Each of the bedrooms looks less like a treatment room than what it appears to be—a bedroom with homey colorful bedspreads and pictures hanging on the walls.

Each room, however, is more than just a comfortable bedroom. In addition to being soundproofed, each is wired to state-of-the-art monitoring equipment that allows the center’s staff of 12, which includes four registered nurses to observe patients through their sleep cycle. Technologists—there are always at least two on duty—use video cameras and other computerized and analog equipment to monitor patient movement, breathing, brain activity, and other physiological phenomena. “It’s a full-service, comprehensive look at what’s going on during your sleep,” Helmut says. “And we also do nap tests—what we call multiple sleep latency tests—and occasionally maintenance of wakefulness tests to assess sleep onset propensities, how able patients are to stay awake, and whether or not they have narcolepsy.”

The sleep problems the Schmidts’ patients experience can be a combination of physical and psychological conditions, though, Helmut says, many tend toward the physiological. Treatment can include medication or surgery. “It’s very important in my clinic to educate patients,” he says. “The more they know about [their condition], the more they will be able to actually deal with which way they want to go, and the more they understand it, the more likely they will be compliant with the treatment approach.”

In treating patients with sleep disorders, most of whom have been referred to the private sleep center by other physicians, the Schmidts have to be as much Sherlock Holmes as Dr Watson. Many of the patients do not even know they have a problem. When possible, the patient’s bed partner is asked to come to the consultation to help Helmut and Markus determine the underlying root of the sleep problem, which can range from sleep apnea to restless legs to narcolepsy to insomnia to depression. This detective work is what makes the Ohio Sleep Medicine Institute different, Helmut says. “It’s absolutely necessary that we look closely at what’s going on with the patient—whether it’s psychiatric/psychological or underlying medical reasons or a combination—and looking very closely at what is seen and the quality of the data that are collected,” he says. “I think a lot of things are overlooked or overread. You have to have intuition as to what might make sense, what is not quite right, and you have to look a little bit closer to find out what’s going on with this patient. You need to piece information together that may have been overlooked and identify what is important for that individual in order to come to an accurate diagnosis. I think that’s key. Most of the time I think I have a fairly good intuition about a patient and what I can expect, but I can be wrong too. And that’s why it’s so important to collect the good, accurate data that helps to formulate a final diagnosis—not an opinion. I don’t like the word opinion… I want to have a diagnosis—definite knowledge as to what might be the basis of my thinking and what might be the best form of treatment.”

Markus adds that it is the comprehensive care patients receive at the Ohio Sleep Medicine Institute that makes the center unique in the field. “We like to think of ourselves as a tertiary, comprehensive sleep diagnostic center—a place where we look at the global view of the patient,” he says. “We do a thorough investigation into what sleep disorders patients have even if they have multiple sleep disorders, whereas I think a lot of other physicians have a more simplistic approach. They look for a unifying diagnosis. Sleep, unfortunately, is a field where those unifying diagnoses are sometimes not always there. You really have to go through everything. We do a very good job in teasing those things out from the beginning so we do not have to keep coming back and reevaluating the patient. For this reason, we do a very extensive initial interview and look for ancillary causes for narcolepsy, for example. From the depression side of things, I think my father’s background in psychiatry has been very helpful and it’s something I’m very pleased to learn from him. And one thing [my father] does very well is look at the person from a holistic perspective and to weed out those elements. I think that’s something we do here better than I’ve seen anybody else do, at least locally.”

Follow-up is just as thorough. Bed partners, acting again as the eyes and ears of the medical “detectives,” help gauge how the treatment is working. “We have a very good follow-up program with the patients,” Markus says. “We really work with patients to get them to comply with [their treatment]. If they have problems, our staff has been fantastic in dealing with them, trying to work with their needs. We really keep in good contact with patients and referring physicians so that if there’s a problem, we can be right on it. I think that’s definitely been a major plus for our center.”

And it is this commitment to getting the right diagnosis that has marked Helmut’s career and often puts him at odds with other physicians. For instance, he notes that narcolepsy is never included as a diagnosis among those who have sleep apnea, although his research indicates that many narcoleptics have severe breathing issues. “I don’t know of any study in the past 20 years on narcoleptics that includes sleep apnea [patients],” Helmut says. “I’ve found that at least half of my narcoleptic patients have very significant apnea, diagnosable apnea, and often severe apnea. That kind of attention to detail helps to identify new disorders as well.”

Helmut makes no apology for flying in the face of convention. His loyalty to his patients is greater than the risks of offending his colleagues. “The patient has to come first, absolutely,” Helmut says. “You have to look for the right answer for that patient because if you don’t, you’re deserting that patient long term… there are often dire consequences down the road. You have to have a willingness to go against the grain, out of the way, and against the mainstream.”

The Pioneer
Helmut Schmidt’s unconventional career as a pioneer in sleep medicine reflects his independent nature. Trained as a psychiatrist, he became interested in sleep medicine in 1966 while completing his psychiatric residency at the Ohio State University Hospitals, Columbus. After his residency, Helmut remained at the hospital as a psychiatrist. In 1975, he set up the hospital’s Sleep Disorders Evaluation Center—the third accredited sleep center in the nation. He would help the center from 1976 until 1990, when he left to set up the Ohio Sleep Medicine Institute.

“In 1988, I was making a proposal to my chairman and dean of the college of medicine suggesting that we should set up a freestanding sleep center facility off campus because I found no need to have one on campus where it was very difficult for patients to come,” Helmut says. “As an outpatient activity, there was really no reason for us to have to be on campus. We had to have something going on campus in the hospital itself, of course. There was no need to have the main activity on campus. I made a proposal to do that in the northern part of Columbus where there was a medical facility built. But they were afraid I was going to do something on my own there. The bottom line was they rejected it, so I decided to do it myself.”

Ironically, it was Helmut’s training as a psychiatrist that caused the biggest hurdles in the clinic’s early success. “One of the problems I’ve had in establishing my sleep center was that I’m a psychiatrist—‘and what does a psychiatrist know about medicine’—that’s the kind of attitude my colleagues and insurance carriers have,” he says. “Insurance companies have their own directories for providers and I could only list myself as a psychiatrist—nobody with sleep problems would come to see me as a psychiatrist but if they knew I was a sleep medicine specialist, they would come. And I kept having problems getting reimbursed for my work and also being known as a sleep medicine specialist.” Not to sit idly by, Helmut went on the offensive to get sleep medicine recognized as a specialty. As part of his and some of his other colleagues’ efforts, sleep medicine has been a self-designated practice specialty since 1996.

In addition to being a clinician, the senior Schmidt has and continues to conduct research. His projects include sleep disordered breathing and surgical approaches, sleep disorders caused by cranial facial abnormalities, and sleep disordered breathing and narcolepsy.

Erectile Dysfunction Research
Like his father, Markus also has spent much of his nascent career doing research. The two men first teamed in 1991 coauthoring an article on the physiology of penile erections for the Southern Sleep Society, and then in a platform presentation on the same subject at the annual meeting of the Associated Professional Sleep Societies. Markus’ professional association with his father began long before the creation of the Ohio Sleep Medicine Institute. As a teenager, he helped his father’s researchers at Ohio State University. This research interest continued through his postsecondary and postgraduate education earning degrees in both medicine and neuroscience.

Much of his research has been and continues to be in the area of the neural control of sleep-related penile erections—much of it under the tutelage of Michel Jouvet at the Department of Experimental Medicine in Lyon, France. It was at Jouvet’s laboratory that Markus developed a new technique for recording erections in rats—a technique it took him a year to perfect. His findings show that a different center in the brain controls erections that occur during sleep than those that occur due to tactile and other stimuli. His research could have important implications for medical treatment apart from sleep. “By understanding and deciphering the brain as a black box and how it controls erections—theoretically, if you can understand what neurotransmitter system is being used in different contextual erections, those that occur during dream sleep, erections that occur more from tactile stimulation—you now know that it is all compartmentalized in the brain,” he says. “The theory is if you can activate that system pharmacologically, you can help someone who has erectile dysfunction by activating a specific arm of that neurotransmitter system. That’s the goal eventually, to use this information to help treatments directly at the central nervous system level. Erectile dysfunction is very prominent. If there is any question as to need regarding treatments for erectile dysfunction, look at the craze that happened with Viagra.” He adds that erectile dysfunction will be experienced by one out of every nine men sometime during their lifetime.

Markus’ work in erectile dysfunction, like his father’s efforts to help establish the field of sleep medicine, is pioneering. “For me, it’s exciting because it’s a neurotransmitter system and a physiology that have never before been examined,” says the younger Schmidt. “The field is wide open to discover how the whole system works, and that’s very interesting.”

The Student
Though his passion lies in research, Markus sees no contradiction in rejoining his father at the center. “I look at it as the best of both worlds,” he says. “I like being in the private setting in many ways in the sense that we have some ideas we want to do research-wise and we’re setting ourselves up to be able to do that—to combine a clinical setting with the clinical research. We will be getting more into that, and being an independent center allows us the freedom to decide how we want to do things and how we want to organize things.” He is also keeping a foot firmly planted in both the academic and clinical world by recently accepting an adjunct post in the neuroscience department of Ohio State University, which will allow him to continue doing research in an academic setting.

The work of both Schmidts has not gone unrecognized. For his research and contributions to sleep medicine, Helmut has received numerous awards including the first “Shoe Box” award from the American Board of Sleep Medicine in 1991—an award that has since been renamed the Helmut S. Schmidt Award. This is another way in which the younger Schmidt is following in his father’s path. Markus has received numerous awards as well, including the Neuroscience Investigator Award from the Cleveland Clinic Foundation three times in a row—the first person ever to do so. He has recently received the Young Investigator Award from the Sleep Research Society.

Even with all of his honors and discoveries, the younger Schmidt—who has yet to take his medical board examinations—is still happily following his father’s lead. “My father is a great teacher,” he says. “I’m using my first 6 months particularly and basically my first year as my fellowship year… where I’ll have a lot of input from him and go over patients together. But I consider it a fellowship and learning the intricacies of the clinical side. We work well together. We have a common goal and some common views on how we see things.”

Chris Wolski is associate editor of Sleep Review.