If one sets out to imagine what sleep medicine might evolve into as pressure grows to control costs and improve outcomes, it can help to have been present at the beginning when the organizations and features of sleep medicine we now take for granted were just being formed.
Such is the case for Philip Westbrook, MD. When he performed his first sleep study in 1971, the field was in its infancy. He was the founding director of the Mayo Center for Sleep Disorders, one of the first sleep labs in the country, and founder of the individual membership arm of what is now the American Academy of Sleep Medicine.
In 2009, he received the Lifetime Achievement Award from the National Sleep Foundation for his role in the creation of many of the conventions of the sleep medicine field that now define it. This includes helping to form protocols for how sleep disorders are diagnosed, guiding the development of several key devices, and shaping the organizations that govern sleep medicine.
Yet where some would fall in love with their creations and refuse to imagine a future without those elements as part of the field, Westbrook has never stopped asking if there is a better way to diagnose and treat sleep disorders. Indeed, some of the conventions of sleep medicine that he helped create, such as laboratory-based testing, play little role in his vision for the field’s future.
While he is quick to say that he does not enjoy conflict, his natural tendency to question has at times put him at odds with colleagues.
“Dr Westbrook has never stopped exploring new things and pushing in new directions,” explains Lawrence J. Epstein, MD, chief medical officer of Brighton, Mass-based Sleep HealthCenters, a former president of the AASM, and a former sleep fellow under Westbrook. “That often took him out in front of the rest of the field. He was one of the first to develop and promote nonaffiliated sleep centers and was an early adopter of out-of-center sleep testing, even participating in the development of novel devices for diagnosis and treatment of sleep apnea. This sometimes put him out of the mainstream, yet he always relished the opportunity to question, be challenged, and debate what these changes meant and how to use them. This reflects his continuing desire to learn and improve.”
The tendency to constantly ask that dangerous question “why?” is one that Westbrook credits to his training in pulmonary physiology. Although it might surprise some who know him now, as a young man he was more likely to follow the rules than question them.
A bright high school student from Riverside, Calif, he almost enrolled at Princeton before switching to Stanford University at the last minute because the New Jersey climate seemed too cold. After obtaining his BA, he dutifully followed his father’s advice and enrolled in Stanford’s medical school even though he secretly hoped that his test scores would not be high enough to get in.
“My father always wanted to be a physician. Why, I didn’t know, but when the Great Depression came, he had to leave college and help run the family business, which was a hardware store.” Westbrook says. “He transferred that desire to become a doctor onto me.”
Although Stanford is sometimes called the birthplace of sleep medicine, Westbrook graduated in 1960, long before William Dement, MD, PhD, set up one of the country’s first sleep centers there. Then, because his family had a long military tradition and he wanted to help pay his way through medical school, he pursued his internship training at Walter Reed Medical Center and then served in the Air Force as a flight surgeon.
After discharge from the military, he completed a residency in internal medicine and a fellowship in thoracic diseases and pulmonary physiology at the Mayo Graduate School of Medicine in Rochester, Minn. He joined the staff of the Mayo Clinic as a consultant in the Division of Thoracic Diseases in 1969, with a focus on clinical pulmonary physiology.
It was at Mayo where both his interest in sleep medicine and his long-contained natural curiosity and desire to question convention were awakened. In the late 60s and early 70s, doing research was more informal than today and Mayo fostered a culture of collaboration among its physicians, who had both the time and the freedom to cultivate pet projects.
“My mentor at that time was a pulmonary physiologist named Bob Hyatt,” Westbrook says. “One day Bob had come back from a meeting and told me about an article that had appeared in a French journal about patients who have this disorder called ‘Pickwickian syndrome’ where during sleep they stopped breathing. I thought that was fascinating.”
With the help of colleagues, Westbrook started looking for people who might have this disorder. They soon found a likely candidate and, with the help of a technician, connected the patient to a electroencephalographic (EEG) device.
“Sure enough, when the electroencephalographic technician told me that the patient was asleep, this person stopped breathing.” Westbrook says. “I thought this was just amazing.”
The belief that he had discovered a patient with what was thought to be an incredibly rare disease set Westbrook on the path of studying sleep medicine. He soon discovered that his patient’s “rare” disorder was not so rare at all. Indeed, many patients at Mayo who had been diagnosed with narcolepsy actually had sleep apnea instead.
Westbrook proposed creating a sleep disorders center at Mayo and the medical group’s leadership agreed. The Mayo Center for Sleep Disorders was born, and its new director, Westbrook, set out to learn as much as he could from the small number of other doctors around the world who also were studying sleep. He spent a month at Stanford in the early ’80s looking at its sleep laboratory, he invited sleep pioneer Christian Gillin to Mayo to “pick his brain,” and he had the Mayo Center for Sleep Disorders join the Association of Sleep Disorders Centers (ASDC).
The first meeting of the ASDC that Westbrook attended was in a small room at an airport hotel in Dallas, and after he had finished presenting, he says he was told that he perhaps didn’t really belong there because he did daytime sleep studies. “I figured any association that rejected me had to have something to it,” he jokes.
Far from leaving, Westbrook just became more active and soon began to think that in addition to an organization for centers, sleep medicine needed an organization for individuals. However, to realize his vision, he would need the help of a person from his past.
SLEEP MEDICINE SOUL MATES
Out in California, Westbrook’s high school sweetheart, Carol, had never forgotten him, since the day they had first met at age 14 on the Balboa pier in Newport Beach. On the advice of a friend, she decided to look him up and the love was still there.
Leaving her native sunny California behind, she moved to Minnesota to marry Westbrook, a fortunate event not just for him, but for sleep medicine. While Westbrook had been studying medicine and learning the politics of the early field, she had been amassing an amazing degree of organizational experience as a working mom running multiple political campaigns for the very successful Reagan-era California Republicans. In addition, she also had started her own printing business in California and her own real estate business in Arizona.
Westbrook asked her to help him launch the organization he envisioned and recruit members, which he estimated would not amount to more than maybe 100—practically child’s play to a professional organizer and business leader like Carol.
“The politics were difficult and that is where Phil helped, but starting the organization was not hard,” she says.
In the fall of 1984, the ASDC announced the formation of a new organization for individuals interested in the clinical aspects of sleep and sleep disorders—the Clinical Sleep Society (CSS). Now the Westbrooks just had to get people to join the newly formed society for sleep professionals.
As Carol had done for political campaigns, she purchased lists of members from existing associations representing fields like pulmonology, neurology, and psychiatry and sent them information about CSS. By the end of the year, thanks in no small part to Carol’s organizing skill, membership had reached 339, more than three times as many members as Philip had initially expected.
In September 1987, the CSS and the ASDC merged to form the American Sleep Disorders Association (ASDA) with two branches of membership: centers and individuals. Carol Westbrook became executive director of the ASDA, a position she held for many years until Philip retired from Mayo in 1989.
Looking for the next great challenge, the Westbrooks moved back to California where Philip had been offered the opportunity to become the founding director of the Sleep Disorder Center at the Cedars-Sinai Medical Center in Los Angeles. Running the ASDA from California was not really feasible, so Carol handed over control of the organization to Carolyn Hiller.
However, she remained involved with the ASDA as it continued to grow and eventually became, in 1999, the American Academy of Sleep Medicine (AASM). In addition, she was the driving force behind the creation of the National Sleep Foundation in 1990.
“I am amazed at what it has become,” she says, looking back.
Philip ran the Sleep Disorder Center at Cedars-Sinai until 1995, when he started his own sleep center, Pacific Sleep Medicine Inc, in Redlands, Calif. However, he remained with Cedars-Sinai as director of its Sleep Medicine Faculty, and also held a faculty position at the UCLA School of Medicine.
Yet even as his career was flourishing and his sleep laboratory was returning profits, he was becoming disillusioned with the complexity of laboratory-based sleep testing, which he saw as a barrier to getting more patients diagnosed and treated. In the late ’90s, when some colleagues started looking at possible ways to fix the problems with the existing home-based sleep testing devices and make quality remote sleep studies possible, Westbrook was intrigued.
“We sat down one night, the four of us, over a glass of wine and brainstormed the ideal device,” he says.
Their idea became the foundation of Advanced Brain Monitoring’s FDA-cleared in-home diagnostic system for sleep apnea, the Apnea Risk Evaluation System (ARES). In 2001, Westbrook left his sleep center, Cedars-Sinai, and UCLA to join ABM as its chief medical officer.
In addition to his work with ABM, Westbrook became chief medical officer of Watermark Medical, a company that seeks to make primary care physicians the point of contact for sleep apnea diagnosis through the use of cloud-based home sleep testing.
Then, in July 2009, Westbrook teamed with another Stanford graduate, Rajiv Doshi, MD, who had approached him with an idea for a positive airway pressure device that didn’t use electricity. He now serves as the chief medical officer for Ventus Medical, the maker of Provent.
These are not empty titles but active affiliations that he manages from his home office in Fallbrook, Calif, with the help of Carol. “Dr Westbrook reviews roughly 10% of our studies each month and meets regularly with our sleep technicians to improve the quality of our studies,” explains Charlie Alvarez, president of Watermark. “He also works with over 200 Watermark Medical-affiliated interpreting physicians on a monthly basis to answer questions and review results. Dr Westbrook is also a resource to primary care physicians and other specialists who have questions on home sleep testing, therapy solutions, and sleep in general.”
In addition, Westbrook’s affiliations are very much guided by his personal vision for the future of sleep as a specialty and medicine in general. For sleep medicine, that means simpler diagnosis using home tests and possibly even screening tests through urinalysis at the patient’s primary care office, he says. Sleep specialists would become involved as advisors and managers only in very difficult cases. In addition, once patients are diagnosed with sleep apnea, primary care providers would be the ones helping them manage their condition with the aid of better treatments and devices.
Having started three sleep centers in his own career, Westbrook says he understands the resistance to yielding to greater use of home-based testing, but it may not be a choice. “Medicine in general has to change and sleep medicine has to change with it,” he says.
Lena Kauffman is a freelance writer and former Sleep Review editor in Ann Arbor, Mich. Questions can be sent to [email protected].