New referral pathways and consumer awareness may bring millions into sleep medicine. But if clinicians ignore physiologic heterogeneity and narrative context, more testing could still produce fragmented care.
By David E. McCarty, MD, FAASM
Sree Roy’s recent editor’s letter in Sleep Review captures something important and undeniably real: sleep medicine is no longer living on the fringe of healthcare. Consumer wearables, GLP-1 programs, longevity clinics, metabolic medicine, and cardiovascular prevention efforts are all increasingly recognizing what sleep physicians have known for decades: sleep is foundational physiology, not some sort of luxury afterthought.
This is good news, overall. Awareness is the first step. However…
For years, sleep medicine has existed in a strange paradox. Obstructive sleep apnea is both extraordinarily common and profoundly undertreated. Nearly one billion adults worldwide are estimated to have OSA, with approximately 425 million having moderate-to-severe disease for which treatment is generally recommended.1 Despite compelling evidence linking sleep-disordered breathing to cardiovascular disease, hypertension, diabetes, mood disorders, cognitive dysfunction, and impaired quality of life,2,3 most individuals with sleep apnea remain undiagnosed. In that sense, Ms. Roy is absolutely right: this is not merely a “clinical gap.” It’s more like systemic failure, and it’s time we started talking about it.
From my lens, however, the next challenge is more nuanced than accessibility alone.
The emerging issue is not simply access to “sleep care,” though (arguably) even access to that is sometimes hard enough. In the age of complexity, the emerging issue is access to the right kind of sleep care for a patient’s specific flavor of sleep apnea. That distinction matters.
The current conversation around integration often assumes that if we reduce friction (meaning: we simplify referrals, embed testing pathways into outside specialties, streamline intake, and increase virtual access), then it follows that outcomes will naturally improve.
I’m not here to start an argument: those efforts are important. Friction in getting around our healthcare system absolutely matters. Anyone practicing clinical sleep medicine knows how many patients disappear between referral, testing, follow-up, and treatment initiation.
Here’s my point: reducing friction alone does not solve the deeper interpretive problem sitting underneath modern sleep medicine.
I’ll start here: “Sleep apnea” is not one thing.
It is a label applied to a broad spectrum of physiologic instability occurring during sleep. Under that umbrella exist profoundly different human beings with profoundly different narratives:
- the patient with severe obstructive physiology and hypersomnolence,
- the exhausted insomniac with mild breathing instability,
- the patient whose central apnea worsens under excessive PAP pressures,
- the asymptomatic individual with central hypopneas during sleep driven by periodic limb movements,
- the patient with unstable breathing during sleep caused by sleep-stage transitions in the setting of chronic pain…or psychiatric illness…or autonomic dysfunction…medication effects…
These are not interchangeable stories. Recent cluster analyses have identified distinct clinical subtypes of OSA—including “excessively sleepy,” “disturbed sleep,” and “minimally symptomatic” phenotypes—that exhibit different comorbidity profiles, cardiovascular risks, and treatment responses, despite similar apnea-hypopnea index (AHI) values.4,5
Despite these obvious differences, modern systems often behave as though these cases are all the same: “sleep apnea.”
This is why the phrase “many moving parts” is part of the Empowered Sleep Apnea project’s language, and why it’s become so important within our Rebis ecosystem. This is not branding language: it’s more of an epistemological stance—an acknowledgment that unstable breathing during sleep exists inside larger biological, behavioral, emotional, pharmacologic, and circadian systems.6 It is a humility statement.
The danger facing sleep medicine right now is not merely a lack of access to diagnosis. It is the possibility that, as awareness expands, we unintentionally scale reductionism alongside it.
Wearables, metabolic programs, and integrated referral systems may successfully identify millions of new sleep-aware consumers. But awareness alone does not guarantee meaningful healing. In some cases, it may simply funnel people into overly simplistic frameworks that reduce complex human suffering into a single number or device metric.
Not all AHI is created equal, and most of our patients will have more than one problem contributing to their story.6
All of this matters ever so much more in the wearable era.
The AHI is influenced by weight, craniofacial development, jaw posture, sleeping position, age, alcohol and medications, fluid balance, altitude of residence, and numerous other conditions. It may vary over time and even across consecutive nights, creating inherent limitations in using a single night’s AHI to categorize disease severity and long-term risk.7
Furthermore, recent work has demonstrated that auto-PAP device algorithms do not always match manually scored polysomnography, particularly in the presence of unintentional leak, and that performance varies significantly among manufacturers.8, 9 Bench testing has shown that all three major APAP devices react differently to added unintentional air leak, with performance alterations that could affect the reporting of therapeutic success at home.9
At the same time, our field continues to wrestle with the reality that many asymptomatic and clinically “well” individuals (particularly older adults) can demonstrate “abnormal” polysomnographic findings despite the absence of any detectable evidence of dis-ease. In healthy individuals without symptoms or signs of OSA, the 3% respiratory disturbance index (RDI) increases remarkably with age: while 95% of healthy subjects under 50 had an RDI below 15; only 50% of subjects older than 65 met that threshold.10 A large meta-analysis confirmed that AHI increases by approximately 1.2 events per hour for each decade of age, even in healthy adults.11
This creates a profound systems-wide interpretive challenge.
If we build systems designed primarily to maximize throughput, we risk transforming sleep medicine into an algorithmic-sorting machine rather than a precision-based healing discipline. We may increase access while simultaneously increasing confusion, overtreatment, diagnostic momentum, and patient alienation.
This is where narrative becomes essential.
Patients do not simply need easier scheduling links or faster home sleep tests (although this would be nice!). They need orientation. They need language that helps them understand why this physiology matters within the context of their own lives. They need frameworks that restore agency rather than collapse complexity into compliance metrics.
The clinician’s role is not merely to identify respiratory events. It is to help patients navigate complexity collaboratively and iteratively. That process requires acknowledging uncertainty, contextualizing data, and resisting premature closure. It requires recognizing that two patients with identical AHIs may have entirely different physiologies, goals, risks, symptoms, and treatment trajectories.4,5
As sleep medicine becomes increasingly integrated into cardiology, obesity medicine, endocrinology, psychiatry, dentistry, and longevity programs, this interpretive sophistication becomes more important.
Otherwise, we risk building what appears to be interdisciplinary medicine while merely creating a larger referral superhighway into fragmented care.
I’m hardly the first to observe that fragmentation is one of healthcare’s deepest wounds. As Kurt Stange wrote in 2009, modern healthcare increasingly suffers from “focusing and acting on the parts without adequately appreciating their relation to the evolving whole.”12
Patients routinely encounter healthcare environments in which each specialty interprets them through a narrow lens: cardiology sees risk, psychiatry sees mood, obesity medicine sees weight, ENT sees anatomy, pulmonology sees airflow, while the patient experiences one intertwined human story.
Sleep medicine has an extraordinary opportunity right now to become a bridge discipline capable of integrating these narratives rather than further fragmenting them.
However, doing so requires resisting the temptation to define success purely through scale.
The question is not simply: “How do we get more people into sleep medicine?”
The question is: “What kind of sleep medicine are we inviting them into?“
Some practices function primarily as high-volume testing and PAP delivery systems. Others operate from a precision-medicine mindset that embraces heterogeneity, uncertainty, and co-discovery. Both may carry the same specialty label. Both may advertise “sleep apnea treatment.” Philosophically, however, these two clinics are worlds apart.
Patients increasingly sense this difference. Many are not simply looking for access, but instead for someone capable of saying: “You are not crazy…this may have many moving parts…your story deserves interpretation, not just categorization.”
That may ultimately become the defining challenge of modern sleep medicine: not merely reducing friction but creating systems capable of handling complexity without losing the human being inside the narrative.
David E. McCarty, MD, FAASM, is the co-creator (with Ellen Stothard, PhD) of the Empowered Sleep Apnea project and the chief medical officer of Rebis Health.
Read the Editor’s Letter That Inspired This Article:
References
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2. Yeghiazarians Y, Jneid H, Tietjens JR, et al. Obstructive sleep apnea and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021;144(3):e56-67.
3. Veasey SC, Rosen IM. Obstructive sleep apnea in adults. N Engl J Med. 2019;380(15):1442-9.
4. Zinchuk A, Yaggi HK. Phenotypic subtypes of OSA: a challenge and opportunity for precision medicine. Chest. 2020;157(2):403-20.
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6. McCarty DE. Beyond Ockham’s Razor: redefining problem-solving in clinical sleep medicine using a “Five-Finger” approach. J Clin Sleep Med. 2010;6(3):292-6.
7. Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnea: a review. JAMA. 2020;323(14):1389-1400.
8. Messineo L, White DP, Hete B, et al. Auto-adjusting positive airway pressure: the fine line between engineering and medicine. Sleep Breath. 2025;29(4):253.
9. Fasquel L, Yazdani P, Zaugg C, et al. Impact of unintentional air leaks on automatic positive airway pressure device performance in simulated sleep apnea events. Respir Care. 2023;68(1):31-7.
10. Pavlova MK, Duffy JF, Shea SA. Polysomnographic respiratory abnormalities in asymptomatic individuals. Sleep. 2008;31(2):241-8.
11. Boulos MI, Jairam T, Kendzerska T, et al. Normal polysomnography parameters in healthy adults: a systematic review and meta-analysis. Lancet Respir Med. 2019;7(6):533-43.
12. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100-3.
