Sleep medicine and graduate medical education--prospects for the future.

As documented by countless numbers of articles in the lay and medical media, there is a contentious debate over health care reform occurring in our society. There is no doubt that such a public discussion, albeit sometimes rancorous, is the signature of a healthy democracy. Nevertheless, throughout much of the discussion, there does seem to be some consensus that there are large numbers of Americans without access to health care because of lack of insurance coverage, and that this number is increasing. Furthermore, most law and policy makers believe that it should be decreased, if not eliminated, even if they cannot agree upon the means by which this should be accomplished. One of the cornerstones of most current policy initiatives is that greater access be placed on preventative medical care, and that the primary care physician be the vehicle by which this is achieved. Consequently, there has been substantial effort placed on increasing the number of physicians graduating from US medical schools both by starting new institutions and by increasing class sizes among existing schools. According to the American Association of Medical Colleges, the first year enrollment in US medical schools rose 2% in 2009 vs. 2008, both by the opening of 4 new medical schools and a 7% or more increase in class size among 12 existing schools.1 However, to date, there has been substantially less effort to address the workforce issues related to graduate medical education (GME) that will be engendered by the increase in medical school graduates and the need for more primary care physicians. In fact, given the increase in medical school graduates, it is projected that there will soon be more graduates than available residency positions! Almost all GME in this country is financed by payments made to teaching hospitals through the Medicare program. However, the number of federally funded GME positions is capped by statute. Although it is generally agreed that more primary care physicians are needed, only ∼36% of these positions are in primary care specialties (Internal Medicine, Pediatrics and Family Medicine).2 Federal policy makers have been heretofore reticent about mandating the specialty distribution of GME positions. However, it would not take much imagination to envision a federal initiative to realign the specialty distribution of these positions to promote the training of primary care physicians. Thus, without any increase in the total number of GME positions, a game of “musical chairs” among the subspecialties will ensue. At the current time, there are 70 Sleep Medicine programs around the country with 140 filled positions. As a small field, we will be left scrambling to compete for funding among much larger specialties such as cardiology (2396 positions) or neurology (1877 positions).2 What will be our strategy to at least maintain, if possibly even to increase the number of GME positions that we have? I submit that as a field, we will need to demonstrate the added value of having a cadre of Sleep Medicine specialists available to treat and consult on difficult to manage patients with various sleep disorders or those with uncommon sleep disorders. It is unrealistic to imagine that Sleep Medicine specialists will be the primary caregivers for the large number of patients with sleep problems given the number of such patients and the number of practicing Sleep Medicine specialists. To date, there have been few studies that have shown that patient outcomes are better with input from Sleep Medicine specialists. Those that have been performed have confirmed that patients receive better care from Sleep Medicine specialists or accredited sleep centers,3,4 but it is unlikely that public policy will be developed based on such limited data. Therefore, our field needs more evidence both to demonstrate better patient outcomes and to emphasize the cost effectiveness of our services. This will be one of our greatest challenges. Otherwise, the field of Sleep Medicine will be increasingly marginalized in the march towards more primary care physicians and fewer specialists.