The Future of Sleep Medicine: Dr. Alison Kole's Perspective

<p>hello everyone this is Cole from the American Journal of healthc care strategy joined by a really special guest today a triple board certified physician Dr Allison Cole Dr Cole please introduce yourself sure thank you so much for having me Cole I really appreciate it I am a uh expert in pulmonary critical care and sleep medicine and sleep is my waking passion I absolutely am enthralled with sleep so I am um first and foremost a mom to two amazing little girls I was a full-time practicing clinician doing ICU work I was a p active pulmonologist and I ran a um large sleep program for a large multip Specialty Group and my neck of the woods here in the great state of New Jersey until I decided to Branch out on my own create a little bit different type of work environment for myself and uh and so with that I decided to start a sleep tele medicine practice with Oak Health Center so I'm the medical director there I'm also the director of uh medical Affairs and clinical strategy at US Health [Music] Connect thank you so much for taking some of your very valuable time with your pack schedule to come and talk with our audience absolutely really excited to talk with you the first question I have is you know you got your mdmph right from toughs way back then did you already know you were going into sleep medicine kind of at the beginning was that already something on your horizon actually no no so I for those of anyone listening here who may have had a little bit not the standard trajectory I would say mine was a little bit off the beaten path not so much directly but I did take a couple years off basically meaning that I finished undergrad and then I actually uh worked as a pulmonary function Tech back in the day you could do that sort of thing and it was at Columbia University and that was my first exposure to pulmonary medicine and so I would be the person cleaning the bronchoscopes and you know handing people saline lavages and things like that I was um doing pulmonary function testing on patients and so I grew this actual real passion for pulmonary medicine initially so when I had the opportunity to go to medical school that's where I really thought I would shine I I think the the uh bells and whistles of walking into a critically ill ICU room and you know with a patient on 400 drips it seemed like you know they had all the little things hanging and I was like people must be Geniuses who take care of these people oh my goodness what is happening here and so I had this deep admiration for all the pulmonologist so I actually started off primarily interested in pulmonary and ICU medicine I truth be told nobody talked about sleep it wasn't anything that was a priority it really wasn't and so it's it's interesting too because you you now have uh you know not sure if you had medical school debt but you had this financial consideration right you already spent years getting trained in pulmonary and crial care so then you decide to to do more training in sleep medicine was that a scary decision at all at that point because you you know you're probably making better money after or you have the potential to make better money after being completing your fellowship and in ping critical care and then it's like oh we're going to do more training in this new specialty such an interesting and great question um you know in reality for me my first I had I knew going into it I unfortunately had that I was 100% responsible for all medical school costs and I went to toughs and um thank you tus for my wonderful education uh that I'm still paying for and probably be paying for for the next 10 years um the reality is that it was incredibly expensive uh but I felt like it was something that I just needed to do so I looked at it like I'm G to have to pay off medical school debt for as long as I'm working which is in my mind you work until you're dead that was the philosophy that I grew up with yeah so I just never thought I would not work um and so I just put that kind of aide I didn't really stress out about the uh the debt of medical school because it was going to be there regardless of what I did so when I had my first job my first job paid of course much better than you know being a fellow but I used to Moonlight as a fellow so um you know I kind of was like okay this is more money this is great I did not perceive that I was wealthy at all and and I had joined my first private practice at that point and you know we we what was offered was sort of the best that I could get but it wasn't wonderful it wasn't like oh wow I'm going to make so much I'm like it's more than I am but it's was on par for what could be expected at the time um the person I worked with actually was deeply invested in doing a lot of sleep medicine so I was doing a lot of the pulmonary ICU he was doing a lot of the sleep medicine and I was around all the sudden this exposure to so much sleep and how you what it meant to get quity sleep I also was taking Co literally every other week and I was like I don't think this is sustainable this is way too much call and a very tiny practice um and so I was like I'm not getting any sleep he's doing sleep he talks about sleep it's all about sleep apnea but I know there's more to it than that and and my fellowship experience was fairly unique in that we had a lot of sleep exposure I was in Sleep Clinic all the time so I had this kind of constant exposure to sleep really for me my um Dad had some health issues a sleep Fellowship position was offered to me and I just felt like I'm like I need to be an attending I needed to feel like I was a pulmonary Critical Care attending so I actually um went and worked for a couple of years the position became available again uh something was calling me to it you could say it was meant to be and I returned from I trained in California returned to New Jersey for a couple years went back to California and it was at that time it was mandatory you could not become board certified in sleep unless you did a full year of sleep fellowship and I did it and it literally changed my life so for anybody's listening who is relatively new graduate you know what it's like even when you leave your residency um or your fellowships you you have your call schedule you you have the high pressure environment you have to live up to the expectations that perhaps you have on yourself or what your attendings are expecting you to deliver and obviously wanting to you know um be provide excellent patient care um and then you do sleep fellowship and yes you want to do all those things but guess what you don't really take call I mean you have a pager um in case there's some issue that happens in the sleep lab which from my lips to God's ears did not occur that year I don't think I got paged once it was amazing amazing and I spent a year not taking call and there's something that that happens in your biology when all of a sudden you don't have that like what's the emergency why am I getting paged what's going to be at the other end of that phone call what's the situation with that patient because coming from an ICU background my phone calls are never like hey everything's fine it's like I need a bed this is going on like there's some emergency right so I went from this like heightened sense of everything is always an emergency especially when I get paged in the middle of the night to suddenly like no Pages um I found myself able to fall asleep I found myself able to stay asleep I was getting more sleep than I had for the entirety of my career even dating back to college and I really was like there's something to this I feel different this is amazing so my horizons expanded so yeah that's that's where I knew I was like oh man oh man I did all this training and it was really fun to feel fulfilled as a pulmonary critical care doctor but now I have this extra training and now I'm really feeling like I'm coming into my own like that just what I wanted to do shifted from that experience what did you learn during that experience that kind of convinced you to go into sleep medicine what did you see I guess that made you make this change that you didn't see in your undergrad in learning about psychology or in your medical School of course where you study a lot of different things is sleep not mentioned in the medical school curriculum though to the level it should be uh I would absolutely say that that is correct sleep is not discussed as it should be and quite frankly when I trained we didn't have as much of Regulation surrounding your hours that you worked and such and so it was almost like a badge of honor it'd be like hey I had a really tough uh surgical rotation I I I didn't sleep at all and it was almost like I'm tough I didn't sleep right now you wouldn't even think about thinking that that was an okay situation that was standard nobody discussed sleep in any kind of real depth it wasn't really um flashy or exciting or emphasized and medical school train is kind of about like learning how to be sleep deprived and still function at a high level at least it was in my day so there is definitely a lack of Education there um and once I did my year where I really focused very deeply you know I had my main exposure as a a pulmonary doctor was we saw these Osa patients and and part of the reason we had all this exposure in Sleep Clinic is primarily people came in with sleep apne they wanted they had their CPAP units these these units needed to be um checked for compliance data Etc so we did a lot of um obstructive sleep apnea which is obviously incredibly common in the United States and the veteran population has a lot of sleep apnea they also have a lot of insomnia we didn't get as much training in insomnia in pulmonary so when I started my sleep Fellowship then I'm learning about insomnia I'm learning about all of the central disorders of hypersomnia I'm learning that hey you can punch and kick and act out your dreams and you might have REM behavior disorder I'm like whoa what is this stuff you're learning about brain waves that's something that we really other than ordering an EEG and pestering neurology to come take a look you know and and learning about spike and wave that's like sort of the extent of it um that's just a pattern that you see on the EEG you know it it's to get that other exposure I'm like the world of sleep is much bigger than I had thought it was just for my pulmonary ICU Fellowship so those things really impacted me in a way and quite frankly my quality of life improved and it was because I was sleeping I had a regular schedule I had freedom to be become more creative more creative about what I think I thought my future could be my horizons were broadened so huge implications for just how we think about the world and and I've seen this firsthand with um friends and and family members and and in one instance individual went from um there was you know kind of comorbidities Co you know ex other existing problems but they went from obstructive sleep apnea where they were having severe depression headaches every day all of a sudden they're trying to see for a week and then their headaches have gone or have been reduced right their their depression symptoms have been a lot more mild it's a lot easier to be treated with their their medication and so it that really was something that growing up uh we you know my parents uh because I think I was born around the time you started your youry so oh go a little bit I think since since then so I was told like all the time right it's so important it's so important but as you know a very young like rebellious person right you know I didn't want to listen to my parents you know what I mean I wanted to stay up late and do whatever and so I kind of didn't take it seriously until I saw me these firsthand changes and it was like wow how many you know diagnosis could we have had or medications could we have given this you know uh this family member if the neurologist didn't say you know you need to go to a sleep doctor first right uh because they were presenting with so many different problems this episode of the strategy of Health was sponsored by modality Global advisor modality Global advisors optimizes Hospital Revenue enhances patient experience and delivers proven results visit modality Global advisors.com to learn more that's it it's a mindset shift from what we're traditionally taught is this patient is presenting with X number of symptoms they're diagnosed with blank you've made that diagnosis this is the appropriate treatment this is the algorithm if they have one these are the medications that you use right that that sort of we're problem solvers y to go into sleep and realize that yes I have the capability of doing just what I've done with all the other things I do which is be a problem solver but now the problem is if I fix your sleep and you are healthy am I now problem solving and delaying right we all inevitably get SI crap happens we can't predict the future but if we're looking at optimizing the potential for having Health in our life good health good quality Health Quality Health dictates the quality of your life period if you feel like crap doesn't matter how much money you have or any of these other things that we deem to be important in our society the reality is our health is important and it's precious and sleep I've come to realize is truly foundational it's like the base layer you need a good foundation in order for the house to be built and without sleep you don't have a lot of the protective mechanisms that are so important to clearing the evil humors from our brain for example and having us just sleep better just having us think better feel better you mentioned mood breathe better all of it comes back to having a good quality of sleep sufficient sleep duration and consistency if possible I mean obviously we're talking about the ideal world but you know making it a priority is the only way to really change anything so that's that's my goal is prevention so you're hitting the nail on the head changing the Paradigm of how we approach Healthcare well because you know snoring right it last it used to be like a meme right you know like a lot of people snoring and then or disturbed sleep as an elderly person right it's like oh you know you're you're over 60 you only sleep three hours a night because you're you know back painer Etc and so it used to just be something that at least in pop culture is expected and tolerated um and we've seen that in a way with other things as well right like the American obesity crisis um you know I'm obese I suffer from obesity working with my doctor to get it treated but um we've kind of like expected these things to go on in American culture right and they're really like the foundational building blocks of Health one of the questions I have in that case we've seen with obesity you know wovi and treatments like this have started to help with with that but uh the Sleep situation is a bit different because it seems like we have treatments right I mean we have the CPAP we have a lot of other things but yet people don't know the diagnosis or they don't care Etc do you think technology you know like apple either day you might have seen announced that they're gonna sleep yeah app detection on the wristwatch do you think that's going to create more and more demand as time goes on and get more and more people diagnosed I think it's going to alert people people to a problem so you have I think Samsung actually has an FDA approved um algorithm or something on their watch I think Samsung is approved I just saw something that popped up it was literally like one of those tiny little paragraphs that you see from like the ASM bulletin saying that there's now a mat that might be FDA cleared for treatment of sleep apne or not excuse me not let me rephrase that a mat that may be able to detect sleep apne and is getting FDA approval and then you have apple with their algorithms and they're um deeply invested in doing research with sleep scientists take a look at their algorithms and how they can help to improve sleep um you know the the bottom line is that there's pros and cons to commercial products the con is something we call orthosomnia that's when you literally have almost an obsession with what your data is showing you all of these things are just tools so I always caution people um I don't poo poo commercial products I think they're helpful for people to gauge I mean one of the ways I use it is for people who are not so great at filling out their sleep diary and they're having trouble sleeping and I'm like all right well you're wearing your watch let me see what that shows and then I get a much better sense than what they're reporting to me what actually might be going on and again I take it as it's not the same thing as coming in and having multiple nights of a polysomnogram and gold standard you know Diagnostics but it is helpful to get a pattern yeah and if your watch is alerting you to an abnormal heart rhythm or a fast heart rate at night hey that's something we see with sleep apnea hm if it's alerting you that there's drops in your oxygen levels again it's not going to be the same level of data but it could be very helpful so again you got to be careful about getting obsessed with it but I do think it's a tool that you're right I do think it's going to increase demand I think the um the the challenge is going to be okay we have demand um where are the providers out there right you know who who are the people that can take care of them and also what is um what are we doing in health care um you know insurance coverage working with Physicians such as myself to make it fair and balanced I mean just trying to uh have a see patient after patient after patient where they're waiting six months in line and then you you have 10 15 minutes to see them at most and they have a complex sleep case is not fair to that person and it's one of the reasons that I got into sort of the entrepreneurial spirit and as I mentioned to you my journey was a traditional medical model which I never in a million years thought would change for me I just thought okay well I'm now a medical director I'm happy about this I've developed the Sleep program this is very exciting this is where my future is and then it wasn't and I don't regret the change at all I mean the fact is that starting a sleep tele medicine program that really is an outof Network um kind of model I can see you for 60 minutes cuz that's appropriate for you you there is no line you know you were paying for your services up front and we will admit a super bill for you it's just a different way of practicing for the patient who really cares about getting deep into the weeds who doesn't want to wait in line for six months to have 10 15 minutes with the doctor who's going to be like all right I'm I'm not going to talk to you about all your options because that takes too long here's some CPAP by-bye right who's going to take the time to say listen there there are multiple options these are what the multiple options are this is what the latest data says might be the appropriate starting point for you this is my plan B and my plan C and this is where research is going in the future that's the level of conversation I like to have with my patients and that's not for everyone but if that's the kind of conversation you want to have find me I will see you we will chat well and I appreciate because that was going to be my next question too is it's like okay we have this technology coming out it might help some people but it's not going to solve all of the the issues right like you were saying like it's not you're not going to be able to cure every you know sleep issue going on or detect every sleep issue just by this Apple watch so that's not gonna do everything what is the solution right and that that kind of goes down to why did you get involved in the business end of things right you probably make reasonable money as any kind of you know physician right and so there's there's that aspect of it where you're able to to maintain your your stand of living you have a family of these things going on and this seems like another responsibility to take on right and so I have to ask what motivated you to say I'm gonna you know pursue adding on even more things what was the Deep motivation for you there well the Deep motivation is that I couldn't continue to live the lifestyle I was living as a full-time practicing clinician Point Blank our call schedule was not what my original job was which was every other week thankfully um but it was every month or so 7 days in a row my phone would go off I needed to make sure the residents felt comfortable with the plan of action for admitted ICU patients there would be other questions that you're triaging and there's endless tasks with all of the the patient volume that you have and I really truly cannot even explain to you how much I miss many of the patients that I have treated but I had to make a decision because nobody was going to look out for me but me and at the end of the day you have to look at your life and say what is most important is it that it was the cre of Dr Cole if that's the case maybe my path would be different for me my priority shifted when I was gung-ho pulmonary Critical Care yeah I see you go go go I didn't have any kids I wasn't married you know life happens and now I have two little beings that are wanting to know why Mommy can't really be emotionally present for them and that's because I'm having dinner I've just been paged and I get to deal with an emergency I am so dog on tired from rounding in the ICU during covid that I you know I've got to take a bath don't touch mommy um I I don't want to get you sick the level of concern that you give to your patients it's very difficult to give that concern to everybody in your life so who's most important for me it was prioritizing family and the the career trajectory I was at was not allowing me to prioritize them in a way that I felt was appropriate so for me even though it sounds like oh my goodness you're doing all this work you're becoming an entrepreneur did I have any training in any of this oh heck no I just figured it out you know and it's one of those things where it's it's having the faith to know that you feel it inside for me it was just like a gut like it's time for a change I really didn't have a huge plan or an elab IT construct of how I was going to navigate that world I just knew I needed a break I was going to give myself that Grace and that at the other at the other end of that break it was going to work out what what makes me a little concerned though for our other colleagues you know especially your colleagues the Physicians is now you do this you do other things right you have four or five things going on right and so you're more efficient it seems like or you're more productive now than when you were just doing the one thing but it seems like you're less burnt out right from what you're saying you made this change so it would seem like you're less burnt out so here's the the concern though right we clearly can't have a system that burns people out all the time right uh by just having patient after patient what changes could be made right so that we don't end up having extremely talented Physicians like yourself go on and say I can't see you know patient after patient anymore I'm G to go and you know work on four or five other businesses and it'll be easier than staying with this one job right what what changes could happen is it do we need more Physicians do we need a complete rewrite of of How It's build like what would you recommend Cole I think whatever I say someone's going to have a criticism for and it's going to be valid so I'm just going to tell you what I think it is and you can feel free to say that's completely wrong and I'm all right with that because I'm not saying that I have a specific answer but but I definitely think we no longer as Physicians I'm speaking as Physicians I'm not talking about APS though I have tremendous respect for what they bring to the table I'm speaking from the P physician perspective we no longer have any power um it's very difficult to get Physicians United there's a lot of other groups are very vocal that are united that approach a problem together they they come together to try to solve that problem it's like hurting cats I feel like sometimes with us um we're all very opinionated we're all very educated and it can be a challenge to get us all on the same page but we have relinquished our power uh the respect of all the years of training we've relinquished it and we've relinquished it to various groups who um you know feel that perhaps that level of education is not as necessary as I believe it is to really give comprehensive care it may be to organizations that um control the money which is reimbursement um and you know I'm talking about insurance plans and if I have to say it it's these are groups that are telling us what to do they're not allowing us to practice medicine as we want and there needs to be a s a significant upheaval of that uh we I also think there's a lot of middlemen that are involved in a lot of processes where you have these sort of other companies coming in they need to be paid too so you're sort of driving up the cost of care um you're decreasing access and you know you've got to pay people for their time it is inflation expenses it's very difficult to actually have a practice that runs well and the solution can't be well I just going to plug and play and see one more patient because there's only so much time in a day people deserve to have some uh balance in their lives um and they deserve to get good sleep I can't I sound like a huge dork for emphasizing that again but at the end of the day the single thing that keeps me from feeling burnt out from allowing me to do multiple things um and have you know my creative Outlets with podcasting to still see patients work on continuing medical education is specifically because at the end of the day my nervous system is regulated I truly feel like I'm going to get most of my sleep now I got a puppy because I'm a glutton for punishment but when the puppy is fully trained I will return to having an optimal night of sleep to the best of my abilities I don't sleep great but with consistency and hard work and having a routine it's much better it's much better how do you identify what that that is what a good night's sleep is for you oh God I think it's just how you feel over time um and if there's Su if you have suspicion there's something funky going on get tested you know how many sleep tests I've done I've done a home polysomnogram I've done an in-lab polysomnogram I've said I te love to test home sleep test equipment I'm always curious what people have come up with what's comfortable what should I be using for my patients or considering in the future and all of that data has told me I really don't truly have anything I need serious uh to worry about I don't have any substantial sleep apnea um just a little bit of mild sleep apnea after a couple glasses of wine and then trying a test at a conference I have to admit so now I know I my oral Appliance to use if there's going to be any wine consumption um but other than that you know I'm okay so I do go to bed with that peace of mind that there's not a true medical issue going on right so if you are a you know kind of liaison or commercial insurer especially one that is is working for an employer an employer insurance insurance plan make sure we are covering and encouraging those sleep tests right because yes yes and I do think we need to start approaching it from you know if you live in a certain part of the country there's a lot of testing that may be more expensive that you can get approved that you can't get approved in the Northeast for example why is there that disparity you know if why is it taking so long to get a CPT code for home polygrams if the technology is already there there's a lot of questions there that we need to work toward because the technolog is there let's kind of move Beyond politics concerns about protecting our own market share and do what's better for people in general and for their health see it is interesting because you you talk about how you're worried about kind of losing the Physicians losing the voice and then Physicians and the importance of the education but then you also discuss focusing on the patient and on the outcomes and I think that that's kind of refreshing right because a lot of times you you don't hear someone say one and the other at the same time right usually it's Physicians need a voice everything else can just you know kind of get the Wayside but I like how you emphasize both points well I truly believe that people who go through what we've been through if anybody's not a physician listening to the show it is a unique right of passage the crap that you go through to get that MD or that do degree after your name it's incredibly incredibly challenging to go through um the training the uh sleep deprivation the fear of hurting someone um because you're not doing what you're supposed to be doing um you know it's having not missing that diagnosis finding that zebra even though most of it is going to be a common problem can you find that that unicorn disease process that nobody else can I mean we go into this it's you ask any med student and even though they've come up with a creative answer to take with them on their interview at the end of the day there's something within them that wants to make the world a better place to help others and I think by saying physician voice it's not physician Voice or patients having a more solid physician voice is how we're going to help our patients because we are the ones that know what they need we eat live breathing we've sacrificed our entire 20s some of us and into our 30s our quote youth years we've sacrificed them to help others and that deserves to be recognized I couldn't agree more thank you so much Dr Cole for coming on uh we're gonna have to have you back on again so we can talk even more because there's so many more questions I'd like to ask so thank you so much for your time and I hope we can have you back on again soon thank you so much cole for this opportunity I really appreciate it</p>