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Perspectives on Sleep Cures

In medicine, we usually confront two types of illness, one for which there are treatments and cures that fully resolve the condition and one for which no cures are available. In the latter, we spend our effort caring for the patient on a long-term basis to help them function as best they can with their chronic conditions.

This division is important, because it explains a great deal about how physicians choose their career paths in medicine. To oversimplify, many surgeons enjoy the "cut it and cure it" model, because they gain more satisfaction from seeing the patient over a shorter period of time and helping them to resolve an issue quickly, for example, cutting out

an inflamed appendix. An internist, on the other hand, must cope with many conditions such as diabetes, hypertension, heart disease, and asthma. Most of these patients require regular followup appointments and medication adjustments to best manage their conditions and enhance their quality of life.

In more than a quarter century of travels through the medical landscape, I've undergone my own transitions in starting out as someone more interested in managing chronic care, as I trained as an internist. Then, I spent a decade working in the field of emergency medicine, where time is always of the essence, and the patient often walks or is carried in and out of your life in a matter of hours. Shortly after entering emergency medicine, I was introduced to sleep medicine, where I saw how this field offered opportunies to do both: cure patients or provide them with chronic care. You see, sleep disorders are frequently long-term problems, but the treatment of sleep disorders can yield a state of continuing success, not often seen in other areas of medicine.

The most remarkable example of continuing success occurs in patients with sleep-disordered breathing who successfully use positive airway pressure (PAP) therapy. The amazing thing is that whenever the patient uses the PAP device, they are "cured" of their condition on that particular night of sleep. But, what's even more astonishing to doctors is to see the results in that person after they have used PAP therapy regularly for several months. The individual looks healthier and younger, and they often interact with more energy and alertness. It appears as if they have been "cured" of the sleep-disordered breathing. But, if they don't use the mask the next night or for several nights or weeks, it soon becomes apparent that they have reverted to their previous exhausted state.

So, should we call this a cure or not? The condition is always there, but it responds dramatically to treatment whenever you use the treatment. In our field, even though we know that PAP therapy works mini-miracles, we now are realizing that many of our sleep breathing patients need much more regular followup to insure that they attain this level of "continuing success" or "cure." So, I think it's fair to say that sleep disorders do represent chronic conditions, but in the case of sleep breathing, we have a treatment that yields results far superior than what is typically seen in managing other chronic conditions in medicine.

This power to help patients resolve their sleep problems is very invigorating, rewarding and motivating for sleep professionals. However, there is one downside that often is not talked or written about. We must also engage with those patients who could have made dramatic sleep health gains but who choose for various reasons not to use their PAP treatment device. When these patients also suffer from diabetes, hypertension, and heart disease, three conditions which by the way appear to improve with regular PAP therapy, it is very discouraging to view the deterioratoin in the patient. It's not that PAP treatment of sleep breathing will solve all their medical conditions, but it plays a big enough role to make a difference in their overall health.

So, just as it is an incredible "high" to see someone make extraordinary health gains with PAP therapy, it is a demoralizing "low" to see someone reject or dismiss a treatment that just might save his or her life!