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“There Are No Registered Sleep Experts in Private Practice“

Sleep Medicine: “There Are No Registered Sleep Experts in Private Practice“


Photo: Ingo Fietze

Doctor Ingo Fietze; © private

Sleep makes up a third of our life and thus is a very important part of us. Even so, we foster a paradoxical relationship with it. For many people the natural need for sufficient sleep is either a forced recovery or a longed-for desire, usually in the knowledge that a life of constant sleep deprivation is unhealthy. spoke with Doctor Ingo Fietze, Department Head at the Center for Internal Medicine at the Charité Hospital in Berlin and Director of the Interdisciplinary Center of Sleep Medicine, on the shadowy existence of sleep, its ambivalent appreciation and relevance. Doctor Fietze, over the past few years sleep medicine and sleep research has attracted the spotlight more and more. Why is that?

Ingo Fietze: That’s because, physicians of various speciality areas, internal specialists, ENT physicians, neurologists, psychiatrists, pediatricians, general practitioners and family doctors are increasingly interested in this interdisciplinary field. To an increasing degree we are succeeding in introducing sleep medicine and new insights of sleep research to the public. Clinical guidelines have been developed for the medical community, which render a standard, qualitative action possible. Sleep medicine as an interdisciplinary profession increasingly integrates fields where it thus far only played a minor role, like in cardiology or anesthesia. There has also been success in establishing sleep medicine into collegiate studies to a certain extent. However, there are currently only a few universities which offer studies about “sleep”. The fact that sleep is a popular topic can be seen in the fact that not just affected people, but also “good sleepers” are interested in it. Thanks to an interested and well informed public, sleep can finally step out of its shadowy existence. How many people in Germany are suffering from sleep disorders or sleep-related breathing dysfunctions, also called sleep apnea syndrome?

Fietze: In Germany thus far there are no real epidemiological studies. This applies to sleep related breathing dysfunctions as well as insomnia. This is a drawback. The numbers for sleep disorders mostly come from the US. There is a population-based study of relatively high prevalence in Germany on the so-called “restless leg syndrome“– almost five percent of the total population suffer from restless legs. The recently published health report from 2010 by the German Employee Health Insurance fund DAK, with its focus on sleep disorders, also noticed a high prevalence. It confirmed the data, which is already known from the US: Every tenth respondent suffers from a sleep disturbance and four percent of interviewees have a severe chronic sleep disorder that requires treatment. These are indeed alarming numbers and support the importance and need for adequate sleep medical care in Germany. Despite the increased attention, the importance of sleep and research of sleep has not been completely established in western industrial nations. But sleep issues by now have become a common national disease. How does that add up?

Fietze: It does add up, because sleep research is still an emerging field. But despite some restrictions in health care politics, we still managed to establish sleep laboratories all over Germany. The care is very good. What we don‘t have – and it is currently not something that is on the horizon – is a compensation mode for colleagues who work in outpatient sleep medical care, so-called sleep consultations in special outpatient clinics. We are also missing a coherent service concept from health insurance providers in this area. Since many people don’t know much about “sleep” yet and their family doctor is not familiar with the health care structure, the potentially affected person also does not know who to turn to. More precisely: If somebody has a sleep issue, he/she maybe reads popular science articles and gets informed via the Internet. He rightly has a tough time finding a sleep expert as a contact person in his vicinity, because there are no registered sleep experts in private practice yet. On the one hand we raise awareness and there are more and more people seeking medical advice. Yet on the other hand, we just have the numerous sleep laboratories for night-time readings and only a few easy-to-reach counselors. Can the reservation in health care politics as it pertains to sleep disorders perhaps be the result of the still existing lack of knowledge in clinical diagnostics and treatment as well as effective drugs?

Fietze: I think it basically comes down to two things: For starters, nobody wants to trigger an avalanche of illnesses. If every third person in Germany sleeps poorly – who is supposed to pay for that? After all, sleeping poorly does not immediately mean insomnia. We have a different approach and say: With the methods available to us today, we are able to make an informed diagnosis and filter out many potentially affected people, who definitely belong in our hands. Thus we have to select who is really sick and who needs to be treated.

The other thing is that we lack prevention programs. Many people, who don’t have a sleep disorder that requires treatment at the moment, actually belong in preventive, informative and advisory programs. Currently it is very hard to get into aided prevention programs. In recent years, the focus here was clearly on the subjects of nutrition and fitness. Yet as a sleep health professional you wish for the trio-”nutrition, fitness and sleep/awake well-being“. We currently would also like to be perceived preventatively.

Photo: Sleeping Woman

With the right therapy many sleep-illnesses can be cured; © Hermera Some media recently reported that many sleep laboratories are teetering on the brink of financial collapse. What is behind all this?

Fietze: Let me put it this way: We have a nationwide network of sleep laboratories. They are predominantly located in hospitals, where inpatients are cared for around-the-clock. This care has been jeopardized in recent years, because not everyone is permitted inside an inpatient sleep laboratory anymore. Thus many inpatient sleep laboratories have had to cut back on their carrying capacity or even close down. But remember: There are many affected people out there. On the other hand, especially patients with sleep related breathing disorders, this meaning sleep apnea, are no longer supposed to be examined in inpatient, but outpatient sleep laboratories. These are sleep laboratories, which bill their services through an “other non-inpatient account”. Some of these outpatient sleep laboratories have established themselves in recent years. In Germany it worked very well like this for three to five years, particularly since the reimbursement was adequate.

Now this adequate reimbursement partially has been reduced by about a third. There is considerably less money now. Many professional groups cannot bill these regionally varying services on an outpatient basis – particularly neurologists and psychiatrists are affected by this. This development in turn leads to outpatient sleep laboratories having to close. The money which health insurance providers currently are offering for outpatient sleep medicine since July 1, 2010 – before this date it was separately budgeted – does not allow for a continuation of qualitative care. This is why now among other things, a memorandum by the mainly pneumological sleep laboratories was initiated. It states, that the number of services needs to be reduced, or else the situation is not manageable. With mostly reduced inpatient possibilities, these cut-backs in the outpatient area are not acceptable. And this is the topic of current discussions. As a professional association we have written to politicians and the health insurance companies and have been heard nationwide since that time. Nationwide and also locally there are now efforts to find a good solution.

Generally speaking, everybody understands that we need to save money. We can also support this by not treating more and more patients, but rather by focusing on more effective therapies. This way we can accommodate each other. Sleep also has an economical influence – it supposedly increases productivity. In the US, employers often setup so-called “nap-rooms“. In China, the afternoon nap, “Xeu-Xi“, is a fixed basic right. Does Germany have some catching up to do here?

Fietze: We have definitely some catching-up to do when it comes to sleep and labor productivity. Every shift worker or everybody who deals with the organization of shift work knows that this has to do with sleep/awake well-being. Many people know that the process can be significantly improved. However, we are not able to do anything about shift work, since it will continue to increase. And so we have to determine how we can deal with sleep/awake well being and find alternatives. The best way not to take sleeping pills during the day or vice versa or drink three pitchers of coffee at night, is if you carefully think about the individual needs and the objective challenges of the labor situation and introduce an adapted reasonable sleep/awake regime. Among other things, it would be great to adopt a “nap culture“in companies that deal with shift work.

Currently we have finished a shift work project with “Berlin HealthCapital“ in Berlin and Brandenburg, which was conducted with several shift working companies. In this project, we researched whether the state of sleep and shift work is indeed really bad and in addition, whether this has anything to do with the organization of the company. For instance, we want to find out any connections between “sleep disorders and stress at work“, “sleep disorders and noise“ and ”sleep disorders and identifying with your job“. Are there already actual studies or early findings on this subject?

Fietze: Based on the Berlin project, companies will now install a relaxation room. The first of its kind was set up with the aid of climate engineers, acousticians, light experts, architects and sleep health professionals for ballet dancers of the Berlin State Ballet (Staatsballett Berlin). Prior to that, we showed in a study, that this occupation group sleeps fitful and poorly. Now the room is finished and is well used. However, a follow-up study is still missing. There is still a lot of action. A look into the future: Will sleep medicine be able to establish itself in the area of health prevention?

Fietze: Sleep medicine has not established itself yet, because it is not relevant what we do, but actually because we are still missing the critical mass, the overall physician community and the lobby for this specific field. This still requires more time. Even so, I believe that in five years at the latest sleep medicine will play an important role in prevention and will continue to gain importance in clinical medicine. I think the topic of sleep already belongs in schools and in part in professional training. The topic needs to be communicated more expansively, to prevent an increasing avalanche of sick people.

From an economical point of view it does not just make sense, but it is urgently necessary, that we treat sleep apnea for example and people therefore live a longer and healthier life, or that we treat people with sleep disorders and they then become fit for work again. Or that we treat people, who get tired easily, so in turn fewer accidents happen on the road. These are all logical reasons for the necessity of our actions. Unfortunately, such long term approaches are often met with little interest, particularly if urgent economical necessities exist.

The interview was conducted by Diana Posth and translated by Elena O’Meara.


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