American Academy of Sleep Medicine, and International Medical Association of Sleep Medicine Specialists. The Academy is dedicated to improving sleep health and promoting high-quality, patient-centered care through advocacy, education, strategic research, and practice standards. SAFER stands for Sleep Alertness and Fatigue Education in Residency. The learning objectives are to discuss the causes and effects of sleepiness and fatigue, evaluate sleepiness countermeasures, and construct a personal strategy for coping with sleepiness. The program will include basic information about sleep, as well as methods for coping with the unique stresses and strains of medical residencies. Ideally, hospitals would have the manpower and resources to allow all employees to obtain adequate sleep and eliminate fatigue in the workplace. Unfortunately, this is not the case. It is well understood that residents work long hours and non-standard shifts that may make it difficult to obtain adequate regular sleep. In order to minimize the negative effects of sleep loss, it is important for residents to understand the basic regulatory processes of sleep. Residents need to recognize the effects of sleep deprivation and know the times of day of highest risk. When sleep deprivation is unavoidable, it is important to use appropriate management techniques. If problems persist or you feel you may have a sleep disorder, intervention by a board-certified sleep medicine physician should be considered. This presentation will be divided into two sections. First, we'll discuss the effects of sleep loss. We'll review models of sleepiness and fatigue, discuss the effects of inadequate sleep, differentiate objective versus subjective sleepiness, and review the effects of individual differences on the response to sleep deprivation. Management strategies will be reviewed during the second half of the module. We will discuss strategies to maximize sleep opportunities, methods to manage sleep before and after call, and effective countermeasures for reducing sleepiness. Sleepiness and fatigue are nearly universal in medical residents, leading to problems with concentration, poor decision-making, and irritability. But it's not just the total number of hours of sleep you get that influence your level of sleepiness. In the next few slides, we will explore some of the factors that lead to sleepiness and how it can be measured. Several large-scale studies have looked at the effect of extended work duration on interns and its effect on their everyday work. The studies involved more than 2,700 medical interns who completed more than 17,000 monthly Internet surveys. The studies measured percutaneous injuries, motor vehicle crashes, and near crashes. Risk was stratified according to the time of day and according to the presence or absence of a prior night shift. These studies examined the impact on interns of extended work shifts. Day shifts that followed overnight work, referred to as extended shifts, were compared with day shifts that were not preceded by night shifts. Results show that after an extended work shift, an intern's risk of being involved in a motor vehicle crash or a near-miss auto accident was dramatically higher. Furthermore, the risk of percutaneous injuries during day work of an extended shift also was higher than during day work that was not preceded by working overnight. The top two reasons for percutaneous injuries were lack of concentration and tiredness. 64% of interns identified a lack of concentration and 31% of interns mentioned tiredness as a reason for percutaneous injuries. As expected, the risk of percutaneous injuries was doubled during the night shift as compared to the day shift. Medical errors without consequences for patient care were 7.5 times more likely after 5 or more 24-hour shifts per month relative to a month without any 24-hour shifts. Similarly, medical errors that resulted in a preventable, adverse patient outcome were 7 times higher in interns who did 5 or more 24-hour shifts per month as compared to those who did not do any 24-hour shifts. Finally, medical errors that resulted in a patient fatality were 4.1 times higher in those who did 5 or more 24-hour shifts per month as compared to those who did no 24-hour shifts in the month. Current models of sleepiness incorporate a two-process model, Process C and Process S. Process C refers to circadian timing mechanisms that regulate nearly all daily processes, including the length and timing of sleep, levels of sleepiness and cognitive performance, hormone levels, and body temperature. Process C is a wake-promoting drive. This process is usually entrained to a 24-hour cycle of day and night, but it has been shown to continue to cycle even in the absence of time cues. Process S refers to the sleep-wake homeostatic process. The longer you are awake, the more sleepiness you will experience. The sleep effects of this process are modeled as a saturating exponential function during time awake, called sleep pressure, and an exponential that models the dissipation of sleep pressure with sleep. The left side of this figure shows a typical day that begins at 7 a.m. Process S begins to rise from the time you wake up, but is counteracted by the wake drive provided by Process C. As evening approaches, Process C wanes and sleep onset is promoted. The right half of the figure shows a night on call. Process S continues to rise because there is no sleep. In addition to the high sleep pressure from Process S, note that Process C falls as it usually does, reaching a low around 4 a.m. At that time, sleep pressure is high and the waking stimulus of Process C is low, resulting in the greatest level of sleepiness. Body temperature follows this cycle, and many people feel cold when working in the early morning hours. Beginning at 7 a.m., Process C starts to rise, and some people feel more alert around noon after a night on call due to an increase in the wake drive. This second wind does not last, and sleepiness remains high until a night of sleep can be obtained. Even though the alternation between sleep and wakefulness is precisely regulated, humans frequently choose or are required to ignore the homeostatic and circadian-mediated signals for sleep. When the sleep-wake cycle is out of phase with the internal rhythms that are controlled by the circadian clock, for example, during night shift work, a range of effects can occur, including impaired cognitive function and performance, increased fatigue and sleepiness, altered hormonal function, and gastrointestinal complaints. This figure shows performance measured as speed on the psychomotor vigilance task, a simple reaction time test to performance that is sensitive to the effects of sleep loss. PVT speed is shown here as the inverse of reaction time, one over reaction time, as it is affected by time awake, sleep loss represented by the red line, time of day, circadian rhythm represented by the green sinusoidal curve, and time on task, workload represented by the blue ellipses. The study involved 49 young, healthy, non-smoking volunteers with a mean age of 22 years and a range of 18 to 30 years. Participants were deprived of sleep for over 42 hours and tested on the PVT for 10 minutes, at 2-hour intervals during the sleep deprivation period. The PVT can be implemented on a personal computer, personal digital assistant, or smartphone. Stimulus presentations typically occur at 2- to 10-second intervals, with 7- to 8-stimulus presentations each minute, for a total of 70- to 80-stimulus presentations over the 10 minutes of the PVT. There are sufficient responses each minute to look at the effect of time on task, minute by minute, over the 10 minutes. Thus, in these data, we can see the interactions of the effect of time awake, sleep loss, time of day, circadian phase, and time on task, workload. Note that the time on task effect, the decline in speed of performance over the course of the 10-minute PVT, is evident even when the person is well-rested and is amplified by time awake and time of day, circadian rhythm. After 24 hours without sleep. The feeling of sleepiness can result from a variety of factors. You will feel sleepy if you are awake when your circadian rhythm drive is low, even if you have had an adequate amount of sleep. Sleepiness results from not sleeping, but is modulated by the circadian wake drive, with alertness decreasing after 16 hours of continuous wake time. Not getting enough sleep on a chronic basis will accumulate and result in reduced alertness. A slight reduction in the amount of sleep, even as little as an hour a night, will result in an increasing level of sleepiness. Frequent awakenings during sleep periods, such as those caused by a call schedule, disrupt sleep and reduce the level of alertness during wakefulness. Sleep inertia is a period of grogginess with low cognitive performance after waking up. It can extend up to 2 hours after waking up. Finally, sleep disorders, such as obstructive sleep apnea and narcolepsy, are strongly associated with excessive daytime sleepiness. Core body temperature is often used as a marker for Process C. In the group data shown in the bottom graph, temperature reaches a high at about 8 p.m. and then gradually drops until it reaches a low at about 6 a.m. The top graph shows a test of short-term memory, and the middle graph shows tests of cognitive performance and subjective alertness ratings, the feeling of sleepiness. Results indicate that all reach a low at about the same time as the core body temperature low point. The colored areas indicate impaired performance and increased sleepiness around the circadian nadir. One way to understand the effects of sleepiness is to compare sleep loss to alcohol intoxication. The graph on the left shows scores on the psychomotor vigilance task in subjects given increasing doses of alcohol. The highest dose of 0.9 grams per kilogram resulted in a breath ethanol concentration of 0.09%, which exceeds the limit for driving in most states. This dose of alcohol resulted in a worsening of PBT score by 1.35 lapses per test, represented by the red dotted line. The graph on the right shows the results for the same test in subjects who were sleep deprived. The performance decrease equivalent to legal intoxication is reached with only 5 hours of sleep loss, which is the same as staying awake for 21 continuous hours. Eight hours of sleep loss, or one night of missed sleep, results in even more severe performance decrements. Another study examined neurobehavioral responses to varying daily amounts of sleep. The left panel shows average neurobehavioral performance on the psychomotor vigilance task, every night across 14 days for groups on different sleep schedules, with 8 hours of sleep represented with a diamond symbol, 6 hours of sleep represented with white squares, and 4 hours of sleep represented with circles. The solid black squares represent a schedule of 0 hours of sleep across 3 days. Whereas complete sleep deprivation produces profound impairment in performance within the first day, chronically reduced sleep, as experienced by many residents, also leads to impaired performance. Average performance of groups sleeping 6 hours a night for less than 2 weeks is as impaired as after one night of sleep deprivation. The right panel, displaying subjective sleepiness, shows that reported sleepiness does not correspond with measured objective performance in the left panel. It is clear that individuals are poor judges of their level of fatigue-driven impairment. While fatigue is most obvious in the laboratory in the context of total sleep deprivation, combined with adverse circadian phase and high workload, in real-world operations, total sleep deprivation is rare. A much more ubiquitous problem is chronic sleep restriction. Sleep restriction is sleeping less than the optimal 7 or more hours in a 24-hour period, but still getting some sleep over days and weeks. Many adult North Americans are chronically sleep restricted. To provide data for the development of mathematical models predicting performance from sleep-wake history, investigators study the effects of different degrees of sleep restriction over days in a sleep dose response study. It is important to recognize that chronic sleep restriction results in detrimental performance changes. A study involved 68 volunteers who lived for 2 weeks in the laboratory. For the 3 adaptation days at the start of the study, all the volunteers were given an 8-hour sleep opportunity. During the adaptation and baseline phase, the volunteers practiced the experimental tasks. On the 4th day, the experimenters collected baseline data on the experimental tasks. The next 7 days were the experimental phase, in which the 68 volunteers were divided into 4 groups of 16 to 18 volunteers each. One group was allowed a 9-hour sleep opportunity, with 9 hours of time in bed at night. A second group was allowed a 7-hour sleep opportunity. A third group was allowed a 5-hour sleep opportunity. And the fourth group was allowed a 3-hour sleep opportunity, on each of the nights of the experimental phase. All volunteers were awakened at 7 a.m. throughout all phases of the study. Prior to the baseline day, all 4 groups had an 8-hour sleep opportunity the night before, and were, on average, able to obtain 7 hours of actual nighttime sleep. For the 7 days of the experimental phase, volunteers in the 9-hour sleep opportunity group averaged 7.9 hours of sleep each night. Volunteers in the 7-hour group averaged 6.3 hours of sleep each night. Volunteers in the 5-hour group averaged 4.7 hours of sleep each night. And volunteers in the 3-hour group averaged 2.9 hours of sleep each night. During recovery, volunteers in all groups again averaged approximately 7 hours of sleep during their 8-hour sleep opportunity. Thus, the manipulation of sleep times during the experimental phase had the desired effect of creating different levels of sleep restriction across the experimental period. In fact, there was one condition of sleep augmentation and three conditions of sleep restriction. During the experimental phase, shown inside the red box in this figure, it was found that on the psychomotor vigilance task, there was a clear sleep dose-dependent effect on performance. The figure depicts speed on the PVT, so lower speed indicates worse performance. The 9-hour sleep opportunity group, represented by green squares, maintained stable performance across the days of the study. Performance in the 7-hour group, represented by purple triangles, declined over time. Performance in the 5-hour group, represented by blue diamonds, declined more. Finally, performance in the 3-hour group, represented by red circles, declined even more. Both the 5- and 7-hour groups appeared to decline over the first few days and then showed stable, although degraded, performance on the PVT. In contrast, the 3-hour group continued to decline across the 7 days of the experimental interval. Furthermore, none of these three conditions of sleep restriction recovered to baseline levels during the recovery period, shown on the right side of the figure. These findings suggest that with 5 or more hours of time in bed at night, the brain can adjust and will stabilize after a few days, but at a lower level of performance. Chronic sleep restriction is extremely common in the United States. In 2013, a Gallup poll found that 40% of Americans reported that they usually sleep 6 hours or less at night, which is largely unchanged from Gallup polls in the 1990s and 2000s. Gallup poll data indicate that Americans currently average 6.8 hours of sleep at night, which is down more than an hour from 1942. High levels of sleep restriction among U.S. adults are also illustrated by data collected by the CDC through the National Health Interview Survey. This figure displays the percent distribution of hours of sleep in a 24-hour period, based on data collected from 2008 to 2010. Results show that more than 28% of men and women report sleeping, on average, for 6 hours or less in a 24-hour period. Many individuals are in a state of chronic sleep restriction during the week and then attempt to catch up on sleep over the weekend. Professions that have high work demands and irregular schedules frequently are associated with even shorter sleep durations. The lapses during tests using the psychomotor vigilance task are thought to be due to microsleeps, which are episodes that can be measured using EEG monitoring. The errors of omission are accompanied by errors of commission and slowed responses in self-paced tests. Sleepiness has profound effects on memory tests and learning. There is substantial evidence to show that sleep is important for long-term storage of new memories, and that this is especially true for motor skills. Creative thinking and judgment also are impaired by sleep loss. Magnetic resonance imaging studies have confirmed the negative effects of sleep loss. Sleep loss has dramatic effects on brain activity within the prefrontal cortex, an area of the brain that mediates higher-order cognitive processes, such as judgment and decision-making. Sleep deprivation adversely affects the prefrontal cortex' executive attention areas and working memory abilities. People are poor judges of their level of sleepiness during prolonged sleep restriction, which means you may overestimate your ability to perform when you are not well-rested. The blue line in this graph shows progressive worsening of scores on tests using the psychomotor vigilance task in subjects allowed only four hours of sleep per night. The same subjects were asked to rate their sleepiness using the Stanford Sleepiness Scale, a subjective measure on the propensity to fall asleep. After a few days of sleep restriction, the subjective measure reaches a plateau at a relatively low level, on a 0 to 7 scale. One of the most dangerous aspects of sleep restriction is that, like alcohol intoxication, it is difficult for people to judge their level of impairment. Therefore, after nights on call or nights with frequent pages, medical residents should be aware that performance may be impaired to some degree. Factors to consider include averaging less than 6 hours of sleep per night, being awake more than 16 hours, and having frequent awakenings during sleep. Do medical schools attract people who need less sleep? Do residents learn over time to perform at a high level even when sleep-deprived? Or does the stress of the medical environment counteract sleepiness? The answer to all of these questions is no. Sleeping until noon when you are not on call or spending most of your time off sleeping are good indicators that you are not immune to the effects of sleep deprivation, sleep restriction, and fragmented sleep. Although you cannot adjust to chronic sleep restriction or sleep deprivation, some individuals appear more resilient on measures of performance compared to others for whom performance deteriorates more rapidly. This graph depicts neurobehavioral responses to 2 episodes of 36 hours of total sleep deprivation. The x-axis data are shown for the psychomotor vigilance task, and the letters on the x-axis indicate individual study participants. Diamonds show one response to a bout of sleep deprivation, and the squares show the same individual's response to another bout of sleep deprivation. Because the squares and diamonds tend to be close together, it is clear that the people who performed poorly the first time they were exposed to sleep deprivation also performed poorly the second time. The color panels reveal that responses to sleep deprivation differed substantially between different subjects, while the overall graph shows that responses were relatively stable within individual subjects between the two exposures to sleep deprivation. It is important to note, however, that even the most resilient people are affected during vulnerable periods. Factors underlining and accounting for these differences in response to sleep loss are not entirely understood and continue to be investigated. While you may have little control over your work schedule, and sleep restriction and sleep deprivation during medical residency may be unavoidable, there are several strategies you can use to reduce the risk that your performance will be impaired by fatigue. Strategies for reducing your fatigue risk are broken into two categories, increasing sleep and managing alertness. Strategy 1 involves getting as much sleep as you need, which includes managing sleep disorders, planning sleep opportunities, optimizing your sleep environment, and avoiding substances that can decrease or hinder sleep. Residents are not immune to sleep disorders. The combination of a sleep disorder and a work schedule that causes sleep deprivation can add up to a dangerous level of sleepiness. Your opportunities for sleep are already challenged by your work and training schedule, so the presence of a sleep disorder undermines the quality of the sleep that you are able to get. For example, if you snore, stop breathing during sleep, and have a neck size greater than 17 inches, you are at risk for obstructive sleep apnea. Treatment with nasal continuous positive airway pressure therapy often results in a marked decrease of daytime sleepiness. Sleep disorders such as sleep apnea, restless leg syndrome, and narcolepsy can occur in anyone and they are associated with increased sleepiness. Insomnia can result in missed sleep opportunities. Excessive treatments are available for all of these sleep disorders. Left untreated, sleep disruption will impact your alertness and your performance. Treatment of sleep disorders that cause excessive daytime sleepiness restores sleep quality and daytime alertness. It is important to be evaluated by a board-certified sleep medicine physician if you suspect that you may have a sleep disorder. Sleep medicine is a medical subspecialty recognized by the American Board of Medical Specialties. Board certification in sleep medicine can be obtained through several member boards of the ABMS, Internal Medicine, Psychiatric and Neurology, Pediatrics, Otolaryngology, Family Medicine, and Anesthesiology. Studies have shown that the effects of sleep loss and restriction are worse if you are already sleep deprived. When you know you will have reduced opportunity to sleep, you should plan in advance to have a night or two of adequate sleep. Try to sleep as much as possible on the day after call, but keep in mind that the circadian cycle, process C, may prevent you from falling asleep at midday. In general, maximize your sleep periods. Sleep is the most effective way to reverse sleepiness. As you plan your sleep opportunities, consider times that you are most, and least, likely to fall asleep. For most people, falling asleep in the late morning and in the early evening will be more challenging than during the nights and in the late afternoon. If you can't fall asleep at a particular time of day, get out of bed and try again a few hours later. If you find your post-night shift sleep episodes to be shorter than needed, consider taking a nap later in the day. The total amount of sleep you get will help sustain your alertness and performance. Spend some time optimizing your sleep environment, wherever it may be. This can have a great impact on the quality of your sleep. Steps to optimize your sleep environment should include noise and light reduction, especially for times when you need to sleep during the day. Because your schedule will be variable, it is important to tell your family and friends when you need protected sleep time. One way to do this is to make use of social media, tweet that you are going to sleep, or change your Facebook status to say, recharging my batteries. You should also develop the healthy habits of good sleep hygiene. This includes setting aside time to relax and creating soothing pre-sleep rituals, such as taking a warm bath or reading a book. If possible, use the bedroom only for sleep to avoid the development of negative associations. As part of your sleep strategy, you also should avoid substances that can alter your sleep or hinder your ability to fall and stay asleep. Sleep-deprived individuals often have the mistaken belief that caffeine and other over-the-counter stimulants have no effect on their sleep. In reality, many stimulants have a long half-life and have been shown to result in frequent, brief awakenings and reduced amount of certain sleep stages. Caffeine and other stimulants are best avoided 8 to 10 hours prior to bedtime. Alcohol may reduce the time it takes to fall asleep, however, it also has negative effects on the structure of the sleep cycle, resulting in awakenings and reducing the restorative effects of sleep. Sleep is the best countermeasure for sleepiness, and naps can replace some of the missed sleep during times of sleep loss or sleep restriction. In addition, several studies have shown that naps taken in advance of a work period can help prevent the effects of sleep deprivation. Getting a nap before the work shift starts can result in decreased sleepiness during the shift. Naps are periods of sleep between 10 and 120 minutes, which are typically secondary to the primary sleep episode. There is a dose-response relationship between the length of the nap and the beneficial effects on performance. The longer the nap, the better. However, even brief naps can have a beneficial effect. When the alerting effects of the circadian cycle, Process C, are low, naps will be less fragmented and more restful than those taken when Process C is high. This means that a morning or late afternoon nap will be better than a mid-afternoon nap. Sleep periods, including naps, can result in sleep inertia, which involves feelings of sleepiness that persist for a time after waking up. Most residents have stories of answering a page during the night and responding nonsensically, often with no memory of the event in the morning. It is important to allow sufficient time to wake up after a nap before engaging in mentally demanding activities. For longer naps of more than 60 minutes, especially those occurring around the circadian temperature minimum near 5 a.m., sleep inertia will be more profound and will last longer. Sleep inertia is generally less severe following shorter naps. There are a number of strategies that have been demonstrated to help sustain alertness levels. These include the appropriate use of caffeine, light exposure, breaks, and sometimes prescription stimulants. When used in a controlled way, caffeine can help reduce the effects of sleep loss and sleep restriction. The alerting effects of caffeine usually last 4 to 5 hours, whereas the sleep-disrupting effects can last much longer. For example, 400 mg of caffeine administered 6 hours prior to bedtime can reduce total sleep time by about 40 minutes. Therefore, caffeine should be used judiciously. A variety of products with varying amounts of caffeine are sold. It is important to check labels to be sure you are getting an effective amount and to be aware of the effect of caffeine on your own physiology. Caffeine has significant side effects and should be used only when needed. Exposure to bright indoor light can limit subjective levels of sleepiness and reduce the degradation of alertness. Although bright light can improve alertness, the pattern of light exposure will also affect the alignment of the circadian clock. A study of health care workers who were on permanent night shifts found significant differences in patterns of light exposure in those who demonstrated circadian adaptation of melatonin secretion versus those who did not adapt to the work schedule. Keep in mind that bright light exposure at night can be alerting, but it also will suppress nocturnal melatonin levels, just as it may shift the circadian clock undesirably. Exposure to outdoor bright light following a night shift also may be alerting, which is undesirable when you want to fall asleep in the morning. Short breaks may not be as effective as taking a nap, but they can play some role in maintaining alertness when options are limited. One study measured the effect of short activity breaks on mean sleep latency, which is the time it takes to fall asleep. Subjects were asked to watch television or take a 5-minute walk prior to taking a nap. Subjects fell asleep more quickly after watching television than after taking a brief walk, demonstrating the alerting effects of breaks. This alerting effect is, in part, due to disengagement from the current task and postural changes. Prescription stimulants have been shown to be effective in reducing both the objective and subjective effects of sleep loss, but they may cause side effects. If you choose to seek prescription stimulants, it is essential that you obtain them from your physician, who will provide appropriate advice and oversight. As you develop your own plan for coping with fatigue during residency, it is important to monitor objective markers of vulnerability. Due to variations in the circadian cycle, process C, you will be less alert between midnight and 6 a.m. Extending wakefulness beyond 16 hours will quickly result in performance decrements. Sleep restriction, even as little as an hour or two per night, will produce a cumulative sleep death that impairs performance. Remember that you will be a poor judge of sleep-related impairment. Check your work carefully when you are at risk. And if necessary, ask a colleague or supervisor for additional support. Your plan for coping with sleep loss during residency should include Getting as much sleep as you need to feel fully restored. Discuss any possible sleep disorders with your personal physician. Optimize your sleep environment. And use naps to supplement your main sleep episodes. Sustain your alertness with mindful use of caffeine and short breaks that include activity. Create a customized strategy to get the best sleep and sustain your alertness. This may include taking a small dose of caffeine before a short nap to limit the likelihood of sleep inertia, or wearing sunglasses to avoid exposure to alerting bright light on the ride home from your night shift. As a medical resident, you are more than likely feeling the impact that sleep can have on every aspect of your physical health and mental well-being. Sleep plays a vital role in maintaining proper health and safety by renewing our mental and physical health each day. However, about 70 million Americans suffer from a sleep problem, and nearly 60 percent have a chronic sleep disease. Our nation's sleep problem is so widespread that the CDC has called insufficient sleep a public health epidemic. Left untreated, a sleep disease increases the risk of chronic medical problems such as obesity, heart disease, type 2 diabetes, depression, and stroke. These health risks are reduced through effective behavioral, pharmacological, and medical treatments, which improve quality of life by restoring healthy sleep and maximizing daytime alertness. In a nation where millions of people are struggling to sleep well at night and stay awake during the day, the need for board-certified sleep medicine physicians is great. A sleep specialist is a physician who is board-certified in the subspecialty of sleep medicine, specializing in the clinical assessments, physiological testing, diagnosis, management, and prevention of sleep disorders. Treating patients of all ages who have a sleep disease involves an intriguing blend of physiology, neurology, and psychiatry. Sleep medicine is an exciting, challenging, and integrative field, covering much of the human body, including the pulmonary, endocrine, respiratory, muscular, and nervous systems. This diversity gives sleep specialists the flexibility to pursue wide-ranging interests within the field of sleep medicine. The majority of sleep medicine physicians specialize in internal medicine, psychiatry, and neurology. However, other specialties that can be a pathway to entering a fellowship and practicing sleep medicine are family medicine, otolaryngology, pediatrics, and anesthesiology. Following a residency program and a specialty related to sleep, physicians interested in sleep medicine participate in a one-year sleep medicine fellowship. A sleep medicine fellowship provides thorough clinical training, as well as research experience in the field of sleep medicine. During the program, fellows learn about the normal mechanisms of sleep physiology and the pathophysiology of sleep disorders. Fellows also gain competence in the diagnosis and treatment of sleep disorders and learn to interpret data gathered in the sleep disorder center. The fellowship incorporates aspects of internal medicine, pediatrics, psychiatry, neurology, surgery, epidemiology, and basic science. The job of a sleep specialist is professionally and personally rewarding, allowing you to improve public health and safety by treating people who have sleep disorders. The multidisciplinary nature of sleep is professionally challenging and allows you to assist in the achievement of optimal health for your patients. For more information on choosing sleep medicine as a career path, contact the American Academy of Sleep Medicine.

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