What is “The Doctor-Patient, Knowledge Gradient” and wh does it matter?

In years past we went to the doctors’ in the belief that we would be treated, that is “cured” of our disorder or illness. Societal norms have changed. As our diseases are channelled into specific areas, often alas for the convenience, profit, administrative benefit, or their investigation and treatment become more specialized or expensive, many of us have come to realize the need for self advocacy. Is this an issue when it comes to sleep problems?

Sleep is not only a case in point but brings with it other complications. It is a relatively new field of investigation, generally poorly understood by doctors who are inadequately trained to deal with the problems they will face in practice. This shortcoming presents as an apparent disinterest in an area of medicine which in turn carries with it, a profound affect on other areas of health, both physical and mental.

Most people have experienced some sleep disorder or another, be-it insomnia, restless legs, snoring, obstructive sleep apnea or jet-lag and/or circadian rhythm disorders. Most of those will have investigated their problem if recognized. It’s easy to spend a few hours reading books, magazines or on the internet only to realize that a solution is not necessarily as readily available or as easy as it seems.

Many investigations and studies into undergraduate medical syllabuses show teaching and training to provide just a few hours (4) in “sleep medicine”. The reader will notice that the doctor and the patient may often be provided or seek a similar time in the appreciation of sleep disorders and dysfunction. As much as the medical student is provided a few ‘structured’ hours, the patient is certainly highly motivated as it is their own problem, or one of a family member and/or someone they care about.

Physicians suffer a lack of undergraduate sleep medicine training

While this “knowledge gradient” is alas not unique, it does encroach on a subject of extreme importance in society and the result is poor recognition, understanding, diagnosis and treatment of sleep disorders in society as a whole. The medical fraternity are not in a hurry to go back to school or undertake significant study time, nor are the administrative and financial bodies who seek to simplify and economize keen to pay out more, regardless of savings in the future. Suddenly finding a disease that affects so many, so greatly and that it was there under our noses for so long does not sit well with any of us.

What perhaps complicates this further is the views already held for as Einstein was claimed to have said,”the greatest hurdle to new learning is old learning’. We have to unlearn what we’ve been taught and believe in order to rebuild the facts as they are presently known, accurately. A paradigm shift if you will. These views and beliefs held currently may reflect societal and cultural beliefs rather than scientific knowledge. They may also be driven by commercial interest and special interest groups such as pharmaceutical companies and the CPAP industry,

In 2017 alone – an estimated 70 million Americans had insomnia, and 43 million suffered from obstructive sleep apnea (OSA), mostly undiagnosed. As obesity rates remain high, this problem is not likely to decrease. Therefore, there is ample room for future growth of CPAP (mask, hose and bedside pump) devices presently worth 4 Billion, sleep studies (4.3 Billion), over-the-counter and prescription medications (1.5 Billion) and other services.These together have been estimated to exceed $28.6 billion in 2017 with the market growing by 3.3%, to 2023, 4.7% average annual growth is forecast – which in my opinion is a vast underestimate.

Perhaps the most obvious shortcoming is a lack of reference. What is good sleep? The doctor and the patient may have very different ideas and definition of this. Few solid definitions exist as it is clear that within reason, an individual’s definition reflects his or her experience (as does that of the doctor). We need a better understanding of the subject in order to provide both general and specific individual norms and therefore care.

A very simple example is “how long does it take to fall asleep?” The majority of those who almost wake themselves up when their head hits the pillow are convinced that’s a good sign, while those that take half an hour often consider themselves insomniacs. Add to that the fact that we usually can’t estimate such things accurately and the need for better guidelines becomes clear. Incidentally 15-30 minutes to fall asleep is still considered both physiologically and commonly usual.

The above observations paint a clear picture;

A. We need better awareness and understanding of an aspect of all of our lives (sleep) because it has a profound effect on daytime health and functioning. We need improvement at the Governmental, professional, societal, community, family and individual levels.Such change is likely to come from the individual level.

B. Peer reviewed studies repeatedly indicate that with an inadequate teaching and training syllabus, the need to accept that our doctors sometimes know little more than we do and therefore unable to objectively solve our problems is required by us and the profession alike.

C. We must alas, stay ‘healthily sceptical’ about people and clinics who are in (and out) of the medical system as they may have financial or other primary motivators. Equally we can’t shoot ourselves in the foot and go without what we genuinely need based on a mild paranoia on our part. We should still seek for honesty and integrity in our own true needs.

Awareness is key – it is the first step toward bettering our health, the health of those we care about and the system itself.

Dr. Stephen Bray

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