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Curious as to what it takes to become a certified sleep doc?
DocWils, Thanks for all you do here.

You must appreciate that this is a subset of of a larger group that probably gets good service from their providers. We who show up here haven't been so lucky and as such may seem more distrustful and a tad more cynical than the larger group.

I'm sure you realized that but I just wanted to put it in writing so we don't offend when sometimes painting with a broad brush. You are a great asset to this forum and your advice is well received. The remarks here are never meant to reflect poorly on the field as a whole but just on our narrow experiences. After all, that's what's important to us.

Respectfully yours, Dude
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Dude, I am not offended in the least, but I do want to help people to understand when I can.

I, too, have been through the mill with apnoea, and pretty much had to train myself to understand the problem since the sleep lab here was not nearly as helpful as I would have wished them to be (that said, they were as helpful as they could have been given their time constraints and their lack of bed-side manners, something that I am a b**t*rd on with my charges in training them right - all hospital doctors should aspire to be country doctors, IMHO, but those days are gone) and I joined here also to get help and share and vent.

The difference is that I am a trained physician and I understand things from a different perspective than most of the board members, and of course, am privy to the "special knowledge" of medicine, meaning I get the lingo a lot easier and know how it all relates, which has nothing to do with intelligence and every thing to do with having gone to med school, spent ten years interning, residencing, training in my speciality, and then decades of practice (but never made perfect) - in short, I have a huge advantage over most of the members here in that respect - no special brains or anything else. Show me a car engine and I will bow to any mechanic out of school, repair electronics? Not me. No smarter than the average bear there either. Sleep medicine? I could read and understand things more easily than a lot of members here, again not because I am smarter, but because I have the training to understand the language used and I already know how all the parts fit. Also, it ain't rocket science, at least not from a medical perspective - on the other hand, it IS starting to throw up amazing things, and I have started encouraging students to spend more time doing sleep related research because of it. What it is turning up is that we are an amazing beast, and there is no part of our lives that are not interrelated in a subtle and amazing way - sleep is just as important as any other waking aspect of our lives and has a far greater impact on our life quality than we previously suspected. It is, in fact, an exciting time to be specialising in sleep disorders. And you don't have to stand for fifteen hours at a surgical table. Nice.....
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BTW, I often take the horror stories I hear here and relate them to my charges, to impress on them how easily they can go wrong in their field. The problem is that, of course, thanks to how the insurance system works, medicine is becoming increasingly impersonal, hospital doctors never get to see patients more than once in they are in the general insurance categories, so they are never given a chance to build up a relationship with patients and have to rely on whatever the charts tell them (one reason why a full a thorough history is vital) and because of this, bed side manner falls by the wayside - I try to impress on them that it is the most important thing, as is clear, plain speaking, since you are there to listen and help them understand, but if you see a hundred people a day in a clinic, there is so little time and these poor buggers forget the listening (and there is the floor boss (for want for a better word in English, we used to call her Matron when I did my internship in England, I forget the American term) who is nagging you that patients are piling up and waiting up to an hour or more, etc.), so, no matter how often I tell them how not to behave, they fall into it under the pressure of work, alas. Okay, that was a big run-on sentence. But it sort of conveys what it is like in a clinic, I think.

Still, coming here is always a reminder for me what I should and should not do. I don't mind the venting, but I do try to offer perspective within that.
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This is a curious thread...pun intended...

The original poster had posted this topic on the other board and there was and still is a "conversation" going on there...

The question was whether we are curious re training of sleep docs...Sure I am.

But the conversation has veered to the inevitable pros and cons of our respective experiences on our journey of discovery that is sleep apnea in all it's lovely forms and variations.

Writing totally personally, from my perspective I have been frustrated and disappointed in the quality of care that I have received from the two sleep docs and the Sleep techs that I have encountered.

Now that is not entirely their fault. I have a complex set of symptoms that are not easily dealt with, and there is the issue. As DocWills has pointed out, as have many posters in other threads, there is little time for complex situations. The patient, ie. Storywizard, has to then advocate for and educate himself. He has to argue gently and forcefully for alternative view points, that may not be in synch with those of the highly trained professionals, with little time, that we have to deal with.

My first Doc asked me angrily why I wanted a titration study?

My second Doc's only recourse after my "failure" at CPAP therapy was a dental device.

Neither gentleman was interested in what a titration study would show, how my sleep actually was, or indeed how I felt physically or mentally.

Again, these are doctors with little time for complex patients.

I am fortunate to have found a respirologist who will go over my titration report with me, and actually takes the time to listen and converse with me. It only takes a few minutes, and I am very grateful.

I know there must be sleep docs in my area who are as diligent as the respirologist, I hope one day to meet them.


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(06-26-2015, 05:15 PM)tedburnsIII Wrote: Yeah, I posted the link because experience on various apnea forums leads me to conclude that board-certified sleep doctors are not accorded the respect and credibility they deserve. Ignorant people have no idea what they must go through to be certiifed, and they should be 'educated' about it.

Maybe their education deserves respect and credibility, but experience shows that many certified "sleep physicians" are practicing assembly line medicine. Look at how many people end up with brick CPAP machines.

As for the certification requirements, it looks like basically 12 months of "apprenticeship" in "clinical sleep medicine fellowship training." If the doctors he's working for are assembly line doctors, he's probably going to be one, too.

Maybe the odds of getting a good sleep specialist is better than I think they are, but they don't seem very good from the experience of apnea patients I've talked to.
Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
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(06-27-2015, 05:42 PM)DocWils Wrote: And yes, we do tell patients that the insurance won't pay for something - we are obliged to, in fact, by law - they are in the US too, so far as I know (not allowed to sucker you into expensive procedures that you are left holding the can for, without your express consent).

I don't think it's required in the US. However, most offices give you a big stack of papers to sign on your first visit. Somewhere in there is a disclaimer that some procedures or tests may not be covered by your insurance.

Occasionally, I've been warned that a particular procedure might not be covered. Sometimes not and I've been royally screwed something like 4X the insurance amount.

It's gotten very common to get that warning on many procedures, even when they are actually covered. i.e. the warning has been watered down to the point where it's meaningless.

To give some credit to the doctor's offices, it is often hard for them to get a straight story from the insurance company.
Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
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(06-29-2015, 03:53 AM)archangle Wrote: To give some credit to the doctor's offices, it is often hard for them to get a straight story from the insurance company.

No kiddin'! Do you want to get an idea of the headache it is for most doctors to deal with the myriad of insurance rules and coverages, all inconsistent? At least in Switzerland, there are clear guidelines and rules to basic level coverage, which the Us doesn't have. But after the basic set, it is anyone's guess what the insurance will shell out for or not - it is a nightmare.

My advice to all my patients - never get sick. It is cheaper for you and less of an administrative headache for me.
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(06-27-2015, 03:49 PM)Mark Douglas Wrote: Current Doc B listened to my recitation of woes, looked at my skin, asked do I have trouble swallowing, and sent me for an ultrasound. After results tells me I have had Hashimoto's and have had for a minimum of 20 yrs and quite possibly 30 yrs. About how long I had been wandering in the desert of incompetent health care...

It's amazing how often a sharp eye and a keen mind finds the medical problems that have been missed for years just from simple observations.

I have decided that I've suffered from gluten related problems for years. GP, gastroenterologist, and EENT never mentioned gluten, but I finally figured it out myself by trying gluten free.

Sometime after I figured that out, I was getting a routine skin exam and asked my dermatologist about some little red spots I have on lots of the pores on my skin. He said that he often sees that in people with gluten problems. What everyone else missed for years while looking for it, he suggests it with a quick look and offhand remark.

I've done that for others a few times myself and figured out some problem they have from an offhand remark. Of course, I've often suggested someone check something that wasn't the cause of their problems, either.

BTW, some people think there may be a link between Hashimoto and gluten in some people.
Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
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Thanks and I will ask Doc B about gluten/Hashimotos link.

This guy is the best Doc I have ever met. Wife was bitten buy something probably a tick. Obviously bitten by something. Having multiple symptoms. Doc B says there is no Lyme disease in Ohio and not treating for same. I researched subject via google. Oh yes there most certainly is Lyme disease in Ohio. Took documentation to Doc B who is astounded. More to the point he didn't just stand on doctrine but actually listened to what I had to offer. This is why I love the man. The medical coconut telegraph told him no Lyme disease. Once given better info provided by a patient with access to Dr Internet he immediately started aggressive treatment for Lyme disease and wife is doing much better. I imagine his patients will be better served because I had access to medical info and more importantly I had the TIME to research the subject. I also would imagine he will tell his fellow docs and so more people will be treated correctly.
I use my PAP machine nightly and I feel great!
Updated: Philips Respironics System One (60 Series)
RemStar BiPAP Auto with Bi-FlexModel 760P -
Rise Time x3 Fixed Bi-Level EPAP 9.0 IPAP 11.5 (cmH2O)
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(06-27-2015, 05:42 PM)DocWils Wrote: Mark, did you read what I said in the next post?
Yes I did but it has taken me a while to process what set me off.
Yes, lucky 30%, but what of all the people who didn't come in because they googled their symptoms and, misunderstanding how to do a proper symptomology (around 90% of the non medical world, sorry, but it is so) did not ask the right questions, did not understand what they were reading, did not seek treatment and died.
If a person decides to self diagnose and treat it is on them. It is said a doctor who treats himself has a fool for a patient. I don't want to do that. I do attempt to educate myself so I can understand what a doc tells me and I can ask intelligent questions (if I have them) in an effort to receive maximum benefit from treatment. . However if I get a canned response that shows a doc has payed absolutely no attention to me for I am just another cattle in the chute what do I do? I do understand a docs need to not go on wild goose chases. I am a trouble shooter, problem solver, diagnostician if you will in my field. I learned early on how easy it is for a customer to offer his take on a problem and then go chasing after that and not follow the numbers. However I also learned if the customer tells me something is wrong .... well they live with the machine not me so if I cannot find a problem it's on me to dig deeper and not just blow them off. When I tell a doc "something is wrong" and he blows me off yes I get angry. I have lived in this body for 62 years and I know when something is not right. I may not know what the problem might be but I know there is a problem.

Those numbers haunt me, and will forever haunt me, and for those lives I mourn. There is nothing on Google to separate the wheat from the chaff, and far too much much bad advice being given by unqualified people, and that of course bothers me immensely. And a lot of the self help forums peddle dangerous notions in the guise of helpful advice, advice that costs the thoughtless person who peddled their particular ignorance nothing, and then left my people to mop up the mess, often too late. We are reverting to the era of snake oil peddling. So, yes, it does bother me, and worry me.

And here we arrive at what set me off. Somewhere some entity may decide for me I am better off forbidden Dr Internet. Based on your 70/30 rule it could be argued the populous as a whole would be better off relying entirely on a docs decisions to heck with what I might think. This is already happening in other places why not medicine? Forcing something on me because someone else thinks it is for my own good.... heaven save me from committed do-gooders. The road to hell is paved with good intentions. Were it not for Dr Internet I may have offed myself in despair.

That said, when it is helpful, as it often is here, for instance, then it is very helpful indeed. But when it is not, it is harmful, and at times very harmful.

I am sorry you had a bad run in with a doc, so have I, more than once, it happens, we aren't gods and we don't catch everything, but you were smart enough to seek a second opinion, and that got you out of the woods, and btw is what we always say, get a second opinion.
Here you show you did not read what I wrote. I have been searching for help for decades. Dozens of doctors have failed to help me. It wasn't until 2011 a doc took the time to explore the idea of OSA. That failure is their's. I fully admit I did not pursue cpap therapy because of financial problems I created for myself. That is on me.

I certainly don't have ego enough to be bothered if a patient seeks a second opinion, so long as it is from a qualified source, I see it every day - today I had one, at my own advice, and did a second opinion for someone else after 4 ops did not help the poor bugger. And since I could not see where the problem was, I sent him on for a third opinion (the problem wasn't the surgery, IMHO, but the massive damage to the foot already before anything had been done - the cutter was fighting a rear guard action in a way, but I sent the patient on to a colleague who has been doing wonderful things in metatarsal reconstruction anyway in the hope he could see a way the original doc could not).

And yes, we do tell patients that the insurance won't pay for something - we are obliged to, in fact, by law - they are in the US too, so far as I know (not allowed to sucker you into expensive procedures that you are left holding the can for, without your express consent). And yes, some docs can't see past the test numbers, but most are better than that.

Sure say your insurance won't pay for it because they don't think you need it (which is conclusive proof ins co practice medicine IMO) however if your own peace of mind requires it and you want to go out of pocket it will cost you X$. Now if this is verboten it is a great example of do-gooders interfering in my life because They Know Better.

Out of curiosity, would you have come up with Hashimoto's by Googling it? I actually doubt it - it is a tough diagnose and one where all the symptoms would have to line up, and you would not likely have focussed on the symptoms that would have found you the syndrome via google.

I was quite confident I had hypothyroidism based upon my symptoms and family history. The all knowing never wrong TSH test said otherwise.....
No I did not know I had Hashimoto's. I have since learned how sneaky is this scourge. However had I been born 40 years earlier any country doc would have looked at my symptoms and started me on dessicated porcine thyroid supplement and perhaps saved me and the people who loved me from 30 yrs of pain.

The tip - the skin pallor and the trouble swallowing were probably things you would not have seen and put in. Heck, a lot of GPs miss it. The fact the TSH and Free t3 and T4 levels were good would certainly have thrown a lot of docs off the scent. As you know (or not) I run, as part of my job, a special diagnostic team for difficult cases, full of talented and laterally thinking physicians and students, to train them how to think medically. In the last year we were turfed two patients with mystery illnesses that turned out to be Whipple's, something most city doctor's will never see in their entire practice, and something we use to trip up med students. But there they were. Two in a year. The first I pegged inside of a ten minute read of the symptoms and a look a the lifestyle of the patient, and it helped that when I was younger I used to work on a horse farm (race horses, in fact), the second took a week of digging by the entire team before it was agreed upon. Hashimoto's is an easy miss unless you know what to look for - the symptom list mirrors a ton of other things, including depression and half dozen other illnesses, and it is the puffy or pallid face and trouble swallowing that would be the tip off in your case, something you might only see in the right light, and when the thyroid got enlarged enough to impinge on the throat, since the other tip off, the anti-thyroid peroxidase antibodies, were not present in the previous doc's testing. Your second doc (20th) got lucky or had a
well lit surgery, your first didn't and didn't think to look at you hard. To his eternal shame, I might add. But it was an easy miss, frankly, unless you are very experienced in that field, given that you were seronegative in all previous testing, and that is a rare thing. Count yourself lucky. To use your AC analogy (and forgive me but I know nothing of ACs) it is as if the AC looked perfect in all ways according to normal testing, but the clue lay outside in the window ledge because the AC was tilted just wrongly but subtly. Would you have seen that from in the office? You got really lucky in your second opinion,(20th) and I am really happy that you did.

Me too! :grin:
Please do not think me ungrateful for all you do here. Thanks
Just one extremely frustrated person.
I use my PAP machine nightly and I feel great!
Updated: Philips Respironics System One (60 Series)
RemStar BiPAP Auto with Bi-FlexModel 760P -
Rise Time x3 Fixed Bi-Level EPAP 9.0 IPAP 11.5 (cmH2O)
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