C

O M M E N T A R Y

The Need for a Knowledge System in Sleep

and Chronobiology
leep problems and the disorders that
cause them influence health-related
quality of life as much as other chronic
medical conditions.1 Of the total U.S.
population, 2035% regularly suffer
from insomnia.1 Only 40% of the time
is insomnia associated with psychological
distress or psychiatric disease; more commonly it is associated with medical illness or with behavioral traits or habits.2
Sleepiness severe enough to hamper the
activities of daily living is estimated to
be present in 30% of the population and
is most commonly caused by voluntary
restriction of sleep time.1 Sleep apnea
and restless-legs syndrome, common
medical causes of sleepiness, are present
in some 24% of the population and in
higher prevalence (1040%) in those
with neuromuscular diseases, renal failure, hypertension, and heart disease.3 Diagnostic strategies and/or effective interventions are available for insomnia and
sleepiness, and for sleep and circadian
rhythm disorders.1,3,4 Moreover, epidemiologic studies show that for a condition such as sleep apnea, 80% of men
and 90% of women with clinically significant illness remain undetected and/or
undiagnosed.3
The underdiagnosis and undertreatment of sleep disorders is understandable, if not excusable, considering the
lack of representation of the topics of
sleep and chronobiology in current medical school curricula. A 1990 survey of
126 United States medical schools could
document only an average of 1.16 hours
per school of instruction in sleep and
sleep disorders throughout a four-year
program; however, the variance was
wide, with 37% of schools reporting no

instruction at any level.5 Given the

prevalence of sleep disorders and the relationship of these disorders to significant underlying medical conditions, a
strong case can be made for the formal
implementation of a curriculum in sleep
and chronobiology in medical education,
residency, and beyond.
CONSTRUCTING

CURRICULUM

Chronobiology examines physiologic

processes that regularly occur over time
and that are commonly associated with
the daily (circadian) cycle of light and
darkness.6 Chronobiology also encompasses cyclic seasonal and daily behaviors and physiologic processes.
Chronobiologic rhythms and sleep
wake cycles are both active, neurobiologically driven processes that influence
human alertness and productivity, common diseases such as ischemic heart disease and asthma, and the expressions of
such disorders as chronic persistent insomnia, narcolepsy, restless-legs syndrome, and sleep apnea.1,3 Chronobiologic processes are crucial elements in
normal growth and development, the
timing of medical treatments, systems
management, and the interface between
medicine and society.3,711
A complete curriculum in chronobiology and sleep disorders must (1) establish a knowledge base; (2) train students/residents in clinical applications
of this knowledge base; (3) recognize
the possible effects of physicians own
sleep problems on professional training;
and (4) emphasize the public health implications of sleep disorders.

Knowledge Base
Medical students should be taught
about the fundamental neurobiologic
processes related to consciousness, vigilance, coma, anesthesia, and mood.
Cardiovascular, renal, pulmonary, metabolic, and endocrine systems operate
differently in sleep and its different
stages (non-rapid-eye-movement sleep
and rapid-eye-movement sleep), and
presenting this information involves appreciation of the dynamic interactions
between the brain and the body.1,3 Students should also become familiar with
the degrees of sleepiness that can affect
a patients sense of well-being, correlating with clinical measures of vigor and
vitality.12 Finally, students should be
presented with the facts about how
sleep quality and/or length and the timing of drug administration1 profoundly
influence the outcomes of medical interventions.
Clinical Applications
Concepts relating to chronobiology and
sleep are useful in clinical judgments,
decision making, and interventions
made in the assessment of illness and
personal health.
One skill to be reinforced in clinical
training is the sleep history. At present, questions on sleep are included in
the Review of Systems, but only in the
domain of Psychological Status or Mental Status. Textbooks suggest that physicians ask patients about sleep disturbances, yet this term either is left
undefined or covers only insomnia or
depression and not sleepiness or abnor-

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mal sleep behavior. Proposed federal

guidelines for physician documentation
address sleep problems only in the context of an examination for a psychiatric
illness, and the suggested domain is a
history of insomnia. Needless to say,
this limited approach overlooks the
identification of problem sleepiness resulting from sleep restriction, the effects
of sleep disorders on patients and their
families, and the presence of other important sleep disorders such as sleep apnea, narcolepsy, or parasomnias.1 Fortunately, there are educational strategies
that can increase students and physicians use of questions that elicit information from patients, bed partners, and
others about sleep and waking behaviors; this information can help physicians identify underlying disorders and
assess the impact of illness and its therapy on sleep.13
An individuals sleep behavior is the
result of habits, and habits that disrupt
or enhance sleep can be acquired by design and by medical interventions. Students should be able to inform patients
of factors that improve restful sleep and
know the steps to be taken when a
sleep-related problem is suspected. Students should learn to ask about sleep
wake behaviors in their evaluations of
psychosocial factors and as part of the
management of medical, neurologic,
cardiovascular, and psychiatric diseases.
In addition, most medical schools
should be able to direct interested students to opportunities to advance their
learning through experiences in basic
science and clinical research and graduate training.
Sleep Disorders and Professionalism
It is important to impart knowledge of
sleep in professional training. There is
too often an assumption that physicians
and other professionals can maintain
performance fitness for 2436 hours at
a time or while regularly experiencing
inadequate sleep. Such an unrealistic
expectation leads to individual and

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management decisions that encourage

sleep debt and can result in bad judgement and performance.4,11,14 Sleep debt
can also be life-threatening. For instance, in a survey of pediatrics house
officers, inadequate sleep was found to
increase tenfold the risk of a fall-asleep
automobile crash.15 Emergency medicine is the only specialty in which
knowledge of the hazards of sleepiness
is a required subject for an ACGMEapproved training program.16 Residency
directors should know the impacts of
sleep patterns and chronobiology on
residents professional and personal lives
and on their abilities to achieve educational goals.

orders, the fact that there are effective

treatments, and the importance of
chronobiology in clinical decision making.
In our experience, instruction about
these topics is appealing to many students, particularly those who see value
in knowing the behavioral dimensions
of health and chronic disease. For example, preliminary data gathered by J.
Owens (Brown University) and C. Rosen (Case Western Reserve University)
show that lectures on sleep disorders in
pediatrics rotations are generally given
ratings as high as or higher than those
given to other content areas.
RESOLUTION

Public Health
Sleep and chronobiology affect human
behaviors and organizational systems.
Physicians must begin to promote
healthy sleep habits, just as they promote good nutrition and exercise, as
part of a healthy lifestyle. Efforts to recognize and treat those suffering from
sleep disorders and sleep deprivation
can prevent many workplace accidents
and motor vehicle crashes. On a larger
scale, community planning that takes
into account the importance of sleep
can lead to positive changes in the designs of social programs, public housing,
and educational systems.
THE COUNTER ARGUMENTS
We have encountered claims that all of
the topics discussed above are already
well represented in the medical curriculum, or are irrelevant, uninteresting, or
too time-consuming.
We know that some information
about breathing disorders of sleep, and
sleep apnea in particular, are encountered in medical training; however, this
topic presents a very narrow view of the
content area. It is possible that decision
makers in basic and primary care education are not aware of the new science
and evidence regarding other sleep dis-

In any medical school there are a range

of opportunities to recast existing
courses and instructional programs to
acknowledge the implications of sleep
and chronobiology across many disciplines. For instance, both topics can
readily be incorporated into a cognitive
neuroscience module or become an explicit content area in psychiatry or neurology rotations.
Unfortunately, currently there is a
paucity of off the shelf instructional
materials in these topic areas compared
with those available for such topics as
dementia or depression. However, there
is a body of core information about the
basic biology and behavioral issues of
sleep and circadian rhythm. Resources
(faculty, reference materials, listings of
local and national research projects,
etc.) are available in most medical
schools, and an inventory of such resources will identify people to mentor
students in the basic and advanced application of knowledge and affiliate institutions where the student may gain
experience in the clinical application of
knowledge. To address the need for instructional material, the Sleep Academic Award program by the National
Center for Sleep Disorders Research
(part of the National Heart, Lung and
Blood Institute) has at the present time

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school educational interventions.
None of this will work, however, unless this knowledge system is reinforced
by leadership at all levels of medical education. The efforts by medical schools
should include attention to incorporating circadian biology and medicine into
postgraduate residency and fellowship
training and continuing medical education courses. Such efforts will echo
back to undergraduates the value of
identifying and treating sleep disorders.
A robust understanding of sleep and
chronobiology will, in our opinion, lead
to better diagnoses, more timely intervention and prevention, and improved
quality of life for our patients and communities.
Kingman P. Strohl, MD
Edward E. Haponik, MD
Michael J. Sateia, MD
Sigrid Veasy, MD
Ronald D. Chervin, MD
Phyllis Zee, MD
Klara Papp, PhD
The authors thank Michael Twery, PhD, for advice and consultation in the preparation of this
report.

Dr. Strohl (Louis Stokes VA Medical Center, Case

Western Reserve University, Cleveland, Ohio), Dr.
Haponik (Johns Hopkins University, Baltimore,
Maryland), Dr. Sateia (Dartmouth Medical School,
Hanover, New Hampshire), Dr. Veasy (University
of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania), Dr. Chervin (University of Michigan
School of Medicine, Ann Arbor), Dr. Zee (Northwestern University, Chicago, Illinois), and Dr. Papp
(Case Western Reserve University, Cleveland, Ohio)
are all members of the Curriculum and Resource Development Group of the Sleep Academic Award Program sponsored by the National Center for Sleep Disorders Research, National Heart, Lung, and Blood
Institute, National Institutes of Health, Rockville,
Maryland.
References
1. National Commission on Sleep Disorders Research. Executive Summary and Executive
Report. Bethesda, MD: National Institutes of
Health, 1993.
2. Fryback DG, Dasbach EJ, Klein R, et al. The
Beaver Dam Health Outcomes Study: initial
catalog of health-state quality factors. Med
Decis Making. 1993;13:89102.
3. Vgontzas AN, Kales A. Sleep and its disorders. Annu Rev Med. 1999;50:387400.
4. Cornelissen G, Halberg F, Schwartzkopff O,
et al. Chronomes, time structures, for chronobioengineering for a full life. Biomed Instrum Technol. 1999;33:15287.
5. Rosen RC, Roselind M, Rosevear C, Cole
WE, Dement WC. Physician education in
sleep and sleep disorders: a national survey of
U.S. medical schools. Sleep. 1993;16:24954.

6. Moore RY. A clock for the ages. Science.

1999;284(2523):21023.
7. Smolensky MH, Portaluppi F. Chronopharmacology and chronotherapy of cardiovascular medications: relevance to prevention and
treatment of coronary heart disease. Am
Heart J. 1999;137, 4 Pt 2:S14S24.
8. Focan C. Marker rhythms for cancer chronotherapy. From laboratory animals to human
beings. In Vivo. 1995;9:28398.
9. Gillberg M, Akerstedt T. Sleep loss and performance: no safe duration of a monotonous task. Physiol Behav. 1998;64:599604.
10. Manfredini R, Manfredini F, Fersini C, Conconi F. Circadian rhythms, athletic performance, and jet lag. Br J Sports Med. 1998;
32:1016.
11. Lyznicki JM, Doege TC, Davis RM, Williams
MA, for the Council on Scientific Affairs.
Sleepiness, driving, and motor vehicle
crashes. JAMA. 1998;279:190813.
12. Briones B, Adams N, Strauss M, et al. Relationship between sleepiness and general
health status. Sleep. 1996;19:5838.
13. Haponik EF, Frye AW, Richards B, et al.
Sleep history is neglected diagnostic information. Challenges for primary care physicians. J Gen Intern Med. 1996;11:75961.
14. Taffinder NJ, McManus IC, Gul Y, Russell
RC, Darzi A. Effect of sleep deprivation on
surgeons dexterity on laparoscopy simulator.
Lancet. 1998;352(9135):1191.
15. Marcus CL, Loughlin GM. Effect of sleep
deprivation on driving safety in housestaff.
Sleep. 1996;19:7636.
16. The Graduate Medical Education Directory.
Chicago, IL: American Medical Association,
1998.

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