It is this lack of recognition of the problem by the physician, and often by the patient, together with the lack of appropriate medical training that results in minimizing and perpetuating the problem. This issue resulted in the Association of Professional Sleep Societies creating a task force in 1988 to review the education and training in sleep and making specific recommendations regarding medical school curriculum (2).

Their conclusion was that sleep-related knowledge was essential as part of the preparation to practice medicine, and that the core curriculum for both pre-clinical and clinical training needed to be developed. This concern was re-emphasized by the National Commission on Sleep Disorders Research which was appointed at the behest of the U. S. Congress in March of 1990 (3).

As part of the the commission's work, a national survey of 126 medical schools was undertaken, evaluating physician education on sleep and sleep disorders in both pre-clinical and clinical training. Results indicated that 29% of medical schools had no structured teaching time allocated to sleep medicine and that, overall, the average of total teaching time on sleep and sleep disorders, across all schools, was less than two hours. Fewer than 5% of medical schools provided four or more hours of didactic teaching in sleep (4).

There is little data available on sleep education in primary care residency programs. Perhaps the most extensive work in this area was a study of pediatric residency programs undertaken in 1994. This study reported on 156 residencies (73.5% of the 215 programs then in existence). The results indicated that 71 programs (45.5%) do not have any formal didactic education. The mean number of hours of didactic instruction was 4.8 total hours per residency program (see Figure 1). The modal and median length of instruction was zero hours.

In a few situations, there was continuity experience of more than 10 hours (7.1% of programs.) However, in two programs more than 60 hours were offered. One must recognize that this is by self-report of the residency directors and not through program audit. It was found that training programs having an affiliation with a sleep disorder center or laboratory significantly increased the likelihood that the residency would offer some type of sleep education, as well as different alternatives. The alternative types of non-didactic instructional sleep offered by these pediatric programs included rotations, grand rounds speakers, case consultations, journal clubs, etc. (see Fig. 2, see Table 1). Table 2 indicates the percentage of programs that provide instruction on specific topic areas. It is apparent that training in other primary care residencies most likely parallels that seen in Pediatrics, yet studies are needed to validate the current status of education about sleep.

Indication of the benefits of instruction in obtaining a sleep history was shown in a study published in December, 1996, by Haponik and colleagues which recorded the frequency of sleep histories taken during encounters with simulated patients by 20 experienced primary care physicians, 23 medical interns who had not yet received any instructions and 22 interns who had some previous instruction about sleep disorders.5 While sleep histories were obtained by the minority of physicians who did not receive instruction (0% of practitioners, 13% of interns), the trained interns asked about sleep much more frequently (81.8%). Their conclusion was that focused instruction about sleep influences physician behavior.

What is needed, therefore, is a deeper appreciation by the medical community about the prevalence of sleep disorders and their ramifications. Training of the faculty in the prim eary core training programs would be one strategy that could help disseminate this education. The use of problem-based learning is also an effective tool. This, together with simulated patients, chart audits, and intensive training modules could help rectify the gap between the problem of sleep ignorance and its solution. Providing education about assessment and simple behavioral and pharmacological interventions would not only fill the knowledge deficiency, but also serve to empower the physician to intervene effectively with his or her patients who, unbeknownst to the physician, seem to be suffering from a plethora of sleep disorders.