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Organization and Structure for Sleep Medicine Programs at Academic Institutions: Part 1—Current Challenges

Year: 2013

Type: article

Abstract: As a field that has emerged in recent years, from multidisciplinary roots within long-standing, traditional academic infrastructures, sleep medicine has assumed highly disparate organizational structures at each institution. Access to the creativity, talent, trainees, administration, and financial investment of one or more departments at each medical center has contributed substantially to advances in sleep and biological rhythms. At the same time, however, the variability of the support structure across institutions and the ability of specific departments to develop only the most relevant aspects of a highly multidisciplinary field has substantially limited the growth of sleep medicine. Surveys in 2009 and 2012 by a Presidential Task Force of the Sleep Research Society suggested that strong, independent, self-sufficient, and cohesive administrative structures for sleep medicine were rare, if not absent. Little progress had been made toward organizational structures envisioned in the 2006 Institute of Medicine report, Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. This white paper, written by members of the Academic Affairs Committee and then endorsed by the Boards of Directors of both the American Academy of Sleep Medicine and the Sleep Research Society, summarizes challenges to sleep medicine that arise at academic institutions. Examples of specific challenges discussed include the absence or rarity of: sleep center responsibility for sleep faculty recruitment; recruitment packages targeted for sleep; salary equity for identical work within the same sleep center by members of different departments; better equity between academic and nonacademic salaries; reinvestment of clinical or other margins back into sleep; access by qualified individuals to academic positions regardless of original specialty training before sleep; oversight of research space and resources by sleep centers; department-blind access to trainees who stand to gain most from training in sleep medicine; coordinated training in sleep and biological rhythms during preclinical medical school curricula; and sleep graduate training programs and opportunities to attract next-generation researchers into sleep and biological rhythms. Solutions to such challenges are complex and likely to differ between medical centers that themselves often have highly disparate organizational structures. However, a white paper subsequent to this one describes key goals that could be targeted, along with potential mechanisms to help ensure financial and administrative feasibility. The outline of current challenges in this paper, and a future vision and potential solutions in the next, are designed to maximize the potential that academic sleep medicine could have during coming years to improve human health in a most fundamental manner. Sleep medicine and the science that underlies it represent a relatively new medical discipline that has emerged in part based on combined contributions made by a wide variety of traditional fields. These fields have enjoyed long-established financial, administrative, institutional, and federal support that has fueled much of the growth and early success in sleep and biological rhythms. However, at the institutional level, traditional academic departments maintain most of their focus outside sleep. No traditional department or medical discipline covers the entire breadth of sleep medicine. No departments of sleep medicine exist at academic institutions, and sleep disorders centers rarely have significant oversight of budgets, faculty appointments, and space. This has limited development, visibility, coherent centralized planning, investment, and reinvestment in sleep medicine. In some circumstances current organizational structures do not facilitate optimal care for patients with sleep problems. They can constrain clinical training despite the high public health burden of sleep disorders, and hamper research training despite recognition of fundamental unanswered questions in this field.1 Current administrative structures often divert positive margin generated by sleep medicine away from academic development of sleep programs. Institutional investment in sleep typically remains minimal, and indirect funds from sleep grants rarely are committed to future research of this field. Collaboration between like-minded sleep investigators is diffi-cult because of physical distances and unrelated administrative structures within systems that provide little incentive to cross existing department silos. This white paper, the first in a series of two, reflects the consensus of the American Academy of Sleep Medicine Academic Affairs Committee, with select external expertise, and is endorsed by both the American Academy of Sleep Medicine and the Sleep Research Society Boards of Directors. This first report examines existing organizational and structural features for academic sleep medicine in the United States, and identifies challenges that emerge from these realities. The second report defines targets and some pathways or structures that could create important progress. The overall goal is not to recommend restriction of sleep medicine from the myriad benefits it continues to receive from close affiliations with traditional specialties that form the roots of this new field. Rather, the aim is to preserve and enhance these collaborative relationships, but at the same time—and critically—encourage new institutional expectations for structural integrity that this field needs to fulfill its promise as a medical and scientific specialty able to deliver the most effective clinical care, train a capable and sufficient workforce, and contribute to fundamental advances in understanding of human health. In 2008-9, the Sleep Research Society (SRS) appointed a task force to assess the status of research-oriented academic sleep centers. The SRS Board had identified institutional structures for academic sleep medicine and sleep science as a focus area of high priority, and the task force was asked to conduct a survey of existing structures so that results might inform plans for future recommendations. These efforts also arose in part as follow-up to the 2006 Institute of Medicine report on academic sleep research and sleep medicine in the United States.2 The task force sent detailed questionnaires on administrative structure as well as clinical, teaching, research, and outreach activities to directors of identified sleep centers. The selected sleep centers were at academic medical centers that participated in a consortium of institutions with NIH-funded Clinical and Translational Science Awards (CTSAs). These institutions were targeted because their sleep disorders centers were considered likely to include many with well-developed academic programs. Completed questionnaires were received from 35 of 38 targeted centers. In May 2012, a few key questions were re-distributed to update the 2009 survey. These key questions focused on administrative and fiscal structures, faculty recruitment processes, training opportunities, research opportunities, and research funding. Updated information was received from 29 respondents. Variation in leadership structures between centers was considerable (Figure 1). In 2009 and 2012, about 11% to 12% of responding centers had a director who reported to a dean of a medical school. In 2009, about 18% of surveyed programs were headed by a division director who reported to a department chair, whereas by 2012 this number had increased to 30%. In 2009, 50% of respondents reported that their leadership structure fell into an “other” category. For example, several respondents described council-like structures with a multidisciplinary composition. Although this pattern was a little less prevalent in 2012, “other” remained the largest category choice. Sleep center leadership and reporting structures. From left to right, sleep center director reports directly to the dean (CD-D), the division director reports directly to the department chair (DD-DC), separate leadership of clinical and academic programs (SL-CA), medical director reports to departmental chair (MD-DC), medical director reports to hospital leadership (MD-H), or another reporting structure (Other). In 2009, about half of the centers reported a medical school or university-based administrative structure responsible for the clinical, academic, and teaching missions. More than one clinical sleep program existed in 14 of 35 institutions, with 11 of these 14 representing separate pediatric sleep medicine programs. Five programs consisted of a clinical sleep center run by a hospital, with no specific or integrated oversight of institutional sleep research and education. In 2009, 50% of surveyed centers described themselves as medical school or university-based comprehensive centers responsible for clinical, educational, and research missions; 26% of surveyed centers were divisions or sections within departments, usually within medicine or a section within pulmonary medicine, with slightly under half of these centers in departments of neurology. About 9% described hybrid, or combined model structures. In 2012, 29% of centers were described as comprehensive centers existing within a medical school or university, whereas 54% were described as divisions or sections within departments. Again, hybrid structures were reported by about 14% of respondents. The updated survey results found that just over two-thirds of programs in departments were in divisions of pulmonary and critical care within departments of medicine. In 2009, 10 programs had one director that reported to a chair or dean. Other programs had multiple directors for various components of the program or multiple reporting lines, creating apparent potential for administrative and programmatic fragmentation. A hospital or private contractor was responsible for managing the sleep laboratory for 19 of the 35 responding programs. Technical revenues did not flow through the sleep programs in about half the programs. In 2009, only 5 among 35, or about 14% of programs reported an ability to recruit and appoint faculty. By 2012, the percentage of programs who reported ability to recruit and appoint faculty climbed slightly, to 25%. However, at all other sleep centers, department chairs were responsible for recruiting faculty, suggesting that many sleep center directors have little or no direct oversight of program development. Administrative responsibility for research grants was reported by only 12 (34%) of 35 institutions in 2009. Only 20% of these programs, all at CTSA-supported institutions, received any indirect costs from grants. In 2012, 37% reported receiving some indirect costs from grants. Figure 2 shows the percentage of programs that received revenues directly from the following sources in 2009 (lilac) and 2012 (fuchsia): professional revenues (prof), technical revenues (tech), indirect costs associated with grant funds (IDC), graduate medical education income (GME), training grants, revenue sharing mechanism with a private management contractor, other institutional funds to support the academic mission, and operational funds from the department or from the hospital. Results suggest highly disparate levels of access to revenue generated though sleep center activity. Access to professional fees was the most frequently reported, but approximately 25% of centers reported that they lacked even this benefit from their own activity. Revenue sources flowing directly through sleep programs. From left to right are shown the percent of respondents in 2009 and then 2012 that indicated professional fees (Prof), technical fees (Tech), indirect grant dollars (IDC), graduate medical education (GME), training grant income (Training G), revenue sharing (Revenue S), institutional revenue (Institutional), departmental revenue (Dept), and hospital revenue (Hospital). In the more extensive survey completed in 2009, centers reported an average of 6 clinical faculty boarded in sleep medicine and one behavioral sleep medicine specialist. All of the centers had participation of pulmonary sleep faculty, 94% had participation of neurology sleep faculty, and 71% had psychology/behavioral sleep medicine faculty. Other disciplines that were represented in at least half of the centers medicine, and only of centers reported participation of In 2009, most centers reported However, less than half reported or graduate in sleep despite the that about half of the centers had graduate and About of the programs reported responsibility for clinical sleep education at their institutions, and the programs reported All programs were highly in medical school and clinical education. More than reported clinical and just over a reported teaching clinical graduate school For research half of the programs reported graduate trainees and In 2009, about 20% of programs reported training grants, and this number remained the same in In 2009, programs about of the training in sleep research at all the but not all centers had sleep research programs (Figure than of programs reported a current center or program grant but over two-thirds of had at least one for sleep 2009 and 2012, grants and grants to have whereas from the American Academy of Sleep Medicine or Sleep Research Society For clinical research, more than half of programs surveyed reported participation in research programs on average each had slightly less than In to clinical research, research was less represented across centers. Research sources that centers reported, from the left with of Health support program grant research grants other grant mechanisms Science private American Academy of Sleep Medicine or Sleep Research Society and funds research research such as clinical and other sources and other of institutional grants (Other). from this of 35 sleep centers from institutions with at many of the academic medical centers, is that their administrative were highly independent, self-sufficient, and cohesive administrative structures were rare, if not absent. These sleep centers did not have oversight over revenue from clinical technical laboratory or grants, did they typically receive support for academic activities from the medical hospital, or This is despite the that these centers were at institutions with half of had sleep research by their survey results a absence of a mechanism by the multidisciplinary sleep field could develop of the department or departments that to the center at each institution. 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Source: SLEEP

DOI: 10.5665/sleep.2690