Sleep Medicine Beyond the Pandemic: Women Leaders in Medicine, Ep. 8

This podcast series aims to highlight the women leaders in medicine across the United States. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.


 

Episode 8: Moderator Jaspal Singh, MD, MHA, MHS, interviews Aneesa Das, MD, and Seema Khosla, MD, about the main issues affecting sleep medicine today, the evolution of consumer-facing sleep applications and gadgets, and how the COVID-19 pandemic has affected sleep medicine. 

Additional Resources: 

Aneesa Das, MD

Aneesa Das, MD, is an associate professor in the division of pulmonary, allergy, critical care, and sleep medicine at The Ohio State University in Columbus, Ohio. 

Seema Khosla, MD

Seema Khosla, MD, is a medical advisor for MedBridge Health Care and the medical director of North Dakota Center for Sleep in Fargo, North Dakota. 

Jaspal Singh, MD

Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.


    TRANSCRIPTION:

    Moderator: Hello, everyone and welcome to "Women Leaders in Medicine," a special podcast series led by our section editor on Pulmonary and Critical Care Medicine, Dr Jaspal Singh. The views of the speakers are their own and do not reflect the views of their respective institutions.

    Dr Jaspal Singh: Welcome everybody to another podcast of Women Leaders in Clinical Medicine. I'm Dr Jaspal Singh in Charlotte, North Carolina. With me today are Dr Seema Khosla of North Dakota and Dr Aneesa Das of Columbus, Ohio. Welcome, ladies.

    Dr Seema Khosla: Thank you.

    Dr Aneesa Das: Thank you so much.

    Dr Jaspal: Well, thanks for joining us today on this special edition about trends in sleep medicine. I was hoping that you both could introduce yourself, start with you Aneesa.

    Dr Aneesa: Sure. Again, thanks so much, Jaspal. I am Aneesa Das and I am at the Ohio State University in the Division of Pulmonary Critical Care and Sleep Medicine and my background is in pulmonary and critical care and then sleep.

    I practice mostly all sleep at this point. For the most part, what I do in my career at this point is a lot of sleep education, and I am chairing the board review course for sleep medicine for the American Academy of Chest Physicians and more in just worked on a board review book, so that's my most recent projects.

    Dr Jaspal: That's a lot of exciting stuff. Seema, how about yourself?

    Dr Seema: Sure. I'm Seema Khosla. My background is Pulmonary Critical Care and Sleep. I've been doing a solo sleep practice for the last 12 years in Fargo, North Dakota, and like many of you, I wear a couple of hats.

    My first hat of course, is my private sleep practice, but then I also serve as medical advisor for MedBridge Healthcare, which does sleep diagnostics in 22 states across the country.

    Dr Jaspal: Wow, that's a lot of work. Both of you I know personally, are very passionate about sleep medicine. Tell us how you got into this sleep medicine. What's your drive and what inspires you in this field? Seema, we'll start with you.

    Dr Seema: Mine is probably a little bit unusual. My first job out of fellowship was in Grand Forks, North Dakota. I'm Canadian, so I had to come to an underserved area to get my visa.

    Anyway, so it was pretty heavy ICU stuff. In the course of a year, we would wind up intubating, like three or four people because of untreated obstructive sleep apnea.

    At 1.1 guy was 35 years old, and I remember going out to the medical ward and decannulating him and then just sitting down on his bed, I was like, "OK, what is the deal? [laughs] Why are you in the situation? I mean, you just had a horrible right heart failure from untreated sleep apnea."

    I'm like, "You couldn't just suck it up and wear a CPAP?" We had this really good conversation about not only choice and selection and that sort of thing, but all of these barriers to care that he had.

    He wound up getting so sick from untreated sleep apnea, because people will just write him off as "non‑compliant" that he wound up in the ICU with a trach. Then it percolated to my brain that we need to do a better job outpatient before we let our patients come to the ICU like this.

    Dr Jaspal: Wow, that's fascinating. Hopefully we're not seeing too many patients like that, but again, I guess we are. [laughs] I guess, that is 2021. Aneesa, tell us what drives you?

    Dr Aneesa: That resonates with me in the sense that, as you mentioned, I too come from that background of Pulmonary and Critical Care. Those of us that go into that field are often into instant gratification. We do it because there's a lot of action.

    The irony is sleep medicine gives you more instant gratification of fixing people and changing how they feel and their quality of life in a quicker way into more dramatically than any other field I've ever seen. That does not mean to say that we don't absolutely change lives in other ways, but it's very quick. I think it's undervalued by a lot of folks.

    We know if somebody comes in and they're miserable, because they're sleepy, they appreciate that difference and we could change somebody's entire life. It's a lot about what you said Seema, is that it comes down to being willing to listen to somebody and realizing that you can make a big difference by taking a little bit better history and being a little bit more thoughtful.

    That's probably what defines us from a lot of other fields, is that when somebody comes and they say, "I can't fall asleep." Rather than write them a prescription, we often ask, "How many televisions do you have in your bed?" "Are you spending really 20 out of 24 hours in your bed?"

    Questions like that, where we get to the bottom of things, and I realize what a big difference we can make by doing that.

    Dr Jaspal: I think those are both great segues into this podcast. The drive and the passion that you have for this is evident. There's a lot of stuff in sleep medicine that's changing a lot. I trained in sleep medicine many years ago as well and trying to think through, so much has changed.

    Along the way, a lot of my Pulmonary colleagues, I'm sure yours as well, have either stopped doing sleep medicine or they don't do as much of it. It's becoming less‑known.

    A lot of them might be listening to your podcast today and wondering, "I haven't really kept up with sleep and I haven't really kept up with the discipline at all." What are main issues in sleep medicine today that physicians, especially pulmonary and trauma medicine physicians need to know? We'll start with you Aneesa.

    Dr Aneesa: Broadly, I think that we've realized a little bit more that all obstructive sleep apnea is not the same. We're moving in a direction of different phenotypic sleep apnea in one sense.

    One person may have sleep apnea because they have a very low arousal threshold and that causes disruption of their airway, another person might have it because of obesity, another person might have it because of a small mandible.

    There's different kinds of phenotypes. The field has moved into a direction of being more cognizant of that. We haven't quite gotten to the place where we can truly do goal directing care base on that. I would say that's the movement that we're going in, and we're building literature and data to support, so that's one thing.

    The other thing is that we have learned a lot about being realistic about what outcomes were affecting in sleep medicine. We still need to continue to look at cardiovascular outcomes, and look very carefully at the way studies are designed when they look at those endpoints. That adherence is probably more important than we had previously recognized, in a lot of pieces.

    That sometimes the most advanced equipment is not always the best. That's probably one of the more recent lessons we've learned as well.

    Dr Jaspal: To summarize that the OSA...That traditional sleep apnea patient as we know it, that there's a huge phenotype from the one that Seema described earlier, that horrible heart failure is very different than the patient potentially with minor comorbidities that mostly easy to treat sleep apnea with CPAP at a modest setting.

    Looking at those phenotypes is very important. The other part is understanding the impact that we have and moving towards what you're getting as a personalized outcomes‑based approach. Is that pretty accurate?

    Dr Aneesa: Absolutely.

    Dr Jaspal: Great. Seema, what are you seeing in the field?

    Dr Seema: I totally agree. We're past that sort of all roads lead to CPAP. What we need to be cognizant of, is that the sense with a lot of our colleagues, that this is OSA medicine, and it's not. It's sleep medicine. We do anything related to sleep. Sometimes that gets lost with just 80 percent of our patients have OSA. Then the other parts get lost.

    In the messaging too, is that even if somebody has OSA. I'm sure, Aneesa, you see this all the time and just follow that. OK, fine, let's say there's like bad news treated, but they're still sleepy. There's still more work to be done.

    Aside from the different treatment options now that we have, which is so much better than where we started, but then that ability to have that conversation with the patient for them to recognize that. OK. Let's do this with bad news treated, but you're still sleeping. There is still something that we can do. A lot of patients aren't aware of that.

    Dr Jaspal: You bringing up a very good point. It also is interesting. As you're talking I'm thinking about, there's a movement in ICU medicine and pulmonary medicine to get to know patients, to get to know their life, get to know their social determinants, wherever that sort of the terminology might be. Sleep medicine already did that.

    You already got a sense of the psychology or the social factors, what are the partner's relationships? What's the home life look like? Getting into that is a very interesting field.

    Sometimes pulmonary critical care physicians like ourselves, or colleagues, and such probably stop short of looking at the PAP therapy in the physiological arrangements, without the psychological and the social underpinnings. Would you agree with that?

    Dr Seema: Yeah. The other thing too, to be respectful of is, it's such a privilege for patients to allow us into very intimate part of their lives, like, who sees you sleep, it's people that you choose to allow you to see your sleep.

    A lot of the time you do wind up talking about childhood sexual trauma. You talk about all of these things that then show themselves at night when our guard is down. It's such an incredible privilege for them to allow us into that space. Then you add to it now we're doing telemedicine into the home. You're literally in their bedroom.

    You're literally in their space. What a responsibility that is for us.

    Dr Aneesa: I couldn't agree with you more to the point that I teach my fellows that. That's one of the first things I tell them, is that your...Once I had a fellow who walked out as the patient was talking about their son's Taekwondo, and I was like, "Oh, wait, what are you doing?" The first thought was "Kappa, we've got three patients waiting," and this doesn't affect parents at all.

    Actually, so much, it does affect care because we are asking them to do very, very specific things that are hard for them to buy into. If that patient doesn't feel that you care about their whole life, then why would they follow our instructions?

    It is an absolute privilege...In some ways, sometimes I feel like I have more patients walk out of my clinic in tears than the other clinic because we talk about this. It's not because I'm mean. I promise. [laughs] It's because I ask those questions that are hardly answered that are important to the outcomes that we're dealing with.

    Dr Seema: Aneesa, I go through more Kleenex in my sleep clinic than I did with my one cancer clinic.

    Dr Aneesa: Yeah.

    Dr Jaspal: Interesting. That's fascinating. I would have to agree with that. It's interesting that you both are seeing this as well. I'm going to shift gears a little bit. Sleep's taking off now in terms of public awareness, which is cool.

    We've been asking for this for decades, for everyone to recognize how important sleep is. Look at this. It's such an important aspect of public health. Now it's taking off to a whole new level where everyone is talking about their sleep to the point where they have gadgets. They have watches.

    I have patients every week telling me, "Oh, my watch tells me this. My app tells me this." What do you think for the pulmonary and critical care or these intramax position. A lot of gadgets, and apps, and technology out there. What are the things that you need to pay attention to these days? Seema, we'll start with you since this is right up your alley of the ASM work that you've done.

    Dr Seema: I love gadgets. Minimum has allowed people to understand that sleep is important. It is almost its gateway for people to become interested in their sleep.

    I remember probably five, six, seven, years ago, it was very patient‑initiated. They would come in with their Fitbit or what have you and say, "Hey, my sleep is different than my friend's. What's wrong with my sleep?" Whereas now I find myself soliciting that information. When I'm doing my exam, I'll see their Fitbit. I'll say, "Hey, do you have your app? Let's look at it."

    For me, the messaging is we're not exactly sure about the accuracy of this information. However, can we look at the trend? Can we glean important information from this? Can it at least make us more cognizant of our bedtime routine, and our wake time, and sleep time?

    Even if all the awakenings may not be accurate and sleep staging may not be accurate, at least people are paying attention to their sleep. Now that a lot of these devices have had oximetry built in, all of a sudden patients are saying, "Hey, my oxygen's have rationed 80." Then you're like, "Oh, OK. This is a problem. Let's take a look."

    Dr Jaspal: Aneesa, do you have any thoughts on this?

    Dr Aneesa: It's funny how you said this because I'm thinking about you as Seema is saying this. Both you and I have engineering backgrounds. What we were always taught, "Don't try to extrapolate more from the data than the data can tell you," which is why I agree with what Seema said as an overall thing.

    You need to take it in trends because we don't have the level of validation data that we would like to be able to say an absolute diagnosis based on something. I agree in that the most purposeful piece of this is increasing the awareness of the individual and telling an individual, "Hey, maybe the reason you're so tired is because you're only sleeping five hours a night."

    Big macrodata versus microdata. That has been helpful or, "You know what, you're getting out of bed on the weekends five to six hours later than you are on the weekdays." That's a pretty big difference. That might be shifting your circadian clock. That might be why you have such a hard time going to bed on a Sunday night.

    Big pieces like that versus, "Hey, on Tuesday, I noticed I woke up five more times than I did on Monday. Does that mean that I stopped breathing more well?" We may not be able to glean that information right.

    Dr Seema: I didn't know you guys are both engineers. I love engineer patients. They come with the spreadsheet.

    [laughter]

    Dr Aneesa: They make their own spreadsheets for me. That was my favorite.

    [laughter]

    Dr Jaspal: It's great, except when they wonder why you haven't looked at their entire spreadsheet in detail and understood every data point. That is not so fun.

    It sound like you're both saying you like the trend of people paying attention to sleep, the discipline as a whole, looking at it for their own wellness and overall health that's getting the attention it needs and points they need for people's health.

    Looking at big trends, not necessarily individual data points, not necessarily relying on the data itself but more the idea of heartily putting in a hope for the hosted picture of what you're looking at for the patient. Is that about right?

    Dr Aneesa: Yeah, I think so.

    Dr Jaspal: Sleep is doing really well. I remember seeing both of you in some meetings here on. They were sailing upwards in membership and excitement and all that stuff. Then along comes COVID‑19.

    It's affected a lot of what we do in sleep medicine. It's interesting to see in the sleep clinic. What are you seeing from the pandemic, a little bit about how your patients now are, families are managing with their sleep in the setting of both working from home, that shift in the pandemic or other things that you're seeing. Let's start with you, Aneesa.

    Dr Aneesa: As you're saying this, there's three different big things that I've noticed. Number one, during the pandemic, I think sleep medicine was the one clinic visit that a lot of people dropped off. Our clinics died down.

    Our sleep lab was shut down for a big portion of time and part because we shifted those beds over to COVID beds. That changed the field a bit. Now everybody is trying to get back in. There's an absence from sleep medicine from my patients' standpoint. That's piece one.

    Piece two, I just saw several patients over the past week that haven't used their sleep app in a year and a half to two years because they were afraid that if they got COVID, they could disseminate it by using positive pressure, which isn't not all that wrong, if you did.

    We don't know that, but they didn't want to take that chance so they came to see me to get back on track. That's another thing that we weren't aware of that some patients were doing. Then probably the most overwhelming thing that at least I've seen in my practice, and it'd be interesting to hear if the two of you have noticed the same thing, a market increase in insomnia.

    That's probably in part related to dampened circadian amplitudes because of people being indoors all day and flipping their lights on at night and decreasing that. It's affected sleep hygiene because people are working from their bedrooms and working from their homes.

    It's being affected by increased stress because of job loss, and trying to balance kids, your dogs, and managing your family and your life. All of your hats all of a sudden have to be worn at the same time, which is very hard to balance. That's what I've noticed. We have not come out of that piece yet.

    Dr Seema: Wearing all your hats at once, you're right!

    [crosstalk]

    Dr Aneesa: Thank to Dr Seuss' book where you're wearing all these hats. It's what I have on my head, that Dr Seuss spoke about the hats on your head. [laughs] Sorry.

    Dr Seema: Me too. I had two that were disconcerting. I was doing telemedicine at home. I've got these two dogs. We had to upgrade our WiFi twice because everyone was using up so much bandwidth. You're right.

    Have you guys also seen that difference where some people in these Zoom neighborhoods were able to catch up on their sleep, and they're doing way better, and then the other group of frontline workers that had way more insomnia and stress?

    I have one lady that works at a big box store. People were awful to her. They were spitting at her. She had to take a leave of absence because she was so worried about her health. I definitely see the split in populations for how they reacted to COVID.

    Dr Jaspal: That sounds interesting. Aneesa, as you were saying, you touched on a little bit of the stresses of the various push and pulls from the occupational to the home, to this nebulous balance concept in a very tough environment to navigate.

    Both of you I know are working moms who are in this. How are you coping with all this? How was your sleep ‑‑ if you don't mind me asking ‑‑ without being a HIPAA violator?

    Dr Aneesa: I think there's been pros and cons for the pandemic for me, honestly, because I do a lot of outpatient medicine.

    It was hard for me to get to a lot of our departmental meetings and our big meetings because I didn't have time to drive the half hour, the hour to a meeting, set for an hour and then drive an half hour back through campus to get to my office, so I missed a lot of meetings prior to the pandemic.

    We were just talking about this and now that, virtually every meeting is being offered on Zoom or another webinar platform, attendance has gone up and there's been a better sense of unity, at least among our division. We actually were just talking about this today.

    Is that, while we absolutely want to get back to being face‑to‑face, it's probably going to be a hybrid. That's been a positive but on the flip side of that, I don't know if you guys have noticed this, but meetings are eking into the evening and into the morning.

    People are very, very commonly adding on a meeting at seven o'clock at night or so. They're like, "Oh, we don't have to go, we can all just hop on Zoom at 7:00." No one might hop on a Zoom call at 7:00.

    Dude, my kids have soccer practice at 7:00. I'm not going to give you an overview. I've taken more Zoom calls from the car, on a soccer field than I can tell.

    Dr Seema: You're totally right. It's so true, it's a bit [inaudible 19:27] boundaries? It gets so much harder to have those boundaries when you can, "Just read a quick study," or, "Oh, let me just go respond to this email."

    Then two hours later you're still there. That work home, it's just that there's no finite line anymore. There's no 20 minutes in the car to decompress.

    [laughter]

    Dr Aneesa: Five minute walk downstairs. Here's your office. Here you go.

    Dr Seema: Yeah, you're absolutely right. I don't think there's an evening where I don't do some work. I've always worked some of the evenings. I'm actually, theoretically I'm 80 percent full‑time equivalent.

    I'm not even supposed to be a full‑time [laughs] but I do every weekend and every evening. I think it's just because it's become more than normal. We're more comfortable working in our home space.

    Dr Jaspal: That lead us to our final question, which is one of the things we asked our guests is the idea of the gender bias, the whole movement towards more of an integration of women in leadership roles and in medicine in general it's finally happening.

    My own wife's a physician, I can think back to what we were talking about yesterday when she was pregnant with our first child, how even maternity leave was only two weeks. I had no paternity leave. Basically, we delivered the baby. Then I went straight to the ICU afterwards, while she was recovering. It was just not expected.

    Now things are changing, but still have ways to go. What advice would you have for women in the field right now in sleep or in pulmonary and critical care medicine that you have for them, and that story that you want to share of any sorts, particular lessons?

    Dr Aneesa: I'll go because part of this is near and dear to my heart. I think that sometimes we're our own worst enemy. There is lots of literature supporting the fact that women will not apply for a position until we believe we have met 150 percent of that criteria. Whereas a man will say, "Screw it, I'm about 35 percent there, I'm going to go for it."

    The reality is you're going up against each other. That doesn't mean that you shouldn't do that. The point is maybe you should go a little bit earlier. I know I'm going up for promotion, and somebody told me the same thing. "Why did you wait till now?"

    The irony is I was like, "I don't think I'm ready yet." What that lends towards is impostor syndrome. That can happen to anyone. It tends to happen to people who are more successful and more driven. I don't know that some of the qualities that lend towards impostor syndrome are necessarily bad.

    Humility is a good thing. Impostor syndrome is not because that's when it becomes a limiting factor to your success. My advice is, if you're unsure of something, get external opinions.

    That's helpful oftentimes for somebody who's in that position of impostor syndrome who can help to support you identify supportive sponsors and mentors who can help to both emotionally and physically support you in your career. Oftentimes, the reason we don't have women in certain positions is because we're just not applying for them.

    Dr Seema: I totally agree with you. I remember when I was pregnant with my first, I was in the ICU. I went into preterm labor at seven months. It took me forever to figure it out.

    [laughter]

    Dr Seema: That's another story. I went out on bed rest. They have never had another physician at that facility go through the same thing. They didn't know what to do with me. I didn't have a female colleague to say, "Oh, this is what Disability Insurance is for." I went out on PTO and unpaid leave when I shouldn't have. You don't know that. Honestly, it took me probably five years till I figured that out.

    Dr Aneesa: Oh, my goodness.

    Dr Seema: It's one of those things that you almost ‑‑ I don't know if you feel the same way ‑‑ you don't want to draw attention to being female and having something that in your head makes you feel you're not as competitive, or you're less than, or this is a liability.

    When you're pregnant, you announce to your partners you're pregnant, you can see them all mentally do the math, for like who's on call that week that you're due? [laughs] If possible, even to have a female mentor or someone that you can like you're saying, like your support group. People that you can say, "Hey, I want to go out for this."

    They will be honest with you and say, "Yeah, you should totally apply to that." I tell my oldest daughter, that same thing that you said, about women will wait until they're 100 percent qualified for something before they apply and won't. That's not to say that one way's better than the other.

    Just by numbers, then we're not shooting the puck at the net as often as the guys are. We're not going to score those goals as frequently.

    Dr Aneesa: I agree. Then my only other if it's OK with you, Jaspal. My only other comment, when we talk about diversity and inclusion, this applies to both women and underrepresented minorities. You mentioned something that made me sad, and that I do as well, that you're almost considering being female a liability.

    What we need to transition to is not saying that I'm not different than men. That it's somebody of a different race, that I'm not different. I actually think it's OK to be different. In fact embrace that difference, because our differences is what brings our value.

    That's where we need to get to, the pinnacle, where we say, "It's OK to be different. Actually, my difference is part of my value, and that's what I'm going to bring."

    Dr Seema: I agree, we need to embrace our differences as our strengths. To your point, when you're with your fellow that walked out on the person talking about Taekwondo, we may be more attuned to that emotional part of it, or willing to listen, or maybe we can identify a little bit more with some of the things that our patients do share with us.

    In that light, we have to reframe it that this is a strength. This is not a weakness, necessarily.

    Dr Jaspal: I completely agree with both of you. That is well said. I cannot close this podcast without talking about what we're talking about before we started, which was basically the aspect of, Aneesa you were talking about how you had this strong opinion about how to handle a massive recent change in the sleep world, and how you want to attack it, and how you want to approach it.

    Talk to us a little bit about what the issue is, if you don't mind and say how have you had [laughs] if you had all the way of holding the cards and how to design, how you would handle this massive attention seeking issue that's happened in our field?

    Dr Seema: You just threw Aneesa this giant hot potato.

    Dr Aneesa: I don't have a great answer. I'll talk about the problem and what the problems I foresee are, for sure. Dr Singh is referring to is a large recall of almost 50 percent of the PAP, Positive Airway Pressure machines in the world. The US has had a recall, there's a safety warning in other countries, but it's an international problem.

    Respironics has recalled lots of other devices. It's important for you to know because if you're not in the pulmonary critical care, sleep field, you may not have heard of this. If you have a patient who's on a Respironics device, they should absolutely go to the website and register their device for the recall.

    Myself along with a lot of other folks are a little bit frustrated by the paucity of information out there and the actual risk. I'm going to ask both of you to stop me and correct me if you feel I'm miss speaking or if I'm not representing anything accurately.

    Dr Jaspal: Sure.

    Dr Aneesa: The way I understand it, there is a foam ring that's used for sound abatement in these devices that is made out of polyurethane, which in and of itself is fine. They found that some of these have been degraded. If they're degrading, the concern is that particles of polyurethane could be inhaled.

    It's a potential carcinogen. It's also a potential airway irritant. That's the theoretical risk. There's also some discussion around the ozone‑based cleaners potentially exacerbating that breakdown.

    Respironics made in their blanket statement that if you're using PAP, you should stop using it because of this risk, unless it's a ventilator and you can talk to your physician, which has left healthcare providers in a bit of a lurch.

    The problem is that we're trying to balance the risk of going untreated for sleep disorder breathing with this unknown nebulous risk of potential, the C‑word, cancer, which is really scary. There's a really acute, potential risk with this potential chronic unknown risk.

    It's very, very hard to make clinical decisions when you don't have the known risk. Again, it's talking about an engineer. We're looking and comparing data that we don't know have data points for. That's extremely frustrating.

    I've talked to colleagues around the country. Every colleague I've talked to is handling it a little bit differently. There's absolutely not a blanket answer. I don't have a blanket answer for what to do. If I did, I would be in much better shape. The answer is I'm having very personalized conversations with most patients that reach out.

    Dr Jaspal: Seema, do you have any thoughts on this whole problem, this pretty hot button item right now in sleep medicine?

    Dr Seema: Well, I think what Aneesa said is exactly right. Not only is there this paucity of information, but then we are straining our own resources trying to communicate with patients.

    The patients aren't calling Phillips. They're calling us. Then they feel scared. They're worried. We spent years talking about how important it is for them to use this machine. Now, all of a sudden, we're saying, "OK, well, maybe we don't need to use this machine anymore."

    It leaves us in this conundrum. We're talking about non‑PAP options. We're talking about maybe transitioning to the competitor's device. We're talking about all these different things, and yet we don't know what the risks are.

    We don't know how to assess. There's no clear guidance on, "Should we be doing imaging? Should we be doing PITs? Should we be checking their devices? Is there a way that we can check if they are...? Is it just the psychical degradation of the foam? Can we measure the POCs? Is there a repair and replace program?"

    There are just so many unknowns that that, in and of itself, lends to the stress both for the clinicians as well as the patients. We're always striving to advocate for our patients and provide them with education, but what we don't know, it makes us feel like we're at a loss for what to do.

    Dr Jaspal: I think that after both your sentiments, it's a very frightening time for many of our patients. It's a very important time for us to have as a discipline strong leadership. That really gets in there. I appreciate both of you ladies exemplifying very strong leadership and passion about doing what's right, responding to a crisis and helping to navigate these very complex waters.

    Thank you. Thanks for joining us today on this podcast. We've covered a lot of ground. We've covered what drove you in this field. We've covered what your interests are. We've covered aspects of what are phenotype of OSA and demystified that a little bit and gained towards more personalized therapies, more outcomes‑based driven things.

    Then therapies in general, and how sleep medicine evolved from back when I trained to basically being a CPAP doctor, to being much more thinking about the overall patient's needs and a much more intimate insight into the patient's life.

    We talked a lot about how to get patients better sleep but also thinking where technology fits in that role. Thinking, understanding the role technology helped a little bit and how we can also use that technology and potentially enhance their overall health and lifestyle and maybe make things better for all.

    We talked about the COVID‑19. We talked about what happened with that. We were going through how the sleep labs went down and how adherence went nuts for a little while.

    Now we're dealing with other aspects like insomnia prevalence, and it just skyrocket, and the complexities of that with the social challenges people are facing today, couple that all together that we need strong people in sleep medicine.

    We didn't touch on certain other things like telemedicine. I'm sure we'd love to at some point have you back, talk with us a little about that, where that's going. We did talk about the current Respironics recall of the masks and how that's a hot‑button item right now. Was there anything else I had missed?

    Dr Aneesa: No. Just to clarify, not the masks. The CPAP devices.

    Dr Jaspal: The CPAP devices, right. Sorry. Was there anything else I had missed, and any other parting thoughts? I just wanted to say it was a pleasure having you both today.

    Dr Aneesa: [laughs] The only other thing that I would just note is there's absolutely still a need for more individualism in this field to care for these patients. This problem is not going away. The awareness is increasing. The patient population is increasing.

    We don't necessarily have a high attrition rate, which is a good thing. I do think that we should remember that lots of different fields can feed into sleep medicine. Internal medicine, pediatrics, psychiatry, otolaryngology ‑‑ I think I said internal medicine ‑‑ pulmonary critical care, psychiatry. Did I miss something? I can't remember.

    Dr Seema: Cardiology.

    Dr Aneesa: Oh, cardiology, that's right. Thank you. This is a field that you can come to from many places.

    Dr Jaspal: Diversity aspect. Seema, what are your thoughts?

    Dr Seema: Aneesa is exactly right, and we would welcome you. Each of us brings with us our own individual background. For example, you two with your engineering backgrounds. You offer that unique perspective. Sleep is ubiquitous. We all need sleep.

    This isn't just the sick population. With all the media attention, people are understanding the importance of better sleep. We do need more people in our field. We are trying to continue to improve it for the next generation. Like all of Aneesa's fellows and the medical students, I would encourage you all to consider a career in sleep medicine.

    Dr Jaspal: On behalf of Consultant360, I can't thank you both enough for taking the time. It's been a lot of fun. It's been a lot of joy. I know both of you for some time. I feel like I know you both a little bit better today. Take care. Have a wonderful day, and look forward to hearing more from you in the future.

    Dr Aneesa: Thank you.

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