“AHA!”
Or: The Story About How the Monkey On My Back Made Me Jump Into a Rabbit Hole
By,
David E. McCarty MD, FAASM (but you can call me Dave)
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Most folks who have found their way into the field of “sleep” have an “AHA!” moment to share, something that changed them, made them see things differently, made them follow a new course. Everybody’s moment is different. This is mine…
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My career in doctoring began in primary care.
Let’s just start there.
I often joke that I’m “recovering primary care doc,” as if caring about human beings and wanting to be their doctor is a monkey on my back, like a heroin addiction. It’s like that, though. I’m not kidding. Those instincts don’t wash out.
Truth be told, as the first physician in our immediate family, traipsing off to go to medical school was just about as foreign a concept as running off to join the circus. I really had no idea what to expect.
My role models were Marcus Welby and Hawkeye Pierce.
The year was 2000, my first year as a practicing primary care doc, fresh out of my internal medicine residency at the storied Massachusetts General Hospital, with a crisp white coat and a new stethoscope. I decided, right out of the gate, to define my turf. I had a Family Practice doc friend who--reflecting on what he did for a living--told me that he was a professional “referralist.” That idea sort of bummed me out. I didn’t want to just send people to specialists for a living!
I wanted to be a doctor, not a travel agent! There had to be issues, I thought, that were mine and mine alone to manage.
One of those issues, I’d decided, was blood pressure management.
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Many primary care docs would “farm out” their problematic blood pressure management cases to cardiology, or nephrology, a habit that’s born in a desire to be “complete,” but which evolves into a way of managing time, in a time-strapped world. It’s a lot faster to refer someone out and let someone else handle the complexity! The way the healthcare system worked, though, it could take weeks to get into one of these specialists, and then, God forbid, something should go wrong with the plans they’d make, it would be nearly impossible to get one of them to call the patient back.
The truth was, for most cases, the system made specialty involvement a barrier to effective resolution of the patient’s problem, and it was just faster and more humane for the patient if I simply managed their blood pressure myself.
And so, just like that, I became a hypertension geek. I read everything I could. I went to conferences. I educated my patients about lifestyle modification, about diet, about sodium. I encouraged home monitoring. I used combination therapy to get the numbers just right. I even once did a guest gig on the local NPR station, for a call-in show about medical issues, all about hypertension. I made it my business to understand it.
Flash forward to 2003, a full three years after I graduated from my residency program, the Joint National Committee on hypertension management (JNC VII) officially recognized obstructive sleep apnea as a common secondary cause of hypertension. Up until that point, we’d all learned to look (mostly in vain) for adrenal tumors or renal artery stenosis as potential “causes” of hypertension, but we’d been taught that most individuals had “essential” hypertension, which was a clever way of saying somebody has something and there’s nothing we can do about it except manage it.
The idea that a treatable condition like Sleep Apnea was a “cause” of hypertension felt revolutionary. The new notion was that, for cases of so-called “refractory hypertension”--defined as uncontrolled blood pressure numbers despite three medications, one of which is a diuretic—the most common cause of all was obstructive sleep apnea!
The revelation hit me like a forehead slap! How many cases had I missed? Knowing that “the buck stops with me,” when it comes to blood pressure management, put my Sleep Apnea diagnosis motor into high gear!
That was when I started sending patients for sleep studies, in earnest. I began looking for Sleep Apnea under different guises. Maybe my patients complaining of depression had it? Maybe that problematic headache case should be checked? Maybe the patient with refractory gastritis has a hidden source of physiologic stress?
Over and over, I’d find disease. After a while, I stopped being shocked at just how many of those studies came back showing significant breathing pathology.
It seemed that obstructive sleep apnea was everywhere, all the time, all at once.
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But that really wasn’t my “AHA!” moment. That moment wouldn’t come until later, when I decided to come closer, and get a better look.
That moment wouldn’t come until I realized that I wanted to learn to read sleep studies—or, rather, until after I got my first glimpse of what that even meant.
Keep in mind: learning to interpret tests is what internists DO. We do cognitive work! It’s like a badge of honor.
By that point in my career, I’d mastered a lot of protocols: As medical residents, we were expected to know how to Gram-stain a sputum sample, how to spin urine and evaluate it for active sediment, how to draw an arterial blood gas from the radial artery and how to decypher the complex acid-base disturbances that we found. I knew how to attend and interpret exercise stress tests. I loved reading pulmonary function tests. My cardiology-heavy MGH residency training made me an annoying know-it-all with 12-lead ECGs. I’d gotten really comfortable with 24-hr Holter monitors. I’d recently taken a class in interpreting DEXA scans, adding another procedure to my primary care arsenal. Overall, I just remember it felt really empowering to offer these tests “in house”, and once again, it felt like a humane and efficient way to provide care.
When my patients had any concerns, I could handle it. The buck stopped with me.
Marcus Welby, at your service!
So, my thinking was: why should a sleep study be any different?
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It was in 2005, with this mindset, that I signed up for a week-long trip to Georgia, bound for the Atlanta School of Sleep Medicine--a crash course that took you through the basics of polysomnography scoring and interpretation, along with a whirlwind tour of the different diagnoses that are captured under the masthead known as “Sleep Medicine”, all in five dizzying days.
The “AHA!” moment that I alluded to before? It was how I felt after that class.
Let me put it like this: the polysomnogram is no simple test. It’s a data set that’s rich, textured, nuanced, and maddeningly complex. The patterns I saw went beyond anything that I was used to. It was mind-boggling. It was overwhelming. It was terrifying.
And it was positively exhilarating!
AHA! That was when I purchased Kryger’s Principles & Practice of Sleep Medicine, third edition. I read that book, cover-to-cover. It blew my mind.
AHA! That was when I cold-called Dr. Andrew Chesson—past president of the AASM and director of a small academic Sleep Medicine program right there in my hometown--at LSU Shreveport—and asked him if he would train me. I wanted to learn how to be a real Sleep Medicine specialist.
Skeptical, he said yes, but he couldn’t pay me.
AHA! That was when I closed my primary care practice twice a week, so I could follow Andy Chesson around as an unpaid fellow, to learn about this wonderful new clinical science by peeking through a keyhole called the polysomnogram. Two years later, Andy handed me a Fellowship Completion certificate along with an invitation to join the faculty. I passed the Sleep Medicine board exam that same year, 2007, the first year the exam was offered.
AHA! I felt like a pioneer in a whole new world!
The rabbit hole—at that point, opened wide and beckoning—swallowed me up, whole.
Once again, off to join the circus!
After that, there was no going back to primary care. I’d just have to take it with me.
Like a monkey on my back.
AHA!!
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Dave McCarty
Boulder Colorado
28 Feb 2024
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As usual, Life Fans, all of this is a setup for a cartoon…this essay got me thinking about how much our Free Will is guided by the lenses we carry…a little something I’m calling “Who’s The Boss?”—Happy Wednesday, Life Fans!
Who’s The Boss?
No matter where you go…there you are!