Out of my 25 years as a certified physician assistant, I’ve spent 15 working in sleep medicine. For much of that time, I’ve had a burr under my saddle. What is that burr? It’s that sleep medicine is not simply sleep apnea medicine. There are approximately 80 or so sleep disorders recognized by the International Classification of Sleep Disorders—many of which also deserve regular consideration.
On any given clinic day, the patient sitting in front of us has a story to tell. In my career, I’ve heard countless and incredulous sleep tales from my patients. As increasingly greater numbers of advanced practice providers (APPs) work on the front lines of sleep medicine, we are tasked with accurately getting the patients’ stories in their entirety and, ultimately, appropriately managing these patients.
Like many other specialties, sleep medicine requires us to wrangle a tremendous magnitude of data on any given clinic day. But the philosophy that has consistently shaped my approach is that our specialty is narrative-based. The human aspect matters. Details matter. The story behind the presenting complaint can be just as important as the data we collect.
I’ll share an example I saw early on in my career when was referred for a consult by his PCP for “insomnia.” We’ll call this patient Chris. As Chris and I made our introductions and I observed him and his mannerisms, it dawned on me that he did not appear to be in any evident lack of sleep type distress. He was well-dressed, alert, amicable, and seemingly unconcerned.
As we talked about his medical history, it became evident that he was not an insomniac at all but was in fact “a working man.” Chris was a professional card player. He made his living playing poker online, and early on, he recognized working into the wee hours of the morning gave him an edge because the later it became, the more errors his opponents made. He made his fortune from their sloppy, sleep-deprived mistakes.
His winning strategy had an unintended effect: Chris had developed delayed sleep phase syndrome due to his work schedule. But he wasn’t symptomatic and had no complaints about his sleep pattern, so he went happily on his way. His PCP later reached out to me, impressed by his story.
The needle in this haystack—found.
My encounter with Chris keeps me grounded in the human aspect of what we do. There is an enormous subjective component to sleep medicine. We are different from, say, endocrinology, dermatology, orthopedics, and countless other specialties because the details of an individual’s story so profoundly shape each encounter.
Accompanying this story, we often have a trove of objective information in the form of screening tools and prior diagnostic data. These numbers and scores frequently provide valuable information, but they can never fully capture the heavily subjective experience that is sleep.
The Three Tiers of Data
In my mind, there are three tiers of data for us to decipher on any given day in the sleep clinic. The first are the diagnostic screening tools. We all know them: STOP-BANG, Perceived Sleep Quality Index, Berlin Questionnaire, the pediatric BEARS sleep screening tool, and the Epworth Sleepiness Scale (ESS). While we’re at it, let’s throw in physical exam findings such as neck circumference, BMI, and maybe even a Friedman or Mallampati.
Next are the diagnostic data, measuring such parameters as sleep onset latency (SOL), sleep efficiency (SE%), wake after sleep onset (WASO), peripheral oxygen saturation (SpO2), sleep-onset REM period (SOREMP), periodic limb movement index (PLMI), respiratory related arousals (RERA) and of course our good friend, the apnea hypopnea index (AHI), to name a few.
We’ll call the last category “surveillance” data. Many providers, especially APPs newer to our sleep medicine community, are probably most familiar with this category. First and foremost is the internationally renowned data download from PAP devices. Even patients love this one. How many times do you hear, “Hey, how do my numbers look?!” Then there is the therapeutic overnight oximetry data, the clinic follow-up ESS, the Insomnia Severity Index (ISI), perhaps the International Restless Legs Scale (IRLS) if relevant, and finally the visit vital signs.
Lots of data points, huh? Guess what? We aren’t treating data. We’re treating people. There’s no refuting the usefulness of all this information; however, there is a patient experience beyond the numbers. There are needles in this haystack that need to be found.
The Five Reasons to Treat
My friend and mentor David McCarty, MD, FAASM, developed a paradigm called The Five Reasons to Treat™.1 These five reasons create a framework with which we can approach every patient.
- The first reason to treat is RISK. It’s well-established that treating sleep apnea can reduce the risk of heart failure, heart attack, stroke, high blood pressure, and countless other serious medical conditions, as well as helping with blood sugar control.
- The second reason is SNORING (or more broadly speaking, chief symptoms). Improving a patient’s disruptive sleep insults, such as snoring, gasping, and restlessness, may finally allow some peace for bed partners, roommates, and who knows, maybe even the neighbors.
- The third reason is SLEEP. We want to improve the patient’s nocturnal experience. What can we do to simply help folks experience higher-quality, more consolidated sleep at night?
- The fourth reason is WAKE. If we can improve their nocturnal experience, there’s a good chance the patient’s wake experience, including daytime mood and alertness, will improve as well.
- The final reason to treat is COMORBIDITIES. Treating sleep disordered breathing may reduce the burden of a myriad of other already existing conditions, such as cognitive changes, asthma, GERD, and nocturia, as well as re-emergence of treated atrial fibrillation.
Although developed with sleep apnea in mind, I would venture that The Five Reasons can readily be applicable to other sleep disorders.
Searching for the Needle
Remember when I said sleep medicine is not simply sleep apnea medicine? Sometimes we’re dealing with big haystacks.
In the clinic, it’s easy to get bogged down by these bigger haystacks. It takes time to sift through all the hay. It’s important to remember that patients may suffer from multiple sleep disorders concomitantly. Perhaps there are multiple needles buried in a single haystack.
There is one tool I have found that gives me a hint about whether we’re on track to achieve our clinical goals, regardless of the disorder. It’s an unvalidated scale that I was introduced to while working with Dr. McCarty and Ellen Stothard, PhD, earlier in my career. It’s called the Self-Reported Sleep-Wake Satisfaction Score (SRSSS), a 1-10 scale with the worst sleep ever experienced being 1 and the best sleep since being an infant (or close to it!) a 10.
Bear in mind, we still aren’t treating data here. This is a quick and practical tool to use during a fast-paced clinic day. The SRSSS is an attempt to translate a subjective experience into an objective format so that we can assess therapeutic benefit. An improvement from 2 to 7 allows for a more concise subjective clinical picture than “my sleep is fine.” This is a completely different type of metric than residual AHI from a download, for example.
Of course, the SRSSS isn’t perfect, but it’s enormously helpful to me from day to day. At the initial intake, I ask, “How satisfied in general are you with all aspects of your sleep, on a 1-to- 10 scale?” I don’t want them to lean on data from their wearable, nearable, or airable device, as those are purely objective. I am simply asking for a gut response.
The SRSSS can be deployed serially at each subsequent visit in the management of any sleep disorder. At each clinic encounter I ask the question, and if the value continually improves, then the presumption is that we’re on track. If not, then I go back into the haystack to try to figure out what else may be buried in there. Is it an additional sleep disorder? Perhaps the culprit is an environmental disruptor or another medical or psychiatric condition. Could it be related to medication, substance use, or maybe even disturbances resulting from treatment of the currently known sleep disorder?
It could be anything. It’s our job as sleep medicine specialists to avoid the convenient default of “Well, your apnea looks good, so it’s not your sleep.”
In my years in sleep medicine, I’ve had the good fortune of mentoring students, training residents, teaching younger colleagues, delivering formal and community lectures, and being interviewed for podcasts and even a radio show. Through it all, my takeaway is consistent: Treat people, not data. Sleep medicine is hard—you have to look through a lot of haystacks. Start digging.
This article originally appeared in SleepWorld Magazine Sept/Oct 2026 issue.
By Darrin P. Guitreau, MS, PA-C
Darrin Guitreau, MS, PA-C, has been a sleep medicine provider for 15 years, currently working for MaineHealth in the Department of Pulmonary and Sleep Medicine at Mid Coast Hospital in Brunswick, Maine. He serves on the steering committee for the Sleep Medicine Advanced Practice Provider Foundation (SMAPP) and is a member of the American Academy of Sleep Medicine.
Reference
- McCarty DE, Stothard ER. Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them. BookBaby; 2022.
