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Dr. Yurcheshen: 
Hi and welcome. I’m Mike Yurcheshen from the University of Rochester Sleep Disorder Center. And I'm joined by a guest today. And today we are thrilled to have an open discussion about integrating evidence and cultural sensitivity and patient-centric insomnia treatments. Kevin?

Dr. Trice: 
My name's Kevin Trice. I'm the Medical Director of Adult Sleep Services at Norton Healthcare in Louisville, Kentucky, and glad to be here with you.

Dr. Yurcheshen: 
Right. So, Kevin, I think you'll agree with me that this is a very complex topic. And I think that 5 minutes will not be at all complete. But when we think about sleep and sleep disruption, really we're catapulting into a time in clinical practice where we really need to carefully consider social determinants of health. So these include things like neighborhood and occupation and racial and ethnic differences in patients who present to you.

Dr. Trice:
Absolutely.

Dr. Yurcheshen:
So how do you approach this in your clinical practice?

Dr. Trice: 
Well, I mean, the first thing I think it's just being aware that how much of a difference they actually can play in, you know, your sleeping disorders. And so to give an example, where I used to live, there was a train less than one block away.

And it was also about ¼ mile from the airport. So we're in Louisville, Kentucky, UPS headquarters, there were planes coming over every 19 minutes, 24 hours a day. So these things can have a tremendous impact on your sleep quality, insomnia, and daytime functioning issues. So you have to be aware to ask the patient about detailed things like trains, drag racing, airplanes, just because they have a normal job, quote unquote, they’re a physician or whatever they're doing, maybe they have sleep disruption from a child at home or a loved one, or their schedule has changed since the last time we talked with them. So I think being aware is crucial, and then really kind of digging down into those socioeconomic factors.

Dr. Yurcheshen: 
Right, and I couldn't agree more. Every community has its own set of considerations. Every patient has their own set of considerations. Something that I'm sure you see a lot of are people who have shift work.

Dr. Trice:
Absolutely.

Dr. Yurcheshen:
And this can be disruptive to sleep in the short term. And frankly, sometimes I see this disruptive to sleep over the longer term as well. You know, patients who may have worked trick work 5 years ago, 10 years ago, found that they never necessarily got back on track.

Dr. Trice: 
Correct. Right. Not only do they form sometimes bad habits, they may have a little bit of a advanced or delayed sleep phase compared to, quote, normal. And despite having a job that kind of allow them to live a little bit closer to their sleep schedule. Now that they've been asked to adjust back to an 8 to 5 kind of schedule, they don't quite come all the way back. So they can develop bad habits in addition to just having a job that demands either rapidly changing shifts, or a shift like a nocturnal shift, which were just not designed as humans to be able to do. So asking those detailed questions, again, over time making sure things have not changed, is important for the providers.

Dr. Yurcheshen: 
Now, for our patients with chronic insomnia and some of them with circadian rhythm disorders, we like to use a treatment called cognitive behavioral therapy for insomnia. This is the recommendation from the American Academy of Sleep Medicine and others for the most robust, effective treatment for chronic insomnia. Do you ever find any barriers for your patients reaching these types of services?

Dr. Trice:  
All the time. All the time. So I think one of the biggest barriers is, although it's like you said, the most robust data out there showing and it is the first-line treatment for chronic insomnia, just getting access to providers to do that, whether that's physicians or nurse practitioners, other midlevel providers, psychotherapists, behavioral psychotherapists, there aren't many providers who do it. If you add on that the time it takes to get seen, because there are also a few providers, you add costs, a lot of them do not take insurance, there are out-of-pocket costs, in our area that can be $150 per hour. And then also the time it takes, unfortunately, our culture is very much resigned to the fact that we want an instant or near-instant fix. And this is something that will take weeks to improve. It's kind of like going to the gym, it's going to take you weeks before you see consistent benefit. So there's a lot of barriers, although we recommend it to making it actually a useful or solo treatment.

Dr. Yurcheshen: 
Yeah, we run into some of these same - very same issues here. And we are fortunate in that we have behavioralists who are with us right on site. But they are you know, one other barrier that we see, unfortunately, is just the sheer demand that they have, trying to get patients in to see them, even when you have access to them locally, it could be weeks or months out.

I do find that occasionally online versions or web-based versions of these things that are automated can fill the gap. But there are still, you know, I still think that there are a lot more patients out there that need the services.

Dr. Trice: 
Always tell the patients don't let the barrier stop you. It's just a barrier, which means you can overcome it. Let us know what the problem is and let us help you find the appropriate solution, whether it's in person or online.

Dr. Yurcheshen: 
That's great advice. Well we've reached the end of our time together. I want to thank you very much for your time and your expertise.

Dr. Trice:
Absolutely.

Dr. Yurcheshen:
And I’m looking forward to working with you again.

Dr. Trice:
Indeed. My pleasure.

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