Sleep societies and sleep training programs in Latin America
2020; American Academy of Sleep Medicine; Volume: 16; Issue: 6 Linguagem: Inglês
10.5664/jcsm.8422
ISSN1550-9397
AutoresDarwin Vizcarra, Rosario J. Fabián-Quillama, Yssel S. Fernández-Gonzáles,
Tópico(s)Sleep and related disorders
ResumoFree AccessGlobal Practice of Sleep MedicineSleep societies and sleep training programs in Latin America Darwin Vizcarra-Escobar, MD, Rosario J. Fabián-Quillama, MD, Yssel S. Fernández-Gonzáles, MD Darwin Vizcarra-Escobar, MD Hypnos Instituto del Sueño, Clínica San Felipe, Lima, Perú; Universidad Peruana Cayetano Heredia, Facultad de Medicina, Lima, Perú , Rosario J. Fabián-Quillama, MD Hypnos Instituto del Sueño, Clínica San Felipe, Lima, Perú; , Yssel S. Fernández-Gonzáles, MD Hypnos Instituto del Sueño, Clínica San Felipe, Lima, Perú; Published Online:June 15, 2020https://doi.org/10.5664/jcsm.8422Cited by:2SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTStudy Objectives:To describe and compare current information about sleep societies, training programs, and requirements for certification in sleep medicine across Latin America.Methods:Online research was conducted from July–September 2019. Search terms and logic were established, including every region or territory in Latin America. Members of sleep societies were contacted to complete missing information.Results:There are 11 sleep societies in Latin America included in the Federation of Latin American Sleep Societies. They have varied levels of available online information. Regarding training programs, Brazil offers a sleep medicine residency and Mexico includes sleep training in the neurophysiology specialty; both countries offer sleep medicine certification. Sleep societies of Colombia and Argentina have developed their own certification processes.Conclusions:There are remarkable differences in sleep society consolidation, training programs, available certification, terminology, regulatory entities, and requirements in Latin America, which may increase difficulties and obstacles for a multinational certification project.Citation:Vizcarra-Escobar D, Fabián-Quillama RJ, Fernández-Gonzáles YS. Sleep societies and sleep training programs in Latin America. J Clin Sleep Med. 2020;16(6):983–988.BRIEF SUMMARYCurrent Knowledge/Study Rationale: The current study presents the status of sleep medicine education and training programs in Latin America. There is a lack of knowledge globally on how sleep medicine is practiced in other areas such as in Latin American countries.Study Impact: Our study brings awareness of the need to expand educational programs in some areas of Latin America and helps promote current training programs and sleep societies among the sleep community. The results of this study will impact global efforts to increase education about sleep in underserved areas of Latin America.INTRODUCTIONLatin America (LA) faces a high prevalence of sleep disorders, such as as insomnia and OSA,1 with public health impact.2 However, sleep medicine is still insufficiently developed and has some unresolved issues such as low social awareness, scarce presence in medical curricula, and limited availability of well-trained specialists.3 Researchers are attempting to overcome these obstacles by strengthening local sleep society activities and training programs, among other efforts.Sleep societies are formed by organizations of single or several disciplines with different levels of social recognition and influence. These societies deal with some limitations in their countries such as variability of health financial resources, little presence in academic health programs, and lack of certification.3,4 Data about these sleep societies, training programs, and current certification in LA are widely dispersed; for this reason, we try to summarize current information about them.OBJECTIVESTo describe the current status of sleep societies in LA.To describe the requirements for certification in sleep medicine and sleep training programs in LA.To compare current requirements for certification in sleep medicine across the region.METHODSPhase 1Online research was conducted on websites in English, Spanish, Portuguese, French, and Creole from July–September 2019. It included all countries and territories of LA. The following search terms and logic were used: [Latin America OR name of the country] + [sleep medicine society/sociedad de medicina del sueño/asociación de medicina del sueño/associação de medicina do sono/société de médecine du sommeil OR sleep medicine/medicina del sueño/medicina do sono/médecine du sommeil/dòmi medikaman OR neurophysiology/neurofisiología OR training programs OR fellowships certification/certificación]. No limit about year or type of publication was set, including social media (Facebook, Twitter, Instagram) and online journals.Phase 2Members of sleep societies or associations were contacted through messages and phone calls to complete information. The following questions were formulated:Is there currently a sleep medicine society or association in your country?Are there formal training programs in your country? For how long?Is there certification for physicians, dentists, psychologists, nurses, medical technologists, and psychologists?Is sleep medicine recognized as a specialty or subspecialty in your country?The final search was updated to September 2019.RESULTSThe online collected data included the members of the Federation of Latin American Sleep Societies and institutions from other Latin American territories (Antilles-Guyane, Cuba, El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Panama, Paraguay, Puerto Rico, and Trinidad and Tobago). No online data were found about any sleep centers from Antigua and Barbuda, Barbados, Belize, or Haiti. Interviewed physicians were Spanish, English, and Portuguese speakers.Sleep societies in Latin AmericaEleven sleep societies are part of the federation. Some of their features and activities are summarized in Table 1. In other LA countries, where sleep societies have not yet been formed, individual efforts from physicians and private institutions lead the development of sleep medicine. Almost every country in the region has at least 1 private sleep center.Table 1 Federation of Latin American Federation Sleep Societies members.CountrySocietiesFounding DateActivities in the CountryArgentinaAsociación Argentina de Medicina del Sueño1995Certification in Sleep MedicineJourneys of Sleep Medicine UpdatePeriodic meetingsBrazilAssociação Brasileira do Sono1985Congresso Brasileiro do SonoCertification in sleep medicineChileSociedad Chilena de Medicina del Sueño2006Biannual sleep medicine meetingNational courseColombiaAsociación Colombiana de Medicina del Sueño1998National Congress of Sleep MedicineCertification in sleep medicinePeriodic meetingsCosta RicaMedicina del Sueño Costa Rica (recently renamed as Asociación Costarricense de Medicina Integral del Sueño)-No online informationEcuadorAsociación Ecuatoriana de Medicina del Sueño-No recent activities availableMéxicoSociedad Mexicana para la Investigación y Medicina del Sueño1998International Congress in Sleep MedicineInternational course in comprehensive sleep medicinePanamáMedicina del Sueño Panamá-No online informationPerúAsociación Peruana de Medicina del Sueño2007Periodic meetingsUruguayAsociación de Sueño Uruguay2001Periodic meetingsVenezuelaAcademia Venezolana Medicina del Sueño-Venezuelan Symposium in Sleep MedicineSleep training programs and residencyMedical residencies are offered to general practitioners who want to specialize in a specific area. They vary greatly across LA in terms of their type of funding, the number of offered medical positions (Table 2), recognized specialties, and duration.5 Furthermore, the development of subspecialties has increased through the offer of training programs, similar to fellowships, mainly under the umbrella of academic institutions.Table 2 Annual medical residency positions rate per 100,000 population.CountryType of FundingaTotal Medical Residency PositionsaPopulationa,bResidency Positions Rate per 100,000 Populationa,cPublicSocial SecurityPrivateMilitaryArgentina2,646NDANDANDA3,36541,261,4908.15Bolivia424---42410,212,9544.15BrazilNDANDANDANDA11,263194,514,5345.79ChileNDANDANDANDA65917,233,5763.82ColombiaNDANDANDANDA85245,663,0991.86Costa Rica-225--2254,633,0864.85Cuba4,801---4,80111,236,67042.72El Salvador15863-2216,210,5683.55Honduras200100--3008,480,6713.53México2,4563,284335NDA6,122115,695,4735.29Paraguay157129203066,333,9764.83Perú813335142291,39129,264,3184.75República Dominicana45533711246839,813,2106.96Uruguay221-25-2463,368,9347.30aModified from the Pan American Health Organization.5bPopulation number corresponds to 2011, according to the World Bank.9cMedical residency positions refer to the total number provided each year in each LA country. NDA = no data available.Regarding sleep medicine, practitioners in LA have initially been trained outside their countries of origin, but the possibility of local training has recently begun to be available. Brazil has a full-time medical program for sleep medicine named Residências Médicas em Medicina do Sono (medical residency in sleep medicine). It lasts for 1 year, and applicants must have previously completed a residency in internal medicine, otorhinolaryngology, psychiatry, neurology, pneumology, or pediatrics.6 Brazil also has a sleep medicine fellowship that lasts 2 years or around 2,000 hours, compatible with a part-time program. In this case, the terms medical residency and fellowship differ primarily in their duration, highlighting that both kinds of training are aimed at professionals who have completed a specialization program. In Mexico, sleep medicine is included in the neurophysiology program,7 which lasts 2 years and is a subspecialty of neurology, pediatric neurology, audiology, and rehabilitation medicine.8 In addition, the Universidad Autónoma de México offers a 1-year postgraduate course, High Specialty in Comprehensive Sleep Medicine.Only the Brazilian, Mexican, and Costa Rican governments recognize sleep medicine specialists (Table 3), but they use different terms. In Brazil, the Federal Council of Medicine and the Brazilian Medical Association recognize specialties and áreas de atuação (areas of performance). The latter are defined as a modality of organization of medical work, done by professionals qualified to perform specific medical actions, derived from 1 or more specialties.10 Consequently, sleep medicine is recognized as an área de atuação in Brazil. On the other hand, in Mexico, the Council of Clinical Neurophysiology recognizes the specialist in "clinical neurophysiology and sleep medicine" jointly, and in Costa Rica, sleep medicine is considered a subspecialty for anesthesiology, family and community medicine, internal medicine, pulmonology, neurology, otorhinolaryngology, head and neck surgery, pediatrics, and psychiatry.Table 3 Sleep training programs and sleep education in Latin American countries.CountrySleep Medicine Recognition by the GovernmentSleep Medicine FellowshipDental Sleep Medicine EducationSleep Education for Other Health Professionals (nurses, technologists, psychologists)ArgentinaNoNoNoNoBrazilAvailableYes*YesYesChileNoYesYesYesColombiaNoNoYesYesCosta RicaAvailableNoNoNoEcuadorNoNoNoNoMéxicoAvailableYesYesYesPanamáNoNoNoNoPerúNoNoNoNoUruguayNoNoNoNoVenezuelaNoNoNoNoYes indicates the presence of that type of sleep training or sleep education (courses or diplomas) in the country, according to the online research or interviews with other physicians. No indicates the absence of that type of training or sleep education. *Brazil has a fellowship and a residency program in sleep medicine.In addition to residency programs or fellowships, some academic institutions or medical societies offer sleep courses. The Mexican Sleep Society offers a sleep medicine diploma, the Mexican Academy of Sleep Medicine provides update courses, and the Universidad Nacional Autónoma de México offers a master's program in sleep disorders and a diploma in polysomnography and sleep medicine. The Pontificia Universidad Católica de Chile grants an online diploma of sleep medicine in clinical practice, and the Universidad del Desarrollo offers a diploma in ventilatory therapy in sleep breathing disorders. The Universidad Manuela Beltrán of Colombia offers a diploma titled Polysomnography "Titration and System 10/20," and the Universidad Austral of Argentina sponsors a sleep medicine diploma. LA physicians can also enroll in the online Master in Sleep: Physiology and Medicine program of the University of Murcia in Spain, which offers 65 European Credit Transfer and Accumulation System credits at completion and aims to update knowledge of physiology, sleep disorders, tests, and procedures. Likewise, the private organization CEVIPO offers the itinerant Latin American Diploma in Sleep Medicine, sponsored by a few academic institutions. None of these courses confer the legal authority to practice sleep medicine. They are aimed at introducing or updating knowledge with limited scope in the acquisition of clinical skills. Nevertheless, they can help improve a curriculum vitae for a physician to apply for a certification process.Certification and accreditation in sleep medicineHealth care quality regulation has 3 approaches: licensing, certification, and accreditation. Licensing is a statutory mechanism by which a governmental authority grants permission to an individual practitioner to deliver health care services. Certification is the process of evaluation and recognition of an individual or an organization by a recognized authority (governmental agency, professional association, or specialty board) for meeting predetermined requirements or criteria for a specialty area. It provides evidence of having the knowledge, skills, and educational experience to ensure quality patient care in a specific field.11 In the same way, accreditation is the process of assessment and recognition of a health care organization for meeting pre-established performance standards by a recognized body (governmental or nongovernmental).11 However, its Spanish translation, acreditación, is also used for individuals in LA, as found on the Web pages of the sleep societies of Colombia and Argentina, who have developed their own certification processes for sleep specialists.12,13 Likewise, the term acreditación is used on the Web site of the Spanish Sleep Society to announce the certification exam in sleep medicine.14 Taking into account the cited definitions, the term acreditación used in these contexts is equivalent to the definition of certification.The Brazilian Medical Association concedes the certification of área de atuação in sleep medicine to specialists who have demonstrated completion of the medical residency program of sleep medicine in accredited services or proof of training in the area of sleep medicine for 2 years. The candidate must pass a theory test and the theory-practice test to obtain the certification.15 Moreover, the Brazilian Sleep Association sponsors certification in dental sleep medicine, polysomnography technology, phonoaudiology, and psychology in the area of sleep.In Mexico, sleep medicine certification is given within the framework of the clinical neurophysiology specialty regulated by the Mexican Council of Clinical Neurophysiology. According to its statutes, it offers certification and recertification as a specialist in clinical neurophysiology and sleep medicine to physicians who have completed the specialty of clinical neurophysiology at recognized centers by the Universidad Nacional Autónoma de México. The candidate must a pass curriculum evaluation or an exam to be certified.7 In the same way, the Mexican councils of neurology and psychiatry offer sleep medicine certification for neurologists and psychiatrists respectively through a certification exam.16,17Table 4 shows a comparison between the requirements for sleep medicine certification in the United States and LA countries.Table 4 Comparison of certification criteria between the United States and Latin American countries.United StatesBrazilMéxicoColombiaArgentinaOffered byABA, ABFM, ABIM, ABOto, ABP, and ABPN (Sleep Medicine Certification Program jointly developed by these boards)Medical Brazilian AssociationMexican Council of Clinical Neurophysiology, Mexican Council of Neurology, and Mexican Council of PsychiatryACMESAAMSRequirementsPreviously certified in an eligible specialty or subspecialty by ABA, ABFM, ABIM, ABOto, ABP, or ABPN. Candidates apply for certification through their respective boards.Hold a specialist degree conferred by the Brazilian Medical Association or the National Commission of Medical ResidencyHold a specialist degree in neurology, pediatric neurology, audiology, or rehabilitation medicine;a certification in adult or pediatric neurology;b certification in psychiatrycMedical specialty related to sleep medicine recognized in ColombiaHold a medical degreeComplete requisite formal training requirements* (1 year of full-time training in an ACGME-accredited sleep medicine fellowship program)Demonstrate completion of medical residency program in sleep medicine in accredited services or proof of training in sleep medicine, performed in a period of 2 yearsHave studied the specialty of clinical neurophysiology in centers recognized by the National Autonomous University of Mexico;a Have studied the course of High Specialty in Sleep MedicinecCurriculum vitae indicating experience in sleep medicine (rotations, courses, diplomas)Curriculum vitae evaluation by AAMS Accreditation CommitteeDemonstrate clinical competence, procedural skills, and moral and ethical behavior*No specific commentaries about ethics on the Web siteHave impeccable professional conductcNo specific commentaries about ethics on the Web siteNo specific commentaries about ethics on the Web siteHold a valid, unrestricted, and unchallenged license to practice medicine*Be a doctor regularly enrolled in the Regional Council of MedicineProvide a specialty diploma legally registeredProvide a specialty diploma legally registeredProvide a diploma legally registeredPass the Sleep Medicine Certification Examination* (exam administered by ABIM)Obtain at least 60% of correct answers in theory test and theory-practice testPass curriculum evaluation or pass an exam;a pass an examb,cPass an examPass a course and an exam*General requirements of the ABIM, used as a reference because all the boards have similar requirements. aRequirements only for the Mexican Council of Clinical Neurophysiology. bRequirements only for the Mexican Council of Neurology. cRequirements only for the Mexican Council of Psychiatry. AASM = Argentine Association of Sleep Medicine; ABA = American Board of Anesthesiology; ABFM = American Board of Family Medicine; ABIM = American Board of Internal Medicine; ABOto = American Board of Otolaryngology; ABP = American Board of Pediatrics; ABPN = American Board of Psychiatry and Neurology; ACGME = Accreditation Council for Graduate Medical Education; ACMES = Colombian Association of Sleep Medicine.DISCUSSIONThe prevalence of sleep disorders and their social and economic impact is increasingly recognized, as is their association with the impairment of health1 and quality of life.2,18 LA sleep societies have reached different levels of consolidation and influence on society and education programs. Their activities have increased compared with previous years,3 which is praiseworthy, taking into account all the determining factors to overcome such as social and economic conditions, sophistication in the health system, and demographic and epidemiologic settings. However, online information is scarce and limited about sleep societies and details of certification and training courses. This limitation reveals lost opportunities for communication, social impact, and recognition.Sleep medicine is not only an extension of closely related medical specialties. It is also a new transdisciplinary area that integrates different disciplines to create a new holistic perspective. This approach includes the role of primary health providers,19,20 who generally have few opportunities for training in sleep medicine, leading to the chance that sleep disorders could pass unnoticed or mistreated. Moreover, only some LA countries have sleep training for nonmedical health professionals and technologists (Table 2), emphasizing the need to include these practitioners in education policies.A low number of medical residency positions could be another limiting factor for the development of sleep medicine in a country, although it has surprisingly not been a limitation for Colombia. This country has an impressive increase in its number of sleep facilities in spite of having the lowest number of medical residency positions offered in the region (Table 3).5 This phenomenon could be attributed to Colombia's Law 100, which enables almost complete medical coverage for sleep studies and treatment for its entire population. As a consequence, this coverage has stimulated private investment in sleep centers across the country, with the advantages and risks that come with it.Not-for-profit organizations such as academic institutions or sleep societies and for-profit private institutions offer sleep medicine education. They have very different requirements, study plans, evaluation of academic goals, and, most important, uneven achievable competencies for an accountable clinical performance. In the majority of cases, sleep medicine courses are insufficient and their requirements are minimal, which could generate a false belief of competence and a risk for clinical practice. This scenario has encouraged some LA societies to develop their own certification process with different scopes and requirements (Table 4).Most LA countries face many barriers, as few opportunities for academic training, limited access to sleep facilities, and inequality in social, demographic, and economic development, making it difficult to create a certification process. Moreover, the diversity of terminology, regulatory entities, and requirements among LA countries increases the obstacles for a multinational certification project as has been developed in other regions.21 A proposed scheme of the requirements and barriers for certification in LA is summarized in Figure 1.Figure 1: Framework of requirements and barriers for sleep medicine certification in Latin America.Download FigureLimitations for this study were the amount of available online data and the difficulties in reaching some physicians to expand on the information. However, physicians who responded to the interviews are considered key opinion leaders in their country.In conclusion, training programs and certification processes are a result of available resources, management, needs, limitations, and policies. Moreover, LA sleep societies differ greatly from each other, with varied levels of consolidation and influence in their countries. All of these differences increase difficulties for a multinational certification project.DISCLOSURE STATEMENTAll authors have seen and approved the manuscript. Work for this study was performed at Hypnos Instituto del Sueño, Clínica San Felipe, Lima, Perú. The authors report no conflicts of interest.REFERENCES1. Santos-Silva R, Castro LS, Taddei JA, Tufik S, Bittencourt LRA. Sleep disorders and demand for medical services: evidence from a population-based longitudinal study. PLoS One. 2012;7(2):e30085. https://doi.org/10.1371/journal.pone.0030085 CrossrefGoogle Scholar2. 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Volume 16 • Issue 6 • June 15, 2020ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationDecember 12, 2019Submitted in final revised formFebruary 25, 2020Accepted for publicationFebruary 26, 2020Published onlineJune 15, 2020 Information© 2020 American Academy of Sleep MedicineKeywordsLatin Americasleep societiestraining programcertificationACKNOWLEDGMENTSSpecial thanks to Cesar Liendo, MD (United States); Arturo Garay, MD (Argentina); Liliana Estrada, MD (Costa Rica); Carmen Madrid, MD (Panamá); Julia Santin, MD (Chile); Rafael Lobelo, MD (Colombia); Andrés Marín, PhD (Colombia); Jorge Pezantes, MD (Ecuador); Dalva Pollares, MD (Brasil); and Ulises Jiménez Correa, PhD (México).PDF download
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