A Simple Patient-Centered Approach to Improving Your Sleep

We visited this week to sleep again, as we do often. And I personally do not believe, and I know a lot about sleep, but I don’t believe you can talk about it often enough because it’s like tapping a hoop along. You’ve got to keep that hoop going by paying attention to it and being vigilant about it, and just developing really good sleeping habits. 

I remember when my daughter was born 36 years ago, the pediatrician gave me what I believe was probably I didn’t realize at the time the best advice any doctor could give any patient of any age. But she was giving my wife and I advice about our newborn baby. And she said, “The thing you have to teach your child to do in the first year of life is to sleep well.” And we dismissed that as a ridiculous notion. How can you teach someone to sleep? They either do, or they don’t. That was 36 years ago. I’ve learned a lot about sleep in that time, and I keep learning more about it. 

Sleep is your built-in non-negotiable life support system. It’s free. It’s accessible. Its effects are profound on your physical, mental, and emotional health, and you cannot hear that often enough. I’m often asked how, you know, like, we recommend certain things about sleep to people, and they say, “How often should I think about that?” Or “How often should I wear this appliance?” Or “How often should I perhaps put tape on my mouth at night?” And I go, “Look, only do it on those nights that you want to sleep well.”. 

And a lot of people will look at me and go, Oh, okay, that’s fine. And miss the point that you should be trying to sleep well each and every night. Now I know we don’t. And the last few episodes with sleep psychologist Rosemary Clancy and again with Dr. Dave McCarty, we talked about Insomnia and what we can do about it.

Dave has a wonderful approach to medicine, to his patients, and to practitioners that he teaches. And it’s a very patient-centered approach. And I’m often asked because that’s how we’ve described our practice at the Sydney Holistic Dental Centre. You know, we’ve described ourselves for the last 40 years as a patient-centered practice, and the obvious question is: What kind of practices are there? And there are many. 

One type of practice is a symptom-based practice which many of you will have experienced in your 7 to 10-minute consultation with the GP. You go into a GP or maybe even a dentist, and you’ve got a broken tooth, and the person will fix it, and that’s it. Or you’ll get a prescription from your doctor for your infection, for your inflammation, for your pain, for your poor sleep, for your depression, for your anxiety. There’s a pill for every ill, and that is a symptom-based approach. 

Another approach is a practitioner-centered approach where the practitioner places themself at the center of the patient-practitioner interaction. And I’ve had the experience with some particularly specialists, but some who just feel that you are just so privileged to be in their presence and what they say goes and what they don’t know doesn’t matter. And if they don’t know, they will definitely not tell you they don’t know. They will just say there’s nothing wrong with you. That is a practitioner-centered approach.

And another approach is a financial approach, where it is all about upselling and trying to maximize profits. No.

A patient-centered approach places the patient at the center of the entire experience and, in our practice, all of our practices. I mean, I’m fortunate to have five seem to be six partners, and we all have a very common approach to our patients. If it was us, if it was me sitting in the chair, if it was my wife, it was my daughter, it was my best friend, what would I be advising this patient, knowing everything that I know? And that is a patient-centered approach, the treatment appropriate to a patient.

The Bay of Narrative

But Dave has a wonderful approach, not just patient-centered, but he takes people on a journey, and I thought I might just share with you that journey. So if you’re looking at this on YouTube, feast your eyes. If you’re not, that’s fine. I’ll describe what it is. Now in Dave’s approach, he says sleep apnea finally has a map, and he invites his patients and practitioners to walk with us. And he starts in The Bay of Narrative. 

And this is your first stop on the island. A sort of educational loading zone where you learn how to talk about your own sleep experience to come up with your own set of Sleep-Wake Complaints. Now, this is so important because some people’s experience of sleep is their own. It’s very personal. But as a practitioner who’s been focused on sleep now for over 20 years, and that’s me and Dave, whose entire career has been focused on this, we get to see a lot of patients of varying kinds of sleep, and we read a lot of literature about it. 

So your experience and this is a common thing where a patient will say, “How are you sleeping?” And they’ll say, “I sleep just fine.” And they go, “Well, do you wake up feeling refreshed?” “I don’t know. I’ve never done that.” As though that’s not unusual. As though why? What? What’s waking up refreshed got to do with sleep? I sleep well. 

The fact that I don’t wake up feeling refreshed has got something. There’s something else related there. Well, no. You need to be in The Bay of Narrative and learn about what is possible. You learn some of the languages of the isle as we explore the different flavors of sleep apnea. Who knew? There are two: obstructive sleep apnea and central sleep apnea. 

Obstructive being a blockage of the airway around the pharynx. It’s got to do with your mouth size, your upper airway size, your tongue size, with the tone of your laryngeal and pharyngeal muscles. And the fact that 95% of the population doesn’t have enough room for all of their teeth tells us that we’re starting behind the eight ball from almost birth, and that is, we almost all have narrow jaws and crowded teeth to varying degrees. 

Thank goodness the human body is more adaptive, and that doesn’t mean you necessarily have a problem, but it predisposes you to some. Legend has it that they all will only let you leave The Bay of Narrative after you’ve learned what you’ve come there to learn. The isle is kind of magic like that. And Dave even introduces some bird calls, real bird calls, in the first 10 minutes of this week’s episode.

Five Reasons to Treat Monument

So after The Bay of Narrative, he then goes to the Five Reasons to Treat Monument (and Coffee Hut!). After you’ve learned what you’ve needed to learn at The Bay of Narrative, you’ll magically find your way to the Five Reasons To Treat Monument (and the Coffee Hut!). Now the monument is large, unwieldy, and irrefutable. This is set in stone. 

There’s nothing that changes about that. Sphinx, like Dave, says. Its towering presence reminds us that there are five reasons to treat sleep apnea. “Risk” being the first one. It predisposes you to so many health risks, physically and mentally. Snoring is not just a social problem that your partner is complaining about. “Snoring” is a reflection that you have a partially blocked airway. So that is important. And it is the second of the five reasons.

“Sleep” itself. How well are you sleeping, and what does a consistently good night’s sleep mean? Well, it’s a function of both quantity, getting 7 to 9 hours of sleep a night, and quality breathing well while you’re asleep. So Sleep is the third reason for the monument. The fourth reason is “Wake”. How are you when you are awake? Are you tired? Do you have the energy to fulfill your potential in life? Because ultimately, that’s what I believe. 

The meaning of life is fulfilling your potential to be the best you can be, whatever that means. And finally, the final reason in the five reasons monument is the “Co-morbidities.” Co-morbidities are things like cardiovascular disease, cancer, the over 100 autoimmune conditions, that is, the body attacking itself. Things like irritable bowel, coeliac, psoriasis, rheumatoid arthritis, multiple sclerosis, Parkinson’s. There are over 100 autoimmune conditions. Diabetes is another serious co-morbidity that predisposes you to all of the above. Obesity is also a potentially serious co-morbidities.

These five reasons will never change. The monument is to be regarded as a permanent structure. Though it’s wise to pay respect to the immutability of the five reasons paradigm, the real action for you happens at the Coffee Hut. That’s where the good conversation takes place. People feel comfortable at the coffee hut. Over Pie and Coffee, you will parse out these reasons carefully. Putting them into context, context with everything you’ve learned during your time wandering around The Bay of Narrative. 

The River of Decision

So see, you’ll need to have this conversation firmly in mind before you make it across the river to the River of Decision. And this is why a 7 to 10-minute consultation in a symptom-based practice or even in a practitioner-based practice, is just simply just doesn’t cut it. You know, if you’re serious about sleep, enter The Bay of Narrative. Pay respect to the Five Reasons Monument. And then let’s talk about The River of Decision. After your Coffee Hut discussion, you’ll have an important decision to make. Do the reasons you’ve come up with at the Coffee Hut. Justify fording a deep and turbulent river, the legendary River of Decision.

If the answer is yes, you’ve got another decision to make. How are you going to get across? How are you going to overcome this problem of sleep-disordered breathing? Before embarking, you’ll set some goals based, of course, on the five reasons discussion you had while enjoying pie and coffee at the coffee hut. Don’t you just love this kind of journey? It’s just… I love it. I love it.

Now you’ll then take careful stops at the different modes of transport. These are the different treatment options. Positive airway pressure therapy is one CPAP, and there are many sleep clinics who will diagnose you with mild, moderate, or severe obstructive sleep apnea and then will immediately recommend to you that you buy a CPAP machine. And this is a combination. 

You have entered a financial and practitioner-centered practice. You see? That’s what the different practices are all about. You’re learning not just about sleep medicine, but you’re learning about different practice philosophies because mild and moderate sleep apnea does not necessarily mean that you need a CPAP machine, which is a mask that fits over either your mouth or your nose or both.

Oral appliance therapy is another approach. That is, the jaw drops back at night and blocks the airway, causing you to snore or actually stop breathing. And they are called hypopnea, restriction in breathing, or apnea is a complete blockage of breathing. Sleep apnea. Complete blockage of breathing. And whether you have a serious condition, you actually can have a sleep study done which measures those episodes and how often that occurs in an hour.

Surgical approach is another one. I personally have very rarely, if ever, used surgical approaches, but I guess if you’re a surgeon in a practitioner-centered practice, then a surgical approach might seem appropriate. Certainly, large tonsils and adenoids are sometimes definitely required. And you know, it’s interesting to hear how many people have had a deviated septum and have a septoplasty. I’ve had that done once, and I had an ENT look in my nose about ten years ago. 

I had that done when I was 20, and an ENT looked in my nose and said, “Oh, you need to have it. You’ve got a deviated septum. You need to have your septoplasty done.” Well, I’d already had it done. And one of the reasons why that may not be addressing the cause. It may be a symptom-based approach to practice is because the reason people have a deviated septum is because they have a narrow, crowded jaw and a high palate. And the roof of the mouth, the palate, is also the same bone that is the floor of the nose. 

So if it’s broad and flat, the septum, which is like a T-junction there, has plenty of room. But if the floor of the nose is vaulted, then the septum will deviate. So surgical approaches hyperglycemia nerve stimulation therapy. I’m not even sure what that is. Dental Orthotropic Therapy. This is about expanding jaws and creating more space within the mouth of the tongue and also more space in the upper airway. And this is all about epigenetic potential, and it is not restricted to children. I’m embarking on this therapy myself at the age of 67.

Buteyko breathing, of course. We’ve talked to Patrick McKeown, the CEO of Buteyko International, and we’ve also talked to Roger Price. And, of course, we’ve spoken to Dr. Rosalba Courtney, who I believe is a world authority. She has a Ph.D. in Breathing. I’ve had the privilege of doing her Integrative Breathing Therapy course. Six-month program. And it is much more than just Buteyko. I mean, Buteyko is a very valuable tool in the tool kit, but it is not the complete answer. And there are other therapies which you can go through in the River of Decision.

And once you’ve gone into the River of Decision, there is treated territory. The river decision defies the usual boundaries of physics and logic. So it’s never clear where you’re going to end up on the isle after you cross. Though everybody hopes for an easy deliverance to our ultimate goal, which is the pleasant dreams beach. The journey for some can be pretty bumpy. We won’t let you walk around in the thorny bush without guidance. 

These are Dave’s reassuring words. Here’s where we’ll take a detour into complications and competing diagnoses, which are everywhere in these parts. We’ll explore the many phases of sleep pressure toxicity. He looks at a whole range of different things about sleep pressure. And interestingly, we talked about that in our episode this week. And we explore the badlands in insomnia, and we talk about cognitive behavioral therapy for insomnia. CBTI, which we also discussed with Rosemary Clancy.

Five-Finger Approach Mountain

And then there is the Five-Finger Approach Mountain. The navigation in the treated territory can be difficult because it’s likely that there will be some several elements contributing to the Sleep-Wake Complaints you discovered during your time in The Bay of Narrative. Next-level orienteering requires an elevated viewpoint. And it’s interesting. Here on the aisle, the best spot to gain your bearings is Five-Finger Approach Mountain. You’ll tour this geological oddity to gain insight into your own experience, evaluating your own history for clues of the following. And this is really important, and I wondered whether, perhaps before we got into the Treated Territory, this would be a good place to explore as well because there are parts to this that are important. 

Now we talk about sleep pressure, and there are two things which drive sleep. One of them is sleep pressure. As soon as we wake up, the cortisol levels start to elevate. And that’s what makes us up in the morning. And as soon as we start moving, our body starts to produce energy, and we go out in the sunlight, and we get a message that the sun is up and melatonin is starting to be produced. 

If you get that sunlight, and also you start to move and you start to use energy, which the currency of energy in the body is adenosine triphosphate (ATP), it’s what mitochondria do. And adenosine is really an integral part of producing sleep pressure. And so that is why the more you exercise, that’s why exercise is such a positive aspect to sleep, but so is getting out in the sun.

And circadian misalignment is a really important issue for us in our modern world because we’ve been warned about the sun. We’re about to do a fabulous episode on Vitamin D and Sunlight with Dr. William B Grant, but I digress for a moment. But circadian misalignment is a huge and growing problem because sunlight has been demonized, and we surround ourselves with blue light. And that comes from our devices in our phones, in our laptops, on our computers, in our LED cool lights. You know how light bulbs don’t get hot anymore? 

Well, the ones that got hot were called incandescent lights, and they were down the red end of the spectrum. Red, orange, yellow, green, blue, indigo, violet. You know that that is the spectrum of light. Well, red the incandescent red light, which is actually good for us, is hot. And we don’t have hot lamps anymore. We have LED lights, so our houses are bathed in blue light, not just our devices but our houses. And that is why creating proactive wind-down time is so important in dimming the lights in the house and getting off devices.

Pharmacological influences are huge. Dave talks about beta blockers. Rosemarie Clancy talks about some benzodiazepines like Valium, which interfere with sleep, and alcohol is another one. Medical influences, psychosocial and psychiatric influences are big. I mean, you know, when you’re really stressed, it’s hard to sleep, and primary sleep diagnosis comes back into it. 

Remember that from the Bay of Narrative – do you have obstructive sleep apnea? Narrow jaws? Crowded teeth, small upper airways, loose pharyngeal and laryngeal muscles? Too much weight around the neck? Etc., etc. So these are primary sleep diagnoses, and ultimately you end up in Pleasant Dreams Beach. Everybody on the aisle hopes they’ll end up there at Happy Z’s, sheep counting ranch, located on the pristine shoreline of sleep dreams. Pleasant Dreams Beach. It’s really great there. And they serve good gumbo, too. You can tell those from Louisiana. 

Everybody wants to be here for sure. But too many poor souls get lost along the way, lost in the vast territory of complications and competing diagnoses. Some never find their way, and they live in the wild parts of Treated Territory forever. Some just give up, abandoning all hope, and go back to the untreated territory to mope and throw rocks at the medical system. Good thing we made it to Pleasant Dreams Beach. 

Anyway, this was a great way of just reviewing sleep and its complications of it and tying it all up in one healthy body. But we’ve had so many great episodes. We started off with the sleep physician that I use as a doctor and desire. I’ve spoken to the Sleep Whisperer, Chris Winter. I’ve had various conversations with Dave McCarty now and Rosemary Clancy, and this is an issue we’re going to continually learn more about and revisit. I hope this finds you well. Until next time. This is Dr Ron Ehrlich. Be well.

This podcast provides general information and discussion about medicine, health, and related subjects. This content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.