A Good Night’s Sleep for Soldiers: One U.S. Army Doctor’s Career
Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
By Special Guest Contributor, Col. Vincent Mysliwiec, MD
U.S Army sleep medicine specialist discusses his path in medicine and how his clinical research may have helped detect a new sleep disorder, allowing soldiers and civilians to sleep better at night.
Col. Vincent Mysliwiec, MD, is at the forefront of U.S. Army sleep research. He is currently assigned to the 121st Combat Support Hospital in Seoul Korea as a Sleep Medicine Specialist. He has dedicated his medical career to learning more about risk factors and treatments for sleep disorders in soldiers. He was accepted to medical school at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and went on to do his residency in internal medicine at Tripler Army Medical Center in Honolulu. During his Pulmonary, Critical Care and Sleep Medicine Fellowship at Brooke Army Medical Center in San Antonio from 1999 to 2002, Dr. Mysliwiec discovered opportunities to dive into the relatively new and under-recognized field of Sleep Medicine. As Operation Iraqi Freedom began, he and his colleagues discovered soldiers were being affected by sleeping disorders such as insomnia, coupled with symptoms of associated conditions like Post Traumatic Stress Disorder (PTSD). They began to examine how the war affected soldiers' sleep habits and behaviors. Recently, Col. Mysliwiec and his colleagues at Madigan Army Medical Center published an article on a newly proposed sleep disorder, Trauma Associated Sleep Disorder, which primarily affects combat veterans. Col. Mysliwiec is one of the U.S. Army's 26 sleep medicine specialists who evaluate tens of thousands of patients each year for sleep disorders.
Often times when one chooses the career of a doctor, there’s a clear road to follow. For my journey, that path looked a bit different, as I’ve always had the desire to serve my country as well. For as long as I can remember, I’ve wanted to join the military, just like the soldiers, sailors, airmen and marines whom I would see at parades. I aspired to be an individual who was proud of what I was doing by both serving my country and helping others.
When I entered the U.S. Military Academy at West Point in the summer of 1988, I was driven to excel. The career opportunities for a U.S. Army physician are plentiful — surgery, family practice, internal medicine, pediatrics, psychiatry — to name a few. However, it was a particular issue I had during my time at West Point that turned me to sleep medicine. During my time at West Point, the academics, sports, and extracurricular activities were numerous, as were the required military duties. To get the most out of the experience, the aspect I thought I could sacrifice was sleep. Frequently, I would sleep for only four hours or less per night. Needless to say, this short sleep duration resulted in difficulties trying to stay awake long enough to get through the day. It got to the point where I fell asleep while standing during one of the lectures by world-renowned Brig. Gen. Charles Brower, who had served as the U.S. Army Aide to President Reagan. The importance of sleep and its implications on my military medical career have persisted.
After West Point, I attended the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland, with my wife, who is also a military doctor. We’ve been fortunate enough to have always worked in the same military hospital since we were married 21 years ago. Following medical school, we moved to Tripler Army Medical Center in Honolulu, Hawaii, for internship and internal medicine residency.
I choose internal medicine as my focus because I appreciated the variety of illnesses and breadth of this medical specialty. In the U.S. Army, you’re not only encouraged to pursue your interests, but you’re supported. Internal medicine afforded me the opportunity to learn about aspects of many disease states and how they affected patients. This knowledge continues to help me daily as nearly all medical and psychiatric illnesses affect sleep in some way.
As my first duty assignment, Tripler was a wonderful demonstration of how U.S. Army Medicine was a team effort. When you are in the military, your fellow soldiers are your extended family. At Tripler, the house staff formed this extended family; we frequently gathered on weekends to spend time together and many of my fellow residents continue to remain life-long friends. The beaches of Hawaii were also a welcome bonus that made our time away from medical training relaxing.
After residency, my wife and I went to Brooke Army Medical Center where I was a pulmonary, critical care, and sleep medicine fellow. While I had initially pursued this fellowship track to care for critically ill patients, it was the relatively new specialty of Sleep Medicine that piqued my interest.
My initial interest in sleep medicine came from my knowledge — and living example — of the significant effect you could have on patients by treating their sleep disorders. Obstructive sleep apnea (OSA) was finally gaining awareness as a medical disorder and with continuous positive airway pressure treatment you could improve not only patients’ sleep, but their daytime performance. The implications of this on military personnel are critical, especially because they typically received six hours of sleep per night, fewer than the recommended eight hours that can help ward off fatigue and other issues.
During Operation Iraqi Freedom and Operating Enduring Freedom, the spectrum of sleep disorders and the importance of sleep were magnified. During times of war, U.S. Army physicians are placed throughout the globe to help oversee the health and safety of soldiers, which often leads to new discoveries in medicine and therapy.
Prior to Operation Iraqi Freedom and Operation Enduring Freedom, sleep was viewed as something you could sacrifice. Military personnel did not have sleep education or sleep training; sleep just happened. Two years after the start of Operation Iraqi Freedom, we witnessed a marked increase in the number of soldiers with sleep disorders, and we saw the cases get more complex in our clinical practice. Diagnoses of obstructive sleep apnea increased six fold and insomnia greater than 20 times during Operation Iraqi Freedom and Operation Enduring Freedom. Along with this, there were soldiers who had complex sleep complaints of disruptive nocturnal behaviors (tossing, turning, thrashing, yelling, and striking out) in the context of traumatic dream enactment. As a sleep medicine physician in the military these issues resulted in major medical challenges — managing the growing number of active duty personnel with sleep disorders; studying the change in the presentation and prevalence of sleep disorders and working within the military to enact the required changes for sound sleep.
As a Lt. Col. at Madigan Army Medical Center, after completing my fellowship training I was able to institute clinical changes, perform world-class research, and work on one of the largest preventive health care reforms ever implemented to address the sleep medicine challenges we faced. Still relatively early on in my career, I was helping implement health care reform and performing research that’s never been done before. Opportunities for unexplored research, excellence in training, and being on the cutting edge of medical innovation and advances remains one of the best benefits of working for the U.S. Army. It was during this time that I was also able to fill a medical leadership role.
As the Chief of Sleep Medicine at Madigan Army Medical Center, I was fortunate to have institutional support to lead the development of a soldier-centered sleep home. When I arrived at Madigan, there were two sleep physicians. Over the course of eight years, we grew to a multi-disciplinary team consisting of five board-certified sleep medicine physicians, in addition to nurse practitioners and physician assistants, respiratory therapists, and sleep psychologists. In this clinical model, we provided world-class clinical care to address the sleep disorders of soldiers, and improve both their sleep and their responses to other treatments for post-traumatic stress disorder and traumatic brain injury. Witnessing the clinical changes, it required research to explain the nature and etiology of the sleep disorders that we conducted.
Prior to this, there was little scientific data regarding sleep and sleep disorders in military personnel. During this time, I had access to scientific colleagues and innovative researchers who assisted me in defining the prevalence of sleep disorders in military personnel. We found that comorbid insomnia and obstructive sleep apnea, two sleep disorders co-existing at the same time, were in fact the most frequent sleep diagnosis in military personnel. To explain the frequently reported complex, disruptive nocturnal behaviors of soldiers, we published a study on a proposed new sleep disorder, Trauma Associated Sleep Disorder. Ideally, by recognizing these disorders, we would look to prevent them in the future.
U.S. Army Surgeon General, Lt. Gen. Patricia Horoho, proposed the Performance Triad with the tenets of sleep, activity and nutrition. As one of only 26 sleep medicine specialists in the U.S. Army, and a recognized expert in Sleep Medicine, I have worked with the Sleep Working Group, a panel of recognized sleep medicine experts, to develop recommendations to improve the sleep education and training of U.S. Army soldiers. As part of the system for health, my input into developing scientifically valid, operationally sound sleep will help ensure soldiers sleep better in the future, which can improve their safety and optimize their performance.
My military medical career is unique and rewarding. Its generous financial benefits have allowed both my wife and I to be practicing physicians debt-free. It has also provided opportunities to advance clinical practice, make scientific discoveries, and work on a global preventive health measure that helps make a real difference in our soldiers’ lives, and eventually, civilians as well. Throughout this time, I have also been fortunate to eat lunch with my wife on most days — even as a busy, military physician.