Editorial board member Alex McDonald, MD, sits down with Indira Gurubhagavatula, MD, MPH, to explore why conversations about sleep are missing in the exam room and how clinicians can help close the gaps.

Tune in next week for part 2 of their discussion.

Indira Gurubhagavatula, MD, MPH

Alex McDonald, MD

This transcript has been edited for clarity.

Welcome back to PeerPOV: The Pulse on Medicine, a podcast series by Physician’s Weekly showcasing the latest insights from your peers across the medical community.

This week, editorial board member Dr. Alex McDonald speaks with Dr. Indira Gurubhagavatula about how clinicians can better address sleep in the exam room.

Dr. McDonald: Welcome everyone to today’s Physician’s Weekly PeerPOV podcast. We are here to talk about one of my favorite topics, and that is sleep. I love sleeping. I just saw a toddler recently at a family event who was crying and screaming because they didn’t want to go take a nap. I was like, “Man, what I would give to take a nap.” But anyway, I digress.

I am very excited. We have a guest here from the American Society of Sleep Medicine. I am not going to butcher her name, so I’m going to call her Dr. G. Dr. G, thank you so much for joining us, and tell us your full name because Dr. G does not suffice.

Dr. Gurubhagavatula: It’s Dr. Indira Gurubhagavatula. I am professor of medicine at the University of Pennsylvania and I am on the board of directors for the American Academy of Sleep Medicine.

Dr. McDonald: Wonderful. Thank you so much. I really appreciate your being here. This conversation came out of some findings recently, with the American Academy of Sleep Medicine’s annual sleep survey, asking physicians and patients about sleep. Can you summarize some of the key findings from that sleep survey?

Dr. Gurubhagavatula: Yeah, it was an online survey of over 2,000 adults all over the US. It was done in June 2025 by an independent research agency. The results showed that nearly half of adults, 45% to be exact, have not talked about their sleep with any health professional at all. Only 15% of all adults that were surveyed reported that they discussed their sleep with an actual sleep specialist. These numbers are very low.

Dr. McDonald: Yeah. You had mentioned this before, when you were sort of the green room, that sleep is the Cinderella specialty—it’s really important, but everyone forgets about it or neglects it. As a family physician, I’m passionate about diet, sleep, exercise, and stress relief as the four foundations of a good health, regardless of what we do on top of that. So, the fact that a lot of people are not talking about sleep with their doctors is a little concerning.

We know sleep is essential. I think that’s sort of unequivocal at this point, but the question is, why aren’t people talking to their doctors? Why do you think these conversations aren’t happening?

Dr. Gurubhagavatula: Well, it takes two to have a conversation. There are probably things happening on both sides, on the patient side and on the clinician side.

As far as patients, sleep is not like a discrete localized anatomic structure. It’s not like, “Oh, my knee hurts” or “I have this rash.” It’s not a discrete organ or organ system either, like GI or heart or lung. So, I think it’s this general, vague, all-over type of a phenomenon, and people sometimes don’t think of it as something to report.

I also think that our patients underestimate how important it is, they don’t necessarily connect it to whatever morbidity or complaints they’re experiencing. I think there is that awareness piece, and the underestimation of sleep’s value. We live in a culture where there’s machismo in getting away with only a little bit of sleep.

Dr. McDonald: Especially in medicine, right?

Dr. Gurubhagavatula: Especially. We are so guilty. And then there are things on the clinician side. Have you ever done a review of systems that had sleep as a line item?

Dr. McDonald: No, not really.

Dr. Gurubhagavatula: Yeah, right? Because it’s all the physical stuff—the head, the eyes—but we don’t really ask about the sleep. As clinicians, we’re not giving it the line item that it deserves in our general overview when patients come in. That’s one thing, that it is just missing from the repertoire of questions we ask.

The other thing is that a lot of people don’t even think of sleep itself as a specialty. I mean, starting from pre-med, to medical school, residents, and fellows—they don’t know that sleep is even a specialty. Think about the last time you registered for a meeting or signed up for an event, and they asked for your name, your title, employer, and then there’s a dropdown, and sleep is missing. It’s not listed as a specialty.

But it’s been one for 20 years. We’ve been around. It’s just that people aren’t thinking of it. I think they know that it’s important. It’s just connecting the dots and then bringing it to life.

Dr. McDonald: Yeah. And as a family physician, I’ll be honest, when I’m in a patient meeting, and it’s 20 minutes, and they have their laundry list of things and I have my laundry list of things, sleep usually falls to the bottom.

In rare moments, usually with young men who are there because their wife, mom, daughter, or sister sent them, who don’t really have anything to complain about and they’re just there for a “physical,” I’ll start going into my what I call my lifestyle review systems: diet, sleep, exercise, stress relief. I will ask those things specifically, but it’s not the first thing I ask, and it’s usually only when I have time to ask those things. I’ll be honest, it’s pretty rare.

Dr. Gurubhagavatula: You’re not alone, and I appreciate you sharing that. I think the audience needs to hear that. None of us are alone in this. I think you’re absolutely right. We ask a lot of our family physicians, internal medicine, all our frontline doctors, the first line that patients come to. There’s just so much asked that it’s hard to get it all in.

Dr. McDonald: Yeah. There’s not enough time in the day, let alone time in a physician-patient appointment. One thing that kind of stuck out for me is that there’s a gender gap here in that the survey found women were 10 points less likely than men to have never discussed sleep with a healthcare professional, but we know that women tend to engage more with the healthcare system. That disconnect sort of struck me as funny. Tell me what your thoughts are, and why that may be.

Dr. Gurubhagavatula: It is fascinating that women experience sleep problems at disproportionately higher rates. They engage with healthcare more, probably because of childbirth and such. And yet, they talk about sleep with their healthcare professional even less often than men do.

Again, I think that it’s about connecting the dots. There are sleep disorders, and then there are sleep complaints. There are sleep disorders that don’t necessarily present as a sleep complaint like sleepiness, especially in women. They may just have a general sense that something’s off (eg, I’m not well, I have malaise, a lot of headaches, or even mood problems like low mood, I’m a little more edgy or irritable or anxious, not as motivated).

And then what happens if a woman reports these symptoms is that it gets attributed to a mental health disorder. They’re more likely being referred elsewhere if this come to attention at all. I’m not saying that there can’t be a comorbid mental health diagnosis; it’s just that it doesn’t rule out that there could be a primary sleep disorder. So, we just need to be less quick to write off when women do come forward, and encourage them to talk about their sleep and elicit those specific concerns.

Dr. McDonald: When a patient comes in with poor sleep or poor sleep hygiene, sometimes they’ll complain about sleep latency or frequent nighttime awakening, which helps you focus. But I think one of the challenges that I have is that when patients come in with vague, non-specific complaints, it’s hard to pin that down.

Often, I’ll talk about mental health, I’ll talk about sleep, and I’ll talk about physical activity when these complaints aren’t really adding up. But the first thing we’re trained to do is check a CBC and make sure they’re not anemic, check a TSH and make sure they’re not hypothyroid. There are all these other things we are trained to think of first, and sleep is often the last thing. Sometimes, in my experience, it takes a couple of visits and really getting to know these patients.

I think that’s one of the values of primary care and its continuity. I develop these relationships with these patients over time, and I can pick up where I left off saying, “Well, we checked your labs. We know it’s not an organic problem causing these vague symptoms. What’s next?” And we can dig down a little bit deeper.

But I know not everyone has a usual source of care or primary care doctor, which makes that even harder, when patients are working in this sort of patchwork, disjointed, dysfunctional disease-care system that we have in this country.

Dr. Gurubhagavatula: I think you’ve hit on a lot of the major points, and I also think that there’s this normalization that happens regarding what’s actually pathology. One of the groups you talked about is women. The other group where a gap was found was older adults.

We tend to think of snoring as just something we do as we get older, or that getting sleepy or falling asleep at different times is just my body aging. People who have insomnia may just say, “Well, that’s a mental health problem,” which still has stigma, and people don’t want to acknowledge that.

I think that we tend to misattribute some of these symptoms to regular aging—this is just what happens when I gain some weight, or it happens when I’m tired or if I have a beer or two—and not necessarily think that it’s something that needs further exploration.

And nobody wants a diagnosis, right? I think that there’s also not wanting the stigma of being labeled with a disease. People already have seen CPAP masks, and they have views and feelings about it, and they’re like, “Oh, I don’t want that thing.” So, there may be reluctance for all kinds of reasons.

Dr. McDonald: Yeah. I think that makes perfect sense. You touched on the age piece, which I want to go back to briefly. Again, 64% of older folks have never brought it up. It’s seen as a generational piece, where this is just part of what happens. It’s always a joke when grandpa falls asleep at the dining room table at 5:30 PM, but that’s not normal, quite frankly. Am I right?

Dr. Gurubhagavatula: Yeah. The adolescents are the ones that have what’s called delayed sleep phase, where they’re able to stay up till two, three, four in the morning, and they sleep until noon or 4 PM the next day. There are therapies for that, to help realign your sleep schedule with what’s expected of you in the daytime.

As we get older, there’s this other type, which is you fall asleep at only five or six o’clock and you’re wide awake by 2 AM, and the sleep itself is normal. Only the timing is off. This is not normal. It is an age-related thing, usually. It’s called advanced sleep phase syndrome.

Those are the kinds of things that, if you were to seek help for it, it could give you back your time with your grandchildren, help you stay awake through a dinner conversation, or help you engage with your partner or go out for a walk or whatever it is you like to do in the evenings. It gives people a little bit of quality of life back.

Dr. McDonald: Yeah, definitely. Drilling into the age piece a little bit deeper, the group aged 35 to 44 years seems most likely to have seen a specialist. Maybe there’s more of an awareness in the—I don’t know if those are the older millennials or the younger Gen Xers—that sleep is something important, and there are sleep specialists out there. Do we think maybe there’s a culture shift happening, or is that just luck?

Dr. Gurubhagavatula: We need to study it more to be able to pin down what’s happening. I think people are much more aware now because of the many streams of information we have coming in at our fingertips. There’s misinformation coming, too, but I also think that when you look at working-age adults, that’s a different group, because they’re experiencing the problems of nonrestorative or disordered sleep at work.

They may be late or missing days, their performance may be suffering, they’re making more errors (or sustaining injuries for people who are doing physical work, requiring more days on disability). So, sometimes they’re upset. They come to us and say, “Hey, I got laid off or I got cited because I was falling asleep at my desk,” and then they’re ready to do something about it because that’s serious enough to want help.

Then, there are the people that are professional drivers. They’re in the ridesharing industry, or they drive these huge big rigs or drive a train or a truck. There is a screening process in place when they get their professional big rig and such. There is a system to pre-screen them, and screening is required before they get their commercial driving license. Some people are contemplating it, and they see their primary doctor before they go forward, and sleep can be addressed there.

Dr. McDonald: Interestingly, only 30% of adults actually talk to their primary care doctor about sleep. That’s basically one-third. What do you wish we in primary care were doing differently or better when it comes to addressing sleep?

Dr. Gurubhagavatula: Well, sleep apnea is exceedingly common in middle-aged adults, and the prevalence just keeps increasing with age. It’s also very common now in pediatric groups. Obesity is a big driver. If you see somebody before you with overweight or obesity—a man with a neck size of 17 inches or more; a lot of men know their shirt size—that should be a red flag that this person needs to be screened for sleep apnea.

Obesity, middle age, male gender, or a woman who’s postmenopausal with overweight or obesity—you can ask them, “Hey, do you snore? Are you falling asleep in the daytime? Would you like a sleep referral? There’s help available and we can help you feel better.”

Dr. McDonald: I was talking to a medical student yesterday who I was precepting, and they did a mini presentation on sleep and all these different screening tools you can use. My favorite is the STOP-Bang questionnaire. It’s pretty quick and easy. My threshold for ordering a sleep study is about this high (for those of you who can’t see my fingers, they’re nearly together).

BMI of 35 is what we call normal in my clinic, so my threshold for ordering a sleep study is very, very low, especially within my system. We can do it very easily. We mail people devices to wear at home as the initial screening test. The barriers to doing an in-lab polysomnogram are not nearly as high now as they used to be back in the day.

Dr. Gurubhagavatula: Yeah, we have home sleep apnea tests now. Patients can sleep in their own home. There are telehealth appointments. It’s all extremely convenient, so more patients can be diagnosed easily and quickly.

Even with lower BMIs, I love the STOP-Bang because it’s so easy. You either have sleep apnea or you don’t. BMI of 35 is not very sensitive. It’s probably more specific than it is sensitive. So even at lower BMIs, you can see decent amounts of sleep apnea.

Another thing you can look for is the chin recessed back, and that’s easy. As a patient walks in, you look at their profile.  You can tell if it’s recessed back a little bit when you open their mouth and say “aah,” and you can see if their tongue is large, if there’s scalloping along the edges, or if there are big tonsils. Just ask, “Hey, do you snore?” If you see that and the BMI is only 30, it’s still not something to exclude.

Unfortunately, symptoms and physical findings are probably only 50/50 sensitive at 50%. So, it’s like a coin toss. It really does need that referral and formal testing to confirm whether patients have sleep apnea or not.

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

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