Emerson Wickwire, PhD, is on a mission to unify disciplines to bring the benefits of “positive sleep” to all.
The growth in understanding of sleep and its importance to overall health and wellbeing has been explosive. However, many patients suffering from sleep disorders are not receiving the help they need. Obstacles include myopic approaches to individual sleep disorders, a lack of shared vision between sleep specialists and health system leaders, and inefficient delivery systems that discourage holistic patient-centered care. What’s more, says Emerson Wickwire, PhD, for decades the field has focused almost exclusively on the apnea-hypopnea index (AHI) to the exclusion of other meaningful outcomes: health economics, workplace productivity, and subjective wellbeing.
Wickwire recognized these challenges early in his career and has become an influential voice in the drive to innovate sleep medicine care delivery to increase access to care, ensure better outcomes for patients, and provide greater value from treatment of sleep disorders. Dually board certified in behavioral sleep medicine and behavioral and cognitive psychology, his approach to integrating behavioral change into all aspects of sleep disorder treatment, not just insomnia, is laudable. With the creation of the Howard County Center for Lung and Sleep Medicine, where he served as sleep medicine program director from 2009 to 2014, he built what many consider to be a model interdisciplinary sleep medicine center. His approach caught the eye of military sleep leadership, who invited him to teach Army sleep medicine trainees.
“He’s the best game in town,” says Colonel Christopher Lettieri, MD, FCCP, FAASM, of the United States Army Medical Corps and professor of medicine at the Uniformed Services University in Bethesda, Md. For years, Lettieri has sent all of the Army’s sleep medicine fellows to study with Wickwire as part of the Walter Reed National Army Medical Center/National Capitol Consortium sleep medicine fellowship. “Our fellows can run a program by themselves as soon as they finish with Emerson,” he adds.
In 2014, Wickwire was recruited to join the faculty at the University of Maryland School of Medicine and lead and manage the Insomnia Program at the UMB Medical Center. “I’m thrilled to be here and deeply appreciative of Steve Scharf, MD, PhD, for recruiting me and providing me this opportunity,” he says. “We have a great team and integrated practice model here at Maryland.”
Since then, he has become a bridge-builder, bringing leading academic, government, and industry experts to campus for seminars and rounds. The goal is to foster the type of intellectual cross-pollination and practical implementation of ideas that he sees as vital to future growth and innovation in the field.
“I believe that innovation takes place at the intersection of established disciplines,” he says. “I’ve always loved to connect ideas and to connect people to create win-win partnerships. But implementation is the key. Success takes teamwork, commitment, and hard work.”
It sounds simple, but partnering with experts in their respective fields to step outside their disciplines and broaden their approaches can present unique challenges. Yet, Wickwire believes that exactly these kinds of collaborations are required to achieve a shared vision for sleep health.
Nancy Collop, MD, was the medical director of the Johns Hopkins Hospital Sleep Disorders Center and professor of medicine at the Johns Hopkins University School of Medicine when Wickwire was completing his postdoctoral fellowship training. She noticed that he had a talent for getting people from different disciplines to work together.
“The yin and the yang of sleep medicine is that it is good that it is multidisciplinary, but a lot of the time, that also means that people are trying to protect their turf,” she explains. “Somebody like Emerson can bring groups together to tackle some of the big issues we have in sleep medicine.”
A Fresh Perspective
One of Wickwire’s strengths is that he did not begin his career in sleep medicine, say both Collop and Lettieri. Wickwire was a successful amateur wrestling coach and expert in literature before he became interested in sleep medicine.
Wickwire’s path began outside Pittsburgh, Pa, a hotbed of amateur wrestling. He was the youngest of a group of neighborhood boys who were going to try elementary wrestling. “My older friends told me they’d kick my butt if I didn’t try it too,” Wickwire laughs. It turned out to be a great decision. “Sports are great teachers of life lessons,” he says. “Wrestling teaches personal humility and the value of hard work sustained over time.”
He eventually became an Academic All-American wrestler at NCAA Division I Boston College. After a year teaching and coaching in Ohio, he moved to Memphis, Tenn, to become a head wrestling coach at a prestigious all-boys school. “Moving to Memphis might as well have been moving to Vietnam,” he recalls. “It was a fantastically different part of the world from what I had known.”
Teaching further broadened Wickwire’s horizons by allowing him to spend two summers abroad studying literature at the University of Oxford in the United Kingdom. Through his parents, Barbara and Emerson Wickwire, and four loving grandparents, he had already absorbed the idea that it was cool to be curious and smart and to have diverse interests. Now he found that having his ideas and beliefs challenged by people with different experiences and perspectives from his own helped his own thinking to evolve and grow.
“There are certain experiences you cannot gain through a book,” he explains. “Without travel, our perspectives remain pretty small.”
Being in a foreign place, either in a different region or in a different country, can push a person out of his comfort zone and force him to reconsider basic assumptions. While in Memphis, Wickwire realized that to have a bigger impact, he would need to expand his skill set and increase his credibility as an expert. He decided that a PhD in sports psychology would advance his career objectives. “My interest has always been optimizing human and organizational performance, and I wanted to study leadership behavior,” Wickwire says.
While in graduate school, he met his wife and life partner, Danita, a native Memphian, which was the personal highlight of his decade in the South. Both had attended Jesuit universities in New England, and they shared a love for the arts.
“Then I stumbled into sleep medicine totally by accident,” he says. At the suggestion of his graduate advisor, Wickwire accepted a rotation at a leading sleep medicine center, Methodist University Hospital. He became hooked on sleep on the very first day.
“As an athlete and coach, I had known for years about the importance of proper diet, exercise, and mindset for optimal human performance. But I’d had no clue that sleep was the link between all of these elements,” he says. “It was like a lightbulb went off.”
Innovating Insomnia Treatment
His first patient was a FedEx manager with shift work disorder. Wickwire realized that principles from coaching and sports psychology could be integrated with traditional sleep medicine approaches to improve both this patient’s sleep and quality of life. Wickwire’s approach was to help this patient develop a novel pre-sleep wind-down ritual, and he found that it did indeed improve treatment outcomes. Today, thousands of patient encounters later, he still employs a similar approach.
“My clinical supervisor, a renowned insomnia scientist, suggested that I write up the case,” he says. “It was clear I was innovating and bringing something new to the table.”
If there was synergy between coaching and sleep medicine that could create innovations in care, where else could new ideas come from? On the one hand, Wickwire was pioneering treatments to improve patient-centered outcomes and quality of life. But on the other, it was clear that the delivery of sleep medicine services was disjointed and inefficient. So Wickwire set off to build upon the interdisciplinary care model he had first come to know during his graduate training in Memphis.
“It was obvious even then that growth in sleep medicine was being hindered by lack of interdisciplinary understanding,” he says. “This was the problem I wanted to solve.”
To do it, he knew he had to do more than study the problem. He had to enter an environment where he could build a network of experts in a variety of fields related to sleep medicine, including science, technology, and business. The break came when he was accepted into a postdoctoral fellowship program at Johns Hopkins.
“Hopkins was just a world-class environment for me,” he says. “Whatever I needed to learn, a world-renowned expert was just a short walk away. I spent significant time in the medical school, Bloomberg School of Public Health, and Carey Business School. These are friendships for a lifetime.”
When an expert was not immediately available, Wickwire leveraged his network and sought introductions. One such contact was Barbara Phillips, MD, a professor of pulmonary, critical care, and sleep medicine at the University of Kentucky College of Medicine in Lexington. As he was completing fellowship training at Johns Hopkins, he visited Washington, DC to meet with her.
“He was extremely earnest and very committed,” she recalls. “There are plenty of people who got into sleep medicine because they saw it as lucrative and that is not Emerson. He just really likes it.”
That sincerity made experts like Phillips open up to him with their ideas, which he incorporated and expanded upon when co-founding an interdisciplinary sleep medicine center after finishing his studies at Johns Hopkins. In turn, it made those experts pay attention to his ideas and study his sleep medicine center’s approach to treating patients.
“Emerson has definitely elevated the stature of behavioral sleep medicine and made it less intimidating for us non-behaviorists,” Phillips says. “Many people considered behavioral sleep medicine as only a way to address insomnia, and he made us see that behavior is an important part of weight management, CPAP adherence, and all aspects of sleep.”
Positive Sleep and Value-Based Medicine
Wickwire’s approach to treating sleep disorders centers around the idea of “positive sleep,” a term he uses to describe focusing on the power of sleep to improve the quality of people’s lives.
“Positive sleep is about healthy sleep and positive wellbeing,” Wickwire says. “Traditional medical approaches fall woefully short when it comes to improving areas like resilience in the face of life’s inevitable ups and downs, interpersonal relationships, recreational engagement, and healthy self-care. Yet these are the exact outcomes that matter most to sleep patients. From the patient perspective, the value of sleep health is enhanced quality of life.”
To improve patient quality of life, sleep clinicians will need to listen to patients more effectively, find ways to change human behavior quickly and reliably, and collaborate with other fields of medicine. These are the primary foci of Wickwire’s work with sleep medicine trainees and sleep medicine professionals.
“My goal is for trainees to learn to communicate more quickly and easily, increase patient adherence, and identify and achieve patient goals for treatment,” he says. He’s also an advocate for telehealth and has been involved with developing patient portal technologies to improve patient-centered outcomes, increase operational efficiency, and reduce costs.
At the same time, Wickwire says, the value of sleep is in the eye of the beholder. To advance the field, sleep medicine leaders must adopt the perspectives of multiple stakeholders and build exactly the kinds of win-win partnerships that Wickwire espouses.
Whereas patients are most concerned with quality of life, other stakeholders are primarily concerned with other outcomes. For example, employers are justifiably concerned with productivity and reduced accident risk—improved performance and medical cost offset result in improved business outcomes. Payors, on the other hand, view the world through the lens of healthcare utilization and population health management.
According to Wickwire, sleep medicine needs to be able to speak each of these languages. As medicine transitions from paying for volume to paying for outcomes, biometric indices such as AHI will, in isolation, be insufficient to signify a successful outcome or to demonstrate the value of treatment. Questions such as did the treatment make the patient’s life better, improve their performance on the job, or reduce overall healthcare costs become important instead.
To advance understanding in these areas, Wickwire has initiated a program of research exploring sleep health economics. He has just received a two-year grant to examine sleep and healthcare utilization among a large national sample.
“It’s a very exciting project,” he says. “At the health systems level, we need to be thinking about value-based care and how to demonstrate value to payors, self-insured employers, and the public. This study will provide valuable insight and, we hope, enable payors and policy-makers to make more informed decisions regarding sleep medicine services. And of course as I’ve just recently returned to academia, this award also helps increase the visibility of our team here at Maryland as an active and expert partner in health services research and sleep health economics.”
Strategy as a Next Frontier
According to Lettieri, Wickwire possesses a unique ability to understand and communicate how to enhance individual patient care as well as how sleep medicine fits into large healthcare systems. Lettieri believes this framework enables Wickwire to think strategically about how to enhance the efficient delivery of sleep medicine services, which is a vital skill for the field at this moment in time.
Healthcare is shifting from paying for volume to paying for value, and measuring and enhancing the value of treating sleep is impossible without a broad interdisciplinary perspective. Furthermore, creating change to improve and disseminate sleep treatments requires someone who is personable and can guide others as they confront new ideas and challenge their existing assumptions.
“I’ve known Emerson for a number of years, and I’ve seen him grow as an individual,” Lettieri says. “It has been great to see him branch off into all of these different areas and be invited not only to be a member of workgroups and panels, but also to chair them. He was added to all these groups and editorial boards early on in his career because of the caliber of person that he is. People meet him, they like him, and they know they will get quality work out of him because he is both brilliant and easy to talk to.”
Wickwire has published over 40 peer-reviewed scientific articles, book chapters, and scientific abstracts, and has written 20 articles for the professional audience on topics including telehealth and technology, home sleep apnea testing, corporate sleep health, and patient communication skills. He serves on the editorial advisory board of Sleep Review and is associate editor of the Journal of Clinical Sleep Medicine. Yet, he is equally focused on advancing the practical delivery of sleep medicine services in ways that reflect the highest ethics of medicine.
As a former award recipient from the National Endowment of the Humanities who remains interested in the arts and literature, Wickwire understands the importance of communication. Unless sleep-related issues and ideas can be expressed in ways that people inside and outside the field can understand, millions of Americans with sleep disorders will remain undiagnosed and untreated.
“In terms of patient care, the work that remains to be done is increasing focus on patient-centered outcomes and quality of life, what I call ‘positive sleep,’” Wickwire says. “Sleep medicine needs to do more than reduce the AHI. We have the opportunity to help patients live longer, healthier, and happier lives. To realize that potential, we have to deliver our treatments with slightly different endpoints in mind that are developed in collaboration with our patients.”
Lena Kauffman is a regular Sleep Review contributor and former editor based in Ann Arbor, Mich.