Please tell us briefly about your current practice as a Sleep Specialist. What do you enjoy most about your job?
Currently, I am working as a sleep specialist and a psychiatrist in the Department of Psychiatry at Duke University School of medicine. I am also the director of Sleep Lab under the Department of Psychiatry. We send patients for sleep study to the lab. I treat patients on an outpatient basis which comprises both psychiatric and sleep disorders. My scope of practice includes both medication management and non-pharmacologic therapeutic modalities such as psychotherapy to treat the patients. I have always been fascinated by the interface between the sleep disorders and mental health issues and how they profoundly impact each other.
The best part of my job is the clinical interaction with my patients. I value the input from my patients pertaining to their treatment and try to focus onpatient-centeredd care with shared decision making.
Why did you choose sleep as your topic of specialization? Do you think our society needs more Sleep Specialists?
I did my residency in Psychiatry. After that, I chose to do a fellowship in sleep medicine because clinically there is a huge overlap between psychiatry disorders and sleep disorders. Including but not limited to depression, bipolar disorder, schizophrenia, etc. that all have a large component of sleep dysregulation. If sleep is regulated properly, there is a good chance of resolution of their psychiatric disorders as well with the help of appropriate therapy. Also, it was an opportunity to approach the field of sleep more through mental health perspective.
While I focus on treating sleep disorders in patients with mental illness, I also enjoy diagnosing and treating patients with other sleep disorders independent of mental health like obstructive sleep apnea, restless leg syndrome, REM (Rapid Eye Movement) sleep behavior disorders, narcolepsy, etc. However, this is not to say that in some ways it might not be affecting their mental well-being as well.
Sleep being an important aspect of an individual’s well-being, it definitely is important that we need more specialists addressing their issues and making it a priority to treat them through available therapies.
Please tell us about the typical roles and duties of a psychiatrist. Does she have to provide psychological therapy as well or her role is defined within the domain of medicine? How does she collaborate with psychologists and psychotherapists?
A psychiatrist is responsible for diagnosing and treating various psychiatric disorders including but not limited to major depressive disorder, bipolar disorder, schizophrenia, any acute psychosis, substance abuse issues, etc. There are various branches of psychiatry like child and adolescent psychiatry which primarily deals with children and adolescents, geriatric psychiatry for elderly, addiction psychiatry which primarily deals with addiction, consult liaison psychiatry or psychosomatic medicine which deals with the interface between medicine and psychiatry in an inpatient setting.
When someone is treated in the inpatient setting where they are admitted in the psychiatric units for variable amount of time. Patient can also be treated on a regular outpatient basis and which is a preferable way of treating when mental illness is of mild to moderate severity. Treatment modalities in psychiatry involves various approaches which could include pharmacologic management with medications, non pharmacologic management with psychotherapy alone, or a combination of them. Depending on the diagnosis, its severity and patient’s willingness to participate in the therapy any of these modalities can be employed.
As a psychiatrist, I frequently collaborate with the psychologist who provided the patient’s with regular psychotherapy in various forms including cognitive behavioral therapy, psychodynamic psychotherapy, supportive psychotherapy, etc. according to the patient’s diagnosis and personality.
To answer your question, the duties of a psychiatrist which include initial consultation, ordering definitive labs, tests as needed, medication management, follow up as needed and collaboration with other providers including psychologist, psychotherapists and providers in other fields of medicine.
There is a general criticism on psychiatrists that they over medicate patients without uncovering the core psychological issues. What do you say about this?
As a psychiatrist who has recently graduated from her fellowship in sleep medicine, I do feel like we have really need to know the patient and various aspects of their history before using any pharmacological or non pharmacological approach. I usually follow biopsychosocial model when approaching a patient in initial consultation and during subsequent follow-up visits.
In the biopsychosocial model, the biological component is of medications, psychological model is the psychological makeup of the patient which can emerge from his or her childhood experiences which translates in to their personality they tend to exhibit consciously or subconsciously, the social component is the support system of the patient outside in the society. Both pharmacological and nonpharmacological approaches tend to be more successful and useful for a patient when we keep all these 3 components in perspective.
Also before prescribing any psychotropic medications, it is very important for us to educate the patient regarding the side effects of the medications; that the medications could take weeks to take effect and we will have to reach appropriate therapeutic dose before the patient can feel any difference. Also, as with any other medication, the medicines used for mental health tend to have side effects. especially the antipsychotics can have severe cardiometabolic risks in the long run which a patient should be aware of.
And if we approach the patient just from the biological point of view and if the only pharmacological approach is given priority without addressing the psychological and social aspects, and without educating them properly about the medications, then definitely it can result in delay in overall recovery and also could invite criticism.
How culturally situated is Psychiatry as a discipline? Being a Nepali and then studying MBBS in Pakistan and now practicing in the United States, what are the different challenges you face and how do you adapt and evolve through these diverse cultural contexts?
It can be both intriguing and challenging to move across cultures, trying to get a deeper understanding to their core values and norms and to adapt accordingly. I definitely think that there is a certain stigma attached to mental health in all parts of the world but possibly more in the east. When I grew up in Nepal, there was an extreme stigma, avoidance and a culture of silence when it came to addressing mental health issues. Many forms of mental health issues also emerge from certain social norms and values and therefore it can be challenging to treat the mental health itself if we are not really ready to address the social aspects which could be significantly contributing to it. However my experience of working in Nepal is very limited, so for an actual comparison of the current situation, I would have to defer it to the psychiatrist working in Nepal or someone who had an experience working in both places for a significant period of time.
In Pakistan, I had a very clinically rich experience in terms of cases, treating patients with mental health issues but the stigma attached to it was no less. Moving to America, I find that people are essentially more open about their issues of mental health and proactive in obtaining much-needed help.
To answer the question about adapting in different cultural contexts is definitely challenging in the beginning. Some of the values seem to be in sharp contrast to each other and that was probably the hard part. However, over time and with the experience I have learnt that despite the difference in cultural norms, language race and ethnicity, the core values of humanity are the same. Both in and outside of my work, I try to connect with the people and understand their values. There are times where we need to examine our own conscious and subconscious biases and learn to overcome them. It can be a lifelong learning experience.
Tell us about a time you made an exciting breakthrough — or any other highlight in your medicine journey.
I recently finished fellowship and joined as a faculty Duke University School of medicine. There are a lot of opportunities to learn and I am especially interested in diagnosing and treating patients with mental health issues and overlapping sleep disorders. Currently, as a junior faculty member, I am aspiring to get involved in further research in my area of interest. My areas of interest are ECT and Transcranial Magnetic Stimulation. Therefore, I am looking forward to an exciting career and hopefully some exciting breakthroughs.
Tell us about a time you had serious doubts about your own ability in this field. How did you overcome that?
Personally speaking, the most challenging aspect has been to go through the process of the license exams, and through the residency match. It is very competitive and an expensive process which can takes years. Like many others; I did have some doubts in my abilities at times. However, I had a tremendous amount of social support which helped me for persevere through the tough times.
In my professional life; Psychiatry can be challenging because it is not as objective as other fields with definitive measures detailing a treatment success or failure. The medications can take weeks to work and patient needs to be on the medications for months if not years. This can sometimes be very challenging.
As a new mother, have you been able to manage your own sleep? What is your strategy to manage your work life balance?
Motherhood can be both challenging and empowering. As a new mom, I felt that it is very important to adjust with the new priorities because they do change with the baby. I give a lot of attention towards getting sufficient number of hours of sleep, social interaction with friends. I do not hesitate to ask for support from my friends and family if needed. Also, there are few things we had to let go in terms of activities and I think we are fine with that.
I work on an outpatient basis so for now, I am not taking any calls overnight or weekend. This has given me a good work life balance at the moment.
What are your observations about the mental health situation in Nepal? What can we do to create a healthier society?
From my experience of growing up in Nepal and the society there, I think that we have a lot to improve on in terms of mental health. The first step definitely would be to raise awareness on mental health issues so that people start seeking treatment. Also, we will have to address the social stigma. We have to create a culture where people are not shamed for being victims of trauma so that they can come forward and ask for help. We will have work towards reducing the stigma of mental illness and work against the biases like that somehow it’s the “patient’s fault” or “they can get over it.”
Tell us about the role of mentorship in your professional life.
I owe what I am today to teachers and my mentors. Mentorship plays a huge role in promoting and shaping someone’s career. I have had excellent mentors who have continued to inspire me in every step of my life and my career.
What is the best career advice you have ever received?
I have received guidance and advice on every step of my career from my mentors and my family especially my father. However looking back, the best piece of advice he has given me might be that “information is power.” He is always advised me that for any person in a leadership role, you have to know intricacies at the workplace from the administrative, logistical and also personal standpoints. I think this piece of advice has helped me make more informed and mature decisions.
The career advice you wished you received in your twenties.
The best advice, I could have received and I wish I did receive in my 20s is that success is not measured by how others see you but by your own happiness and contentment in life. You are more likely to be successful professionally if you enjoy what you are doing.
Your advice for the students who might be struggling to manage their sleep.
I have a few things to say to students who are struggling to manage their sleep: Working on sleep hygiene issues like letting go of excessive amount of caffeine and having fixed sleep wake schedule can have a profound effect on sleep. Also doing things to reduce the anxiety, like meditation and exercise can help with the sleep. Medications are always an option but it is important to work on these simple measures first.
Final words of advice for someone who wants to pursue their interest in your field?
We are definitely in need of psychiatrist and sleep specialists. If you are thinking about pursuing a career in psychiatry or sleep specialist or both, I will be more than happy to offer you some advice and guidance. Please do not hesitate to contact me at [email protected].
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