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Faculty Spotlight: Paul Peterson, MD

Wednesday, December 13, 2017
P Peterson

For this week’s Faculty Spotlight interview, Paul Peterson, MD, looks both to the present, past and future. He currently sees patients and performs sleep and electrodiagnostic studies at Duke Raleigh Hospital. Peterson also recalls the complex problem solving and incredible diagnostic skills of the mentors that drew him into neurology as a medical student, and looks to the future, where he sees telemedicine and cheaper diagnostic tools revolutionizing the field of neurology and sleep medicine in particular.

What are your responsibilities at Duke? What does your typical work day look like?
Our practice, Duke Neurology of Raleigh, is part of the community private diagnostic clinic. I see patients in the clinic Monday through Friday, and rotate call at Duke Raleigh Hospital, amongst colleagues. A typical routine clinic day for me begins around 6:30 a.m. with reviewing any sleep studies performed the night before at the Duke Raleigh Sleep Laboratory, before starting my clinic at 7:30 am. I typically see patients throughout the day, before concluding clinic around 4:30 pm.

I see a mixture of general neurology patients interspersed with sleep medicine patients. Two days of the week I perform electrodiagnostic studies (ie EMG/NCV) starting at 7:30 am with 8-10 studies a day on those days. On these days, if there are any sleep studies for me to interpret from the night before, I will do those before starting procedures for the day, as well. My primary responsibilities would be the same in the clinic, but I would be on-call for the hospital calls through the evening and night. Weekend coverage for the hospital rotates among several of my community-based neurology colleagues.

How did you first get interested in neurology? What do you currently enjoy most about your work?
My interest in neurology began in medical school, at the University of Texas Medical Branch in Galveston from 1991-1995. The chairman of neurology there at the time, John Calverley (deceased 2004), was an excellent teacher and we had an entire year of neurosciences education in the 2nd year--with clinical neuroanatomy, neuropathology, and neurological diagnosis--founded upon anatomic localization followed by diagnostic formulation. Our class size was about 200 students.

I recall Dr. Calverley would have patients unknown to him, brought onto the stage in our auditorium, and be presented the case by students familiar with the patients. He would examine the patients in detail in front of everyone, then the patient would be conveyed out of the auditorium and he would proceed to query students in the auditorium on the case in systematic fashion ending with his final diagnosis. Then, the students on the case would present the final diagnosis actually made on the patient. I do not recall him ever not having considered a diagnosis the patient had, and more often than not, his primary diagnosis was the final diagnosis. He did this all without knowing any test results or reviewing any images. He was a master clinician who made neurology interesting and engaging. 

The most enjoyable part of my work is solving complex problems for patients.

It’s been a decade since you completed your fellowship in sleep medicine here at Duke. What’s been the biggest change in your work between now and then?

Perhaps the biggest change in sleep medicine has been in the technology arena surrounding one of the common conditions we see and treat: obstructive sleep apnea hypopnea syndrome. In the years since I completed my training we have had the introduction of ambulatory sleep testing, auto-adjusting positive airway pressure machines, new treatments such as hypoglossal nerve stimulation and improved oral appliances to treat the condition.

What changes to your work do you see coming over the next 10 years?

How neurologists practice and how they are paid will likely change drastically in the next decade.

First, the practice of neurology and sleep medicine will shift into the virtual arena. In terms of sleep medicine, much of the evaluation and treatment of obstructive sleep apnea hypopnea syndrome will move out of the sleep laboratory and clinic into the retail arena, becoming more readily available to patients, as industry continues to develop inexpensive diagnostic and treatment tools.

Industry is already developing over-the-counter therapy devices which will be able to adjust themselves. Furthermore, oral appliances will be generated using laser accurate anatomic maps of the patient’s dental and oral anatomy, and printed using 3D printing technologies, and cost much less than they do today.

Some insurance companies now offer home sleep testing free of charge to members, and I foresee this trend continuing as they attempt to bring this diagnostic testing to all their members to lower long-term overall costs.

Companies such as Google and Apple are working to develop phone app technology which may be coupled with biodynamic data obtained by wearable sensors connected via Bluetooth, to measure sleep and parameters, which may then be coupled with computer generated paradigms along the lines of cognitive behavioral therapy for insomnia, bringing this therapy to many more individuals. Insomnia is the most common sleep medicine condition overall, perhaps only surpassed by behaviorally-induced insufficient sleep, costing billions of dollars in lost productivity to companies worldwide.

In terms of neurology in general, the shortage of individual neurologists will be far outstripped by the need for them, and teleneurological services will skyrocket. Already there are organizations embracing this need and working on efficient and affordable solutions to be able to provide these services. Payors and hospital organizations are also embracing this move, as the shortage of neurologists becomes ever more acute. There will be consolidation of neurology niche services, both on the inpatient and outpatient arenas--such as telestroke and tele-ICU inpatient and teleneurology for subspecialties such as headache medicine, dementia, sleep medicine, movement disorders outpatient.

Payment will change from fee-for-service to value-based, and there will be consolidation of payments for the care of patients for an episode of care. For example, a stroke patient entering the hospital with an acute stroke will currently have several teams/providers caring for them over the course of their hospitalization: from emergency medicine, vascular neurology, radiology, to potentially an endovascular team. This will likely change to a global payment scheme wherein all these providers and the hospital are provided a set reimbursement based upon outcomes, efficiency, and costs.

In summary, therefore, I believe the two biggest paradigm shifts in neurology will be the shift from clinic-based to virtual care, and how neurologists are compensated for their work.

What passions or hobbies do you have outside of the Department?

I have a diverse set of interests outside of work.

Photography is one. I shoot in a variety of genres--primarily landscape and nature, but also infrared, high dynamic range (HRD), and time-lapse using traditional DSLR and lenses (up to 600 mm). I also dabble in aerial photography and videography using drones, and have a variety of wearable tech gear such as GoPro cameras and gimble stabilizers.

Another interest is music, primarily creating music in a variety of electronic genres including ambient, cinematic, downtempo, trance, among others. I use Ableton Live as my digital audio workstation for recording, editing, and producing. I mix with iZotope's Neutron 2 and master productions in iZotopes Ozone. I have over 200 songs presently and one of these days when I have the free time will make the leap to publishing some albums using one of the online aggregators such as CD Baby.

I enjoy enjoy painting, primarily in oils.

When time permits, I like to travel and adventure and in the past few years have been to Italy, Spain, and most recently spent a week in Israel, in November 2016.

Peterson and his girlfriend visit Jordan's ancient city of Petra.
Peterson demonstrates his photography and painting skills with this photo of a recent oil painting.