becoming the mindful gme leader: strategies for success · becoming the mindful gme leader:...

Becoming the Mindful GME Leader: Strategies

for Success

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John D Mahan MD Nationwide Children's Hospital/

The Ohio State University Hilary McClafferty MD University of Arizona

Pnina Weiss MD Yale University

This presentation will be using Poll Everywhere!

There are two ways to answer the poll:

1. Text PASNCH2017 to 22333 to join the poll then text the letter next to your chosen answer.

2. Select your answer at PollEv.com/PASNCH2017.

OR

By the End of This Session, Participants Will Be Able to:

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Define the value of sleep and demonstrate methods to assess appropriate sleep needs and recognize fatigue in yourself and colleagues

Define the dynamic relationship between burnout and resilience and methods to promote resilience and wellness in yourself and colleagues

Define the essential characteristics of mindfulness activities (mindful movement and eating; relaxation techniques; and meditation)

Demonstrate mindfulness techniques and methods to develop mindfulness skills for yourself and colleagues

Contributors

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Kathi Kemper MD MPH; Center for Integrative Health and Wellness and The Ohio State University Wexner Medical Center, Columbus, OH

The Pediatric Resident Burnout – Resilience Study Consortium

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“Life moves pretty fast. If you don’t stop and look around once in a while, you could miss it.”

Ferris Beuller

Outline

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1. Introduction and Agenda (JDM)

2. Assess your sleep and sleepiness – discussion (small group activity)(PW/JDM)

3. The dynamic relationship between burnout and resilience (HM)

4. Assess your burnout and resilience – discussion of strategies for mitigating/preventing burnout (small group activity) (HM/JDM)

5. Mindfulness – the construct (JDM) and group demonstration (HM)

6. Developing a Mindful GME Leader Action Plan - Incorporating Mindfulness and Healthy Choices into your life (small group activity) (HM/JDM)

7. Report out and Wrap-up (PW/HM/JDM)

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1. Introduction – A Story

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Why Did You Come to This Session?

A Brief History of Burnout

Roots of burnout concept (1970’s) - transformation from industrial society into service economy.

Social Transformation & Psychological Pressures = burnout.

Increasingly seen as erosion of positive psychological state.

Global phenomenon - meaning differs between countries (medical vrs stress diagnosis).

Burnout derived from job stress (Helping Professions)

Maslach Burnout Inventory

Three Domains

Emotional Exhaustion (EE)

Depersonalization (DP)

Personal Accomplishment (PA)

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Leads to decreased effectiveness Related to work associated stress

Source: Wallace JE, Lemaire JB, Ghali WA. Lancet 2009; 374: 1714-21.

Physician Wellness: A Missing Quality Indicator

“When physicians are unwell, the performance of healthcare systems

can be suboptimum. Physicians wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality

health care.”

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“These are the duties of a physician: First…to heal his mind and to give help to himself before giving it to anyone else."

Epitaph of an Athenian doctor, 2 AD

Burnout Question 1 – Prevalence Pollleverwhere 1. Burnout among Pediatric Fellowship Program Directors is greatest at:

A. Boston Children’s

B. Children’s Healthcare of Atlanta

C. My Institution

D. Nationwide Children’s

E. Nemour’s

Burnout Question 2 – Prevalence Pollleverwhere

2. Identify the 2-3 most common factors that you believe contributes to burnout in Fellowship Program Directors

Text In

Burnout – Spot Checking the USA

0 10 20 30 40 50 60 70 80

General Pediatrics

General Surgery

OB/GYN

Mean Burnout

General Internal Medicine

Family Medicine

Urology

Emergency Medicine

2011

2014

2017

% Reporting Burnout

0 1 2 3 4 5 6

Bureaucratic overload

Spending too many hours at work

Feeling like a cog in a wheel

Increasing EHR

Income not high enough

Too many difficult patients

Insurance issues

MOC

Lack of professional fulfillment

Threat of malpractice

Too many appointments in a day

Difficult employer/colleagues/staff

Affordable Care Act impact

Inabilty to deliver desired quality

Compassion fatigue

Family stress

Unable to keep up (research, guidelines)

2015

2017

% Reporting Burnout

Causes of Burnout in Physicians “Death by a Thousand Paper Cuts”

Satisfaction with Work-Life Balance

% Satisfied that work leaves enough time for personal and/or family life

0102030

40

50

60

70

Outsideof work

At work

Male

Female

Female/Male Physicians Reporting Very & Extremely Happy

Putting It Together: Addressing Burnout & Promoting Resilience in Physicians

Work/ Systems Factors

Local/ Micro-

environ-ment

Self-Care/ Personal Support

Chinese Proverb [Physician Outcomes]

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If we don’t change our direction,

we are likely to end up where we are headed!

Challenge: Being Mindful of your Physical and Mental Well-Being

S L I D E 18

Pnina Weiss, MD

Associate Professor

Yale University

Sleep:

A Necessary Part of Every Day!

S L I D E 19

Why is sleep important for us?

S L I D E 20

Sleep problems are common

Percentage of adults who report insufficient rest or sleep during the preceding month

S L I D E 21

3. Epworth Scale: How likely are you to doze or fall asleep in the following situations?

S L I D E 22

4. What is the average number of hours of sleep that you get/night?

S L I D E 23

What is the recommended number of hours of sleep that you SHOULD get/night?

Hours/night

Adult (18-64 yrs) 7-9

Older adult (> 65 yrs) 7-8

NSF: Hirschkowitz et al. Sleep Health. 2015

S L I D E 24

Gallup poll 2013- 40% of adults get less than 7 hours of sleep/night

40% < 7 hrs Sleep/night

S L I D E 25

Why is inadequate sleep a problem?

• Sleepiness

• Mood

• Cognitive function

– Impairs performance • Mistakes

• Safety

• Productivity

• Health risks

– Cardiovascular

– Endocrine

– Psychiatric

– ? Cancer risk

S L I D E 26

Sleep deprivation causes many problems! Well-being Sleepiness ESS (Pikovsky, et al. Isr Med J 2013; Woodrow, et al. Med Ed 2008; Rose, et al. Behav Sleep Med 2008)

VAS, SSS (Arnedt et al. JAMA 2005)

MSLT (Howard, et al. Acad Med 2002)

Mood Sadness, decreased vigor, egotism, social affection (Friedman, et al. NEJM 1971)

Difficulty thinking, depression, irritability, depersonalization, inappropriate affect (Friedman et al., J med Educ 1973)

Anger, tension, depression and fatigue (Light et al., Curr Surg 1989)

Anger, anxiety (Qureshi, et al. J Pak Med Assoc 2010)

Emotional reactivity (Zohar, et al. Sleep 2005)

Burnout (Sargent, et al. Behav Sleep Med 2009)

Safety Needlesticks (Parks et al, Chronobio Int 2000 ; Ayas et al., JAMA 2006)

MVA (Marcus et al. Sleep. 1996; Steele et al Acad Emerg Med 1999; Barger. et al. NEJM 2005)

Driving simulation (Tornero, et al. Accid Anal Prev 2012; Ware, et al. Behav Sleep Med 2006)

Education Cognitive

testing

Psychomotor vigilance (Hart et al. J Med Educ 1987; Sharp et al., J Pineal Res 1988; Arnedt, et al. JAMA 2005; Bartel, et

al. Occup Environ Med 2004)

Working memory (Bartel, et al. Occup Environ Med 2004; Gohar, et al. J Clin Sleep Med 2009)

Creative thought (Nelson, et al. J Osteopath Assoc 1995)

Fine Motor skills, Visuomotor performance (Hawkins et al., J Med Educ 1985)

Response inhibition (Lingenfelser et al., Med Educ 1994)

In-training exam (Jacques, et al. J Fam Pract 1990)

Patient

Care

Simulated

and actual

clinical

performance

ECG interpretation (Friedman, et al. NEJM 1971; Lingensfelser et al., Med Educ 1984)

Fetal wt estimation (Ben-Aroya, et al. Fetal Diagn Ther 2002)

Umbilical artery catheterization (Storer, et al. Acad Med 1989)

Simulated patient monitoring (Denisco et al, J Clin Monit 1987, Sharpe, et al. Crit Care Med 2010)

Simulated procedures (Taffinder et al Lancet 1998; Ayalon et al., Am J Obstet Gynecol 2008; Grantcharov et al BMJ 2001)

Clinical procedures (Goldman et al., J Surg Res 1972)

Patient

outcomes

Medical errors, fatigue related adverse events (Barger et al. PLoS Med. 2006)

S L I D E 27

Why do we sleep?

https://smoens.files.wordpress.com/2010/12/class1_sleephomeostasis31.jpg

S L I D E 28

Attention declines after 16 hrs of wakefulness

Need 9 hrs of recovery sleep after all nighter!

DON’T PERCEIVE THE IMPAIRMENT!

S L I D E 29

How much sleep is too little?

Belenky et al. J Sleep Res 2003

S L I D E 30

Sleep restriction increases the risk of car crashes- new data

• AAA Foundation for Traffic Safety 2016

• If sleep for 1 or more hours less than usual amount in the past 24 hrs- 2x/ the risk of a crash

S L I D E 31

New parents!

• Sleep less!

• More sleepy

• More likely to doze off

• Worse daytime function

• Worse sleep quality

• More likely to crash or have near miss MVA

Hagen EW et al. Am J Epidemiol 2013 Malish S. et al. Matern Child Health J 2016

S L I D E 32

We also suffer from sleep disorders!

• Insomnia (15-40%)

• OSA (2-4%)

• Restless leg syndrome (5-15%)

S L I D E 33

Exercise

• What the barriers to getting sufficient and good quality sleep?

• What strategies can you use to address them?

S L I D E 34

Best sleep hygiene advice

S L I D E 35

3. Identify the Barriers to Adequate, Good Quality Sleep and Develop Strategies to Improve (Small Group Activity)

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4. McClafferty: The Dynamic Relationship Between Burnout and Resilience

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Stress: Use a Two Pronged Approach

Acute stress management

Chronic stress management

Stress Impacts:

Critical thinking (ignore warning signs)

Decision making, judgment

Communication skills and efficiency

Motor function (procedural skills)

Positive Trait In Exaggerated Form

Altruism Loss of sense of self, martyr

Compassion Compassion fatigue, loss of empathy, depression

Perfectionism Compulsiveness, self doubt, imposter syndrome

Competitiveness Isolation, alienation of peers

Resiliency Sense of invincibility, unsustainable pace, exhaustion

High Achievers Workaholic, burnout

Positive Traits or Risk Factors?

Where Are You on the Spectrum?

Take a moment to reflect..

McClafferty

2017

Strengths & Resilience

Why do we care?

McClafferty

2017

Emotional Resilience

Psychol Rep. 2016 May 18. pii: 0033294116649707.

The ability to generate positive emotion and to

recover from negative emotion is a modifiable factor

closely linked to burnout.

The ability to ‘bounce back’ after being

psychologically challenged.

The goal is healthy resilience.

Smith: The Brief Resilience Scale

Please indicate the extent to which you agree with each of the following statements by using the following scale:

1 =strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

I tend to bounce back quickly after hard times

I have a hard time making it through stressful events

It does not take me long to recover from a stressful event

It is hard for me to snap back when something bad happens

I usually come through difficult times with little trouble

I tend to take a long time to get over set-backs in my life

The BRS is scored by reverse coding items 2, 4, and 6 and finding the mean of the six items.

McClafferty

2017

Common Traits of Resilient People

Strong social connections

Emotional awareness

Strong sense of purpose

Openness to challenges

Flexibility, openness to change

An internal locus of control

Identifying as a survivor, not a victim

Strong problem-solving skills

Able to set and reach reasonable goals

Able to ask for help

Takes good care of themselves

Sense of optimism

Stress in America: Paying with Our Health. American Psychological Association, 2015

Stress Management: Alternate Approaches

Build Resiliency

Reframe: threat versus challenge

Not only opportunity to solve the problem

Maintain a realistic perspective

Stay focused on ultimate goal

Proportionate response

Surgeon Heal Thyself, Uttam Shiralkar, 2107

Resilience: Associations in Medicine

• Sense of humor

• Higher levels of intelligence

• Spirituality/organized faith community

• Most powerful predictor for physicians: maintaining caring connection with others

McClafferty

2016

Wayne/Mary Sotile- http://www.sotile.com/advice_articles.php?article

Personal Steps: Building Resilience

• Embrace self-care over self-denial.

• Attention to consistent exercise, healthy nutrition, rest, play, relationships, and coping skills.

• Real risk in "waiting-until" for a lifetime of deferred gratification.

• Be generous and gracious, i.e., be mindful.

McClafferty

2016

Wayne/Mary Sotile- http://www.sotile.com/advice_articles.php?article

Sleep

Stress Management

Nutrition

Exercise

McClafferty SENS Model of Physician Wellness and Resilience

Narrow the Focus:

Empathy or Compassion: A Critical Distinction

Empathy:

• noun: the ability to understand and share the feelings of another. “I am in pain with you.”

Compassion:

• adjective: sympathetic consciousness of others' distress together with a desire to alleviate it.

• “I understand your pain and want to help you”

--Merriam-Webster

5. McClafferty/Mahan: Assess your Burnout and Resilience Strategies for Mitigating/Preventing Burnout (Small Group Activity)

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5. I Feel Burned Out From My Work:

A. Never

B. Few times a year or less

C. Once a month or less

D. Few times a month

E. Once a week

F. Few times a week

G. Every day

Burnout Question – 5 Polleverywhere

6. I Have Become More Callous Toward People Since I Took this Job:

A. Never

B. Few times a year or less

C. Once a month or less

D. Few times a month

E. Once a week

F. Few times a week

G. Every day

Burnout Question – 6 Polleverywhere

Well Being Index Score Yourself

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Mayo Well Being Index Yes/No 1. Have you felt burned out from your work? - 2. Have you worried that your work is hardening you emotionally? - 3. Have you often been bothered by feeling down, depressed, or hopeless? - 4. Have you fallen asleep while stopped in traffic or driving? - 5. Have you felt that all things you had to do were piling up so high that you could not overcome them? - 6. Have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)? - 7. Has your physical health interfered with your ability to do your daily work at home and/or away from home? –

Score (# of yes responses) = _____ Dyrbe LN. J Gen Intern Med. 2013

6. Mahan/McClafferty: Mindfulness – the Construct Group demonstration

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Benefits of Mindfulness Training

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Decrease in personal isolation Improved listening and attentiveness Better at addressing patient’s concerns Increased adaptive reserve Increased self-awareness More thoughtful decision making Stress reduction Enhanced performance IMPROVED PATIENT OUTCOMES

JAMA Intern Med. 2014 Apr;174(4):527-33. West CP, Dyrbye LN, et al

Jon Kabot-Zinn & Mindfulness Based Stress Reduction

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"To say that this wise, deep book is helpful to those who face the challenges of human crisis would be a vast understatement. It is essential, unique, and, above all, fundamentally healing.“ --Donald M. Berwick, MD President emeritus and Senior Fellow, Institute for Health Improvement

Mindfulness Based Stress Reduction

Mindfulness Activities and Building Resilience

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Mindfulness Activities Mindful Movement Mindful Eating Relaxation Techniques Autogenic Training Meditation

Mindfulness: Being Centered on the Present, Being Here

Mindfulness Activities Mindful Movement Mindful Eating Mindful Movement [Thich Nhat Hanh]

"It feels very annoying, and very worthwhile." Ed Halliwell on what mindful movement taught him about his patterns of thinking

Mindful Eating

Engagement of Working Memory & Locus Ceruleus/Noradrenaline Systems

Activities https://www.youtube.com/watch?v=oWerJwf3-3I

Mindful Eating

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Meditation Meditation: “We train the mind by learning

to transform negative emotions into positive ones, ill will into goodwill, hatred into love.” – Eknath Easwaran

Meditation Techniques Breathing

Loving Kindness

Transforming (analytical, placement)

Walking, Listening

Activates Neural Structures Involved in Attention and Control of Autonomic Nervous System

Activity

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Learning Methods

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Presentations Courses Apps Readings

Mindfulness for the busy professional

10% Happier, by Dan Harris [ABC newscaster]

Mindfulness for our nation

A Mindful Nation: How a Simple Practice Can Help Us Reduce Stress, Improve Performance, and Recapture the American Spirit, by US representative Tim Ryan

Layman’s primer on meditation

Full Catastrophe Living, by Jon Kabot-Zinn

McClafferty: Group Demonstration

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Mindfulness

‘Thoughts & Feelings’

Recognize

Accept

Release

From Jon Kabat-Zinn

Mindfulness Short Exercise

One minute of mindfulness

Follow your breath

Mindfulness Short Exercise

Two minutes of mindfulness

Mindfulness

Share with a partner:

Easy? Hard? Effective trigger?

Mindfulness

How could you apply mindfulness at work ?

7. Becoming the Mindful GME Leader Action Plan - Incorporating Mindfulness and Healthy Choices into your Life (Small Group Activity)

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8. All: Report Out and Wrap-up

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References Maslach C, Jackson SE, Leiter MP, Maslach Burnout Inventory Manual; CPP Inc; 1996 Eckleberry-Hunt J. An exploratory study of resident burnout and wellness; Acad Med. 2009; 84: 269-277. Braseau CM. Relationships between medical student burnout, empathy and professional climate. Acad Med.

2010; 85: S33-S36. Raymond PL, Raymond RA. Don’t Jettison Medicine. Carthage Publications. 2003 Soltile W and M: http://www.sotile.com/advice_articles.php?article=3 Jensen PM. Building physician resilience. Can Fam Physician. 2008;54: 722–729. Olson K, Kemper KJ, Mahan JD. What Factors Promote Resilience and Protect Against Burnout in First-Year

Pediatric and Medicine-Pediatric Residents? J Evid-Based Comp Alt Med. 2015; 1-7. Cahn BR, Polich J. Meditation states and traits: EEG, ERP, and neuroimaging studies. Psych Bull. 2006;

132:180-211. Kemper KJ, Khirallah M. Acute effects of online mind-body skills training for health professionals., J Evid-Based

Comp Alt Med, 2015; 20: 247-53 . Chaukos D, Chad-Friedman E, Mehta DH, Byerly L, Celik A, McCoy TH, Denninger JW. Risk and Resilience

Factors Associated with Resident Burnout. Acad Psychiatry. 2017;41:189–194. Sood A, Prasad K, Schroeder D, Varkey P. Stress Management and Resilience Training Among Department of

Medicine Faculty: A Pilot Randomized Clinical Trial. J Gen Intern Med. 2011;26:858–61. Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost, and meaning in work. BMJ Qual and Saf.

2015; 24;608-10.. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a

systematc review and meta-analysis. Lancet. 2016;388:2272-2281. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout. JAMA 2017;317:901-902. Mahan J. Burnout in Pediatric Residents and Physicians: A Call to Action. Pediatrics 2017; 39: e20164233. Pangioti M, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-

analysis. JAMA 2017

Summary

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Sleep is more than a luxury and represents an important factor in physical and mental well-being. If appropriate, develop a plan to augment your sleep/rest.

Resilience – the ability to bounce back after being psychologically challenged – is important and can be measured and developed in faculty and GME leaders.

Mindfulness and mindfulness techniques can be important in building resilience in faculty and GME leaders.

Mindfulness activities (mindful movement, eating, meditation) can be learned and practiced through a variety of different learning and reinforcement methods.

Commit to 1 or 2 mindfulness activities, it might actually help you – and as Yogi said – “It ain’t over till it’s over.”

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Thank you!

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Extra stuff

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Resilience Ability to bounce back after being psychologically challenged

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Olson, Kemper, Mahan JEBCAM 2015

Pediatric Residents

Resilience – Regain Your Drive

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http://movieclips.com/kt7u9-field-of-dreams-movie-doc-saves-karin/

“If you can’t live longer, live deeper.” Italian Proverb

How to Build/Retain Physician Resilience Insights: Jensen – 17 Family MDs Attitudes and perspectives Balance and prioritization Practice management style Supportive relations

Courses: Sood (Mayo) - SMART (Stress Management and Resiliency Training) 1. Identify personal and professional challenges 2. Learn how stress affects the brain 3. Develop personal plans to improve resilience

Epstein (Rochester) - Health Professionals Mindfulness & Meditation Courses

Mindfulness TED Talks

https://www.ted.com/talks/andy_puddicombe_all_it_takes_is_10_mindful_minutes?language=en

https://www.youtube.com/watch?v=m8rRzTtP7Tc

https://www.youtube.com/watch?v=JVwLjC5etEQ

https://www.youtube.com/watch?v=Ze6t34_p-84

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Online OSU MB-STREAM

12 modules; 1 hour CME for each

Topics: Relaxation Response; Mindfulness; Heart-centered practices (mantram meditation); Guided Imagery

Format Case

Self-reflection

Evidence-based info with hyperlinks

Link to audio/video guided practice

Clinical tips & Tools for teaching patients

Self-reflection

Resources

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University of Arizona Center for Integrative Medicine: ‘Wellness in

Training’ Interactive Online Course

Foundations and background Self assessments Stress physiology Resilience Gratitude Mindfulness Buffet of mindfulness interventions Resources

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FREE Mindfulness Online Recordings (For Patients – but Good for ALL)

Guided Imagery

http://go.osu.edu/guidedimagerypractices

Mindfulness

http://go.osu.edu/mindfulness

Heart-Centered Practices

http://go.osu.edu/heartpractices

Relaxation Response

http://go.osu.edu/relaxationresponse

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Mindfulness Apps

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Apps for Mindfulness Headspace

The Mindfulness App

Stop, Breathe & Think

Mindfulness Training App

Mindfulness Coach

Breath 2 Relax

Calm

Happify

Eat Right Now®

Mindfulness Practice Add a Few Simple Skills Practice Each Day

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Prevention

Measurement - MBI; Brief Resilience Score

Don’t Jettison Medicine

Exercises Help trainees/faculty remember why they chose medicine

Help them to understand and manage sources of stress, e.g. how they start they day influences their mood when arriving at work

Sleep log and record of happiness level

Generate “bucket list” of positive activities www.youtube.com/watch?v=zjEPnN9f8w4

Nationwide Children’s Hospital/OSU COM Short Course Mind-Body Skills Training

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Four 1.5 hr workshops complemented by online MBS training (12 modules); N = 12

[Mind-Body Skills Training for Resilience, Effectiveness, and Mindfulness (MB-STREAM) program]

1. Relaxation Response 2. Body Scan

3. Mindful Meditation 4. Heart-Centered Practices

5. Yoga 6. Ongoing Practice Suggestions

Booster dose: Monthly group meetings/activities; Access to MB STREAM modules

Pre/Post surveys (MBI, PSS, Resilience, 5 Facet Mindfulness, Self-Compassion)

**Led by 3rd yr Med-Peds resident (Laura Romcevich)

Early Outcomes: Course worth it! • Online Modules useful = 77% • In-person training useful = 88% • Time investment worth it = 88%

Early Outcomes: Mind/Body Effects • Stress (Cohen) 19.9->15.4* • Resilience (BRS) 19.3->23.0* • Burnout (1 item) 2.7->2.3

* = p< 0.05

S L I D E 86

How long should recovery sleep be?

After 24 hr SD – need 9 hours of recovery sleep

9 hrs

6 hrs

Jay et al. Sleep 2007

S L I D E 87

Sleepy drivers have car crashes

0

50

100

150

200

250

300

350

400

450

0:00 3:00 6:00 9:00 12:00 15:00 18:00 21:00

Num

ber

of C

rash

es

Time of Day

Driving home post-call

Pack et al/ Accid Anal Prev 1995

20% of fatal accidents in the US involve a drowsy driver

S L I D E 88

Parents with young children sleep less!

Hagen EW et al. The Sleep-Time Cost of Parentings: Sleep duration and sleepiness among employed parents in the Wisconsin sleep cohort study. Am J Epidemiol 2013. 177(5): 394–401.

S L I D E 89

Parents of small children are more likely to be sleepy and doze!

Hagen EW et al. The Sleep-Time Cost of Parentings: Sleep duration and sleepiness among employed parents in the Wisconsin sleep cohort study. Am J Epidemiol 2013. 177(5): 394–401.

S L I D E 90

New parents have more car crashes (and near misses!)

• Sleep duration 6.4 hours

• 30% - daytime sleepiness

• 60% -poor daytime function

• 66% -poor sleep quality

• 22.2% reported at least one near miss accident

• 5.6% reported a crash

• Poor sleep quality was associated with a 6-fold increase in near miss accidents

Malish S. et al. A preliminary study of new parents, sleep disruption and Driving: A population at risk? Matern Child Health J 2016. 20(2):290-7