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Family physicians have the knowledge, skills, and attitudes to be in a competent position to assess patients’ fitness to drive. As family physicians, we are an essential part of the team that assesses drivers’ medical fitness. Our experience over time in understanding a patient’s myriad medical conditions, our long-term relationships with patients, and our relationships with patients’ families are assets. There is a complementary role that each profession plays in assessment of driving, and family physicians are a crucial part of the team. Our expertise in patient-centred communication is an essential part of the way we practise and is vital in discussing driving issues.
As family physicians, we are well trained to have the skills necessary to assess fitness to drive. As in many areas of medicine, use of clinical tools can be helpful in our decision making. One of the well-known tools for assessing fitness to drive is the Canadian Medical Association driver’s guide, Determining Medical Fitness to Operate Motor Vehicles.1 Although comprehensive, it has been criticized for not being helpful in predicting which combinations of conditions and medications will affect driving ability. Fortunately, a new tool called the SIMARD MD (Screen for the Identification of Medically At-Risk Drivers, A Modification of the DemTect)2 has been developed in Alberta for health care practitioners to help identify cognitively impaired patients whose driving skills might have declined to unsafe levels. This test is a user-friendly paper-and-pencil test, which takes 5 to 7 minutes to administer and is easily scored. It has a high predictability in terms of whether a patient is safe to drive, unsafe to drive, or needs to be referred for driver evaluation.3 For family physicians, this can be performed during a yearly physical examination without much difficulty or during a routine visit in which a driving concern is identified.
Just as we discuss smoking cessation, the topic of driving limitation or cessation can be addressed in a yearly physical examination well before the need to report to licensing authorities arises. As with any medication review for side effects, we can advise and counsel patients about medical conditions and possible medication side effects that might impair the ability to drive safely. The trust of our patients and the importance of “finding common ground” can enable us to preserve the physician-patient relationship when discussing driving issues. As family physicians, we have an established rapport with patients and can observe changes over time. Our relationship and collaboration with family members is also paramount in gathering corroborating information about patients’ driving ability. Family members often disclose concerns about a loved one’s driving that can be very revealing. Furthermore, a study done by Jang et al in 2007 found that 72.4% of Canadian family physicians agreed that physicians should be legally responsible for reporting unsafe drivers to licensing authorities.4
In our role as counselors, we often assist patients with transitions and life changes. For many of us, driving is a symbol of independence and a source of self-esteem. When an individual retires from driving, he or she not only loses a form of transportation, but also loses all the emotional and social benefits derived from driving. For various reasons, physicians might be reluctant to discuss driving cessation with their patients. Physicians might fear giving bad news or be concerned that the patient will resent the loss of independence. Physicians sometimes avoid discussions of driving altogether because they believe that a patient will not want their advice or will become angry.5 These concerns are all valid. However, physicians have an ethical responsibility to protect their patients and the public’s safety through assessment of driving-related functions. Just as we assist a patient or family with any life transition, we have a responsibility to include driving issues in our scope of care.
As family physicians, we can provide resources to our patients to help them explore medical and rehabilitation options to improve their driving safety. Specialized driver assessments by occupational therapists or the American Automobile Association’s computer-based driving tool Roadwise Review could be helpful.6 This free tool allows drivers to measure (using their home computers) the 8 functional abilities shown to be the strongest predictors of accident risk among older drivers. A Canadian resource is CanDRIVE,7 an interdisciplinary health-related research program initiated in 2002 that is dedicated to improving the safety of older drivers. A study is under way that is recruiting 1000 senior drivers from across the country for a 5-year investigation of seniors’ driving habits. The study will determine factors key to safe driving, measure the effect of medical conditions on driving ability, and provide information for development of a quick test to assess driving ability. Resources are available on the CanDRIVE website for physicians and patients and include a video entitled “Knowing When to Stop Driving.”
When all other options have been exhausted, family physicians can recommend driving restriction or driving cessation. Studies show that physicians are influential in patients’ decisions to stop driving. In fact, advice from a doctor is the most frequently cited reason that a patient stops driving.8 A physician who can work together with a patient and family in a caring and compassionate way to plan ahead and provide support can facilitate driving cessation and reporting, which does need to be detrimental to the physician-patient relationship.
As family physicians, we have a responsibility for patient and public safety, and assessment of medical fitness to drive is an essential part of this role. Fortunately, we are not alone in assessing driver fitness but are a crucial part of a team of health professionals. There is no one ideal assessor, but as family physicians we must use the strengths we have as a specialty—to provide continuing, comprehensive health care for individuals and families in order to improve road safety and ultimately decrease morbidity and mortality.