Tuesday, 29 March 2016

Fitness to Drive.

   Most Provinces have a requirement for physicians to report any patient who has a medical condition that may make it dangerous for the patient to drive.  Although there are many obvious situations in which one should not drive, the situation is by no means always clear cut.  The loss of a driving license involves a major life change, particularly in a climate like Canada, where one's winter mobility is dependent on one's ability to drive. There is considerable variation in the rules between  provinces varying all the way from the physician's judgement as to fitness to drive to rigid rules directed by the Ministry of Transport as in OntarioIn Quebec it is mandatory to report patients the physician has reason to believe will continue to drive despite being warned not to. There were 95 medico-legal cases between 2009 and 2013, falling into three categories:
     1. Physician failed to report a patient to the Ministry of transport.
     2. The report made was considered inappropriate by the patient.
     3. A physician  refused to support an application to reinstate driving privileges.

     Increasingly physicians are put in a conflicting situation between their civic duty and their requirement to provide privileged information to government agencies.  During most of my career, it would have been considered entirely appropriate for a physician to instruct a patient not to drive, either as a temporary or a permanent measure and to convey that judgement to the family, particularly in  the case of an elderly or non-compliant patient.  Thereafter, it became a family responsibility to see appropriate measures were taken.  In fact, when  the situation was appropriately presented to the patient and family, most people accepted the temporary or permanent restriction on driving.  Some, of course didn't and reacted aggressively to the situation.  I recall a harassed clinic business manager who came back from the bank after being loudly berated by a patient because of the fact that I had reported to the ministry that she should  be temporarily prevented from driving until the cause of a seizure she had suffered be investigated.  She informed him that she had found a much better doctor elsewhere who "really knew what he was talking about".
     Of course, despite what bureaucrats may think, most patients aren't stupid and it didn't take long for  them to learn what not to  tell their doctor in order to keep their driving license, thereby confusing the issue and the physician and perhaps impeding an appropriate diagnosis.
      Much  is made of privacy and confidentiality issues, but for a long time now they have been eroded and apart from occasional 'show trials' to convince patients that the administration cherishes privacy, they are steadily being whittled away.   
      Medicine is unlike any other profession and not amenable to algorithmic solutions of most of the problems that physicians have to address.  Experience is no longer considered as one of  the most important tributes of a good physician and anecdotal evidence is regarded as insignificant. The combination of physical and mental co-morbidities that physicians must address do not lend themselves to solution by a Google search no matter how much administrators  might like to think they are and that is why all the clinical practice guidelines in the world, no matter how cleverly crafted will never be more than that.  Guidelines.  Any attempt to make them rules will be to the detriment of the patient.  That is why physicians are professionals and not technicians.
     Would you support a mandatory information and road test for everyone over a certain age?

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