Shawn Marshall , MD, MSc, FRCPC 1,2,3,4, Erin M. Demmings , MD, MEd 1, Andrew Woolnough , MSc 13, Danish Salim , BSc 1, Malcolm Man-Son-Hing , MD, MSc, FRCPC 1,2,45
1 CIHR Team on Older Person Driving (Candrive II), Ottawa Hospital, Ottawa, ON
2 Bruyère Research Institute, Bruyère Continuing Care, Ottawa Hospital, Ottawa, ON
3 The Ottawa Hospital Rehabilitation Centre, Ottawa Hospital, Ottawa, ON
4 Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON
5 Geriatric Assessment Unit, Ottawa Hospital, Ottawa, ONDOI: http://dx.doi.org/10.5770/cgj.15.30
ABSTRACT
Background
Many specialists encounter issues related to fitness to drive in their practices. We sought to determine the attitudes and practices of Canadian specialists regarding the assessment of medical fitness to drive in older persons.
Methods
We present data from a postal survey of 842 physicians certified in cardiology, endocrinology, geriatric medicine, neurology, neurosurgery, orthopaedic surgery, physical medicine and rehabilitation, or rheumatology regarding their attitudes and practices relating to the assessment of their patients’ fitness to drive.
Results
Overall response rate was 55.1%. Except for rheumatologists (18%), most specialists reported that fitness to drive is an important issue in their practices (68%). Confidence in the ability to assess fitness to drive was low (33%), and the majority (73%) felt they would benefit from further education. There were significant differences ( p < .05) in responses between physicians from different provinces, owing to reporting policies. More geriatricians than neurologists report drivers with mild Alzheimer disease to authorities regardless of reporting policy (mandatory 90.7% vs. 56.0%; non-mandatory 84.1% vs. 40.0%) ( p < .05).
Conclusions
Canadian specialists accept the responsibility of determining their patients’ fitness to drive but are not fully confident in their ability to do so. However, they are receptive to education to improve their skills in this area.
Key words: older drivers , medical fitness to drive , survey , physician’s role
For many older persons, driving an automobile is the preferred and often essentially the only means of transportation available.(1–4) The ability to drive allows the independent mobility needed to pursue social and recreational activities. The loss of driving privileges can have devastating psychosocial consequences leading to depression,(5–9) social isolation, and increased stress on family and friends.(1,4,10) However, motor vehicle crashes are the second most common means of traumatic injury in older persons.(11) Of any age group, apart from teenaged drivers, those over the age of 70 years have the highest rate of crashes per mile driven.(12)
Physicians often play a key role in evaluating older people’s fitness to drive. In many North American jurisdictions, including California and 7 of the 10 Canadian provinces and 6 of the 50 American states,(13) it is mandatory for physicians (and other health professionals) to report to licensing authorities persons whom they deem medically unfit to drive. However, physicians report that they have little training in this area and are ill equipped to do so.(14–17) This situation has occurred despite the wide availability of publications from the American Medical Association(18) and Canadian Medical Association(19) that provide guidance on assessing medical fitness to drive.
Recent surveys have reported on the attitudes and practices of Canadian family physicians(17) and psychiatrists(20) towards the assessment of older people’s medical fitness to drive. Among their main findings is that these physician groups often lacked confidence in their ability to assess fitness to drive. Another study surveyed physicians regarding dementia and driving safety, and less than 60% of physicians addressed driving issues with their patients. The factors associated with addressing driving issues were awareness of the American Medical Association guidelines and years in practice (more experienced physicians had greater perceived accountability for driving safety).(21) Given that many other specialist physicians also encounter issues related to fitness to drive in their practices, we conducted a survey to determine the attitudes and practices of physicians from eight different medical and surgical specialties.
The study protocol was approved by the Research Ethics Board of Bruyère Continuing Care, Ottawa, Canada. A national, cross-sectional mail survey was conducted in a random sample of Canadian medical specialists in whom driving issues were deemed relevant to their practice. The 10 specialty groups surveyed were cardiology, endocrinology, general surgery, geriatric medicine, internal medicine, neurology, neurosurgery, orthopaedic surgery, physical medicine and rehabilitation (physiatrists), and rheumatology. These specialties were chosen based on likelihood of needing to make decisions regarding medical fitness to drive compared to other specialties (e.g., dermatology, obstetrics and gynecology); ophthalmology was not included given the well-described vision standards for driving. A computer-generated random sample of 200 physicians from each group was identified from the 2004 Canadian Medical Directory.(22) To survey physicians in the disciplines of general internal medicine and general surgery, only those who were singly listed in the Canadian Medical Directory as general internists and general surgeons and were not listed as holding other subspecialty certifications were included. Fewer than 200 geriatricians were listed, and so all in this group were surveyed. Physicians who reported that their primary language is French or had practice addresses in paediatric hospitals were excluded.
Jang et al .(17) examined the attitudes and practices of family physicians regarding fitness-to-drive issues in older persons. Using their questionnaire as a template, we developed a questionnaire exploring the attitudes and practices of Canadian specialists towards determining their patients’ fitness to drive (Appendix A). Additional questions of particular relevance to individual specialties were added (Appendix B). Therefore, individual surveys included a core set of questions asked of all respondents and a number of specialty-specific questions. Pilot testing of the survey was performed with one or two representatives from each of the 10 specialties, and the survey was revised based on their feedback.
The survey commenced by asking whether the physician was in active clinical practice. Those answering “no” were asked to return a blank survey and the identifying coded postcard. The survey contained five main sections: attitudes towards driving assessments and reporting; practices and activities pertaining to driving assessments; knowledge of jurisdictional driving policies and programs; the demographic and practice characteristics of respondents; and a comments section. A five-point Likert response scale was used for most questions (e.g., from “strongly agree” to “strongly disagree”, and “always” to “never”).
Ten days before the initial mail-out, a pre-notice postcard was sent to prospective respondents. Mail-out of the questionnaire commenced in May 2005, and to preserve anonymity a coded postcard to be mailed back separately from the completed anonymous questionnaire was included. This allowed the research team to identify responders but not their responses and target non-responders in follow-up mail-outs. Also included in the mail-out package was a cover letter on University of Ottawa letterhead hand signed by at least one colleague in the specialty of the prospective respondent and a stamped self-addressed return envelope. To maximize response rates, non-responders were sent second (October 2005) and, if needed, third (April 2006) questionnaire packages.(23,24)
The sample size of 200 physicians per specialty group was based on the number of available Canadian physicians to survey in order to have equal representation from each specialty. Geriatric medicine had only 196 physicians registered in 2004, and other specialties such as rheumatology and neurosurgery had 200 to 300 specialists registered. Response rates were calculated as a percentage based on specialty groups and total physicians.
SPSS version 19.0 (SPSS Inc. Chicago, Il) was used for descriptive statistics, as well as analysis of categorical data, which were analyzed using the weighted Pearson chi-square to compare differences between reporting provinces and specialties. Significance was determined at p < .05.
There were poor response rates for internal medicine (22%) and general surgery (28%) because many respondents stated that while they were certified as general internists or surgeons, their practices were primarily of a subspecialty nature. Given the unacceptably low response rates, these two groups were excluded from further analysis. The overall response rate for the remaining eight groups was 55.1% and varied from 47.4% (cardiologists) to 73.3% (physiatrists).
Table 1 shows the characteristics of the respondents by medical specialty. There are some notable and anticipated gender differences across specialties (e.g., 57% of geriatricians and 3% of neurosurgeons were female). With the exception of Quebec, the response rate by province reflected provincial populations.
TABLE 1
Characteristics of respondents by specialty
Table 2 shows the responses reported by specialty regarding attitudes towards assessment of fitness to drive. Most of the medical specialists (68%) reported that fitness to drive is an important issue in their practice, except for rheumatologists (18%). Among the surgical specialties, assessment of fitness to drive is an important part of practice for most neurosurgeons (67%) but fewer orthopaedic surgeons (42%). Regardless of the perceived importance of assessing fitness to drive, confidence in the ability to do so was low (33%) across all specialties surveyed, with cardiologists (54%) having the most confidence in their abilities.
TABLE 2
Attitudes of respondents toward assessing fitness to drive by specialty
Most respondents (63%) across all specialties felt that physicians should legally be required to report unsafe drivers to authorities. However, less than half of respondents (27%) in all specialties did not feel that physicians are the most qualified discipline to do so, and most (73%) felt they would benefit from education in this area.
Most respondents across all specialties felt that assessing fitness to drive had negative consequences for patients (76%) and their families (69%), as well being detrimental to the patient–physician relationship (70%). Most (66%) felt that physicians are in a conflict of interest situation (patient confidentiality versus public safety) when assessing fitness to drive. Few respondents (9%) felt that authorities evaluate unsafe drivers in a timely manner, and most (89%) felt that a clinical screening tool designed to assess fitness to drive in the office setting is needed.
Most physicians (87%) from mandatory reporting provinces were aware of the requirements for reporting unsafe drivers to licensing authorities. Overall, 73% of these physicians knew the proper steps to take to report unsafe drivers; rates were lower for orthopaedic surgeons (31%) and rheumatologists (35%). Only 26% clearly understand the procedures for evaluating unsafe older drivers at the provincial department of motor vehicles.
The respondents’ practice patterns correlated well with their perceived importance of the issue to their practices (Table 3). Most respondents (86% mandatory and 82% non-mandatory) indicated that they believed their patients adhered to their driving recommendations; no differences were identified between specialists in mandatory reporting provinces versus those in non-mandatory reporting provinces. Significantly more physicians in mandatory reporting provinces than in non-mandatory reporting provinces report patients whom they consider unsafe to drive (67% vs. 41%) or whose ability to drive safely is questionable (63% vs. 49%) ( p < .05). Geriatricians (93% mandatory and 86% non-mandatory) and neurologists (85% mandatory and 63% non-mandatory) had the highest rates of reporting patients in the latter category, while cardiologists (44% mandatory, 19% non-mandatory) had low rates of such reporting. More physicians from mandatory reporting provinces reported feeling unduly pressured by patients to reconsider the decision (65% mandatory vs. 53% non-mandatory; p = .02). Similar percentages were found regarding undue pressure by family members, but no significant differences were identified between province type. Overall, 6% to 57% of respondents reported that patients had left their practice over driving issues; this was reported by significantly more respondents from mandatory provinces (29%) than non-mandatory provinces (22%) ( p = .043).
TABLE 3
Practices of respondents regarding assessing fitness to drive by specialty
Geriatricians and neurologists generally believe (range 72–93%) that older persons should have their driving ability assessed more frequently than middle-aged persons (Table 4). A minority of geriatricians and neurologists felt that all persons with mild dementia are unsafe to drive; however, significantly more neurologists than geriatricians ( p < .05) held this view. A significantly higher percentage of geriatricians than neurologists ( p < .05) report drivers with mild to severe Alzheimer disease or vascular disease. More neurologists from mandatory reporting provinces than from non-mandatory reporting provinces indicated that they report drivers with moderate to severe Alzheimer disease or vascular disease (~ 86% vs. ~ 50–55%).
TABLE 4
Attitudes and practices of geriatricians and neurologists regarding assessing fitness to drive in patients with cognitive difficulties/dementia
Most orthopaedic surgeons (> 61%) indicated that they discussed driving issues with patients after a right lower leg arthroplasty (Table 5). The rate for physiatrists was significantly lower (31%; p < .05). None of the orthopaedic surgeons from mandatory reporting provinces and 5.6% of those from non-mandatory reporting provinces indicated that they report these patients to the authorities.
TABLE 5
Attitudes and practices of orthopaedic surgeons and physiatrists when assessing fitness to drive in patients with a recent lower leg arthroplasty, and attitudes and practices of orthopaedic surgeons and neurosurgeons when assessing fitness to drive immediately after surgery
Most neurosurgeons (83–90%) felt that patients with postoperative pain should resume driving based on their own judgement (Table 5), whereas 59–65% of orthopaedic surgeons held this view. The majority of neurosurgeons (83–94%) indicated that they counsel patients experiencing postoperative confusion or delirium on driving, compared to 22–33% of orthopaedic surgeons ( p < .05). There were no significant differences between specialists from mandatory and non-mandatory reporting provinces.
In many jurisdictions, physicians, including those in medical and surgical specialties, are legally obligated to report patients under their care whom they deem medically unfit to drive. We found that most specialists accept this responsibility but do not feel confident is doing so and would benefit from further education regarding the evaluation of medical fitness to drive. As would be expected, there was a strong correlation between the perceived importance of assessing medical fitness to drive and the survey responses. For example, rheumatologists reported that driving assessment was not an important part of their practice, and they had the least confidence in their ability to assess fitness to drive. This study shows that there is a gap between the perceived responsibilities of Canadian specialist physicians in the assessment of their patients’ fitness to drive and the confidence and expertise to do so.
Our results are consistent with those of similar studies performed in other Canadian physician groups. Thirty percent of family physicians(17) and 26% of psychiatrists(20) reported being confident in their ability to assess their patients’ fitness to drive, compared with 33% of specialists in our study. Similarly, 27% of family physicians(17) and 27% of our respondents felt that physicians are the most qualified group to assess fitness to drive. In our study, the specialty with the highest confidence rating (54%) was cardiology. This is likely due to publications by the Canadian Cardiovascular Society(25) and distribution of a rigorously derived, explicit set of driving guidelines for patients with cardiovascular disease. It also likely relates to the context of reporting—cardiologists focus on the likelihood of acute incapacitation from a cardiac event for which risk must be determined, whereas other specialists may tend to focus on chronic conditions, such as cognition impairment or hemiparesis, that may functionally impair driving and that could potentially be evaluated through direct observation of ability. Seventy percent of our respondents felt that reporting patients to authorities negatively affects the patient–physician relationship. This is in keeping with rates for Canadian family physicians (78%(17)) and psychiatrists (67%(20)). Overall, 73% of our respondents, 88% of Canadian family physicians,(17) and 83% of Canadian psychiatrists(20) reported that they would benefit from further education on assessing medical fitness to drive, as did 80% of Scandinavian physicians.(26) Therefore, it is likely that the issues faced by physicians regarding the assessment of fitness to drive exist, not only across specialty and practice but also internationally.
A high percentage of specialists (87%) from provinces with mandatory reporting requirements were aware of this responsibility. In contrast, 9–30% of respondents in provinces with discretionary requirements incorrectly stated that the reporting of unsafe drivers was mandatory in their jurisdiction. Similar results were found in a survey of American geriatricians;(27) a much higher percentage of those practising in California (where reporting of patients with moderate to severe Alzheimer disease is mandatory) were aware of the reporting requirements, compared with those practising in states with discretionary reporting. It remains controversial whether the legal requirement of mandatory reporting of unsafe drivers helps or hinders their safety.(28) Mandatory reporting has the potential to facilitate the removal of unsafe drivers from the road, but also creates a disincentive for physicians to pursue driving assessments,(17) possibly owing to factors such as not having flexibility to interpret driving assessment results and wishing to act in the fairest manner for their patient.
In our study, there was a correlation between the frequency/ importance of evaluating patients with diseases that impair cognition/consciousness and the perceived importance of assessing fitness to drive within one’s practice. Almost all geriatricians and neurologists (who routinely evaluate disorders such as dementia and seizures) reported that assessing fitness to drive is an important aspect of their practice, whereas few rheumatologists (who are much more likely to manage conditions that physically, rather than cognitively, affect driving ability) did so. Between these two extremes were endocrinologists and cardiologists, who encounter conditions that sporadically affect consciousness (e.g., cardiac arrhythmias and hypoglycaemia) more frequently than rheumatologists, but not as frequently as neurologists and geriatricians. The correlation held true among the surgical specialties, with more neurosurgeons than orthopaedic surgeons assigning importance to the evaluation of fitness to drive. It appears that specialists are more attuned to the cognitive factors, rather than the physical factors, that are important for driving. This approach may make clinical sense, as physician intervention is probably more often required with drivers who have cognitive problems because these patients often lack insight into their deficits and cannot self-regulate their driving exposure as easily as those with physical limitations. However, from a Canadian medicolegal perspective, this may be a misperception, as there is precedence for physicians’ being found legally liable for failing to report patients with physical contraindications (e.g., severe cervical spondylopathy(29,30)) to driving.
With regard to the issue of whether to promote the independence of individuals versus stressing public safety, geriatricians and neurologists tend to err on the side of public safety: about one-third would recommend licence removal from patients with mild cognitive impairment (a syndrome in which functional dependency has not yet occurred and that leads to dementia at a rate of 10–15% per year(30)). However, no study has shown that such patients have higher than expected crash rates, and clinical practice guidelines do not recommend that they have their driving ability assessed.(31,32)
The response rates in our study were variable for the different specialty groups; however, they were greater than 50% for all groups analyzed. As would be expected, the response rates were higher for the specialties that deemed assessment of medical fitness to drive of higher importance to their practices; however, the overall response rate was equal to or better than that in similar surveys.(17,20) The fact that the survey was conducted in English and the predominant language in Quebec is French likely accounts for the lower response rate from that province. Since the study design assured anonymity, we could not determine whether responders were different in any important way from non-responders. However, in a similar survey,(17) the demographic characteristics of the total sample surveyed was similar to those of responders. We were unable to perform chart reviews of responders’ actual practices; therefore, there may have been differences between how physicians responded to the survey and their actual practices. Finally, since physicians whose primary language is French were not surveyed, the results cannot be generalized to them.
While accepting the responsibility of determining fitness to drive in their patients, Canadian specialist physicians are not confident in their ability to do so and are receptive to educational programs that would improve their skills in this area. Medical education groups and transportation officials should take advantage of this opportunity.
The following questions ask about your attitudes towards driving assessments.
Please circle your response:
The following questions ask about the frequency of your practices/activities pertaining to driving assessments and reporting.
Please circle your response:
The following questions ask about driving policies and programs in your province.
Please check the appropriate box :
The following questions ask about you and your practice.
Questions unique to Neurologists/Geriatricians
Questions unique to Endocrinologists
Questions unique to Cardiologists
Questions unique to Physiatrists
Questions unique to Rheumatologists
Questions unique to Neurosurgeons
Questions unique to Orthopedic Surgeons
The authors declare that no conflicts of interest exist.
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This research was funded by the Canadian Institutes of Health Research and the Ontario Neurotrauma Foundation. We would like to acknowledge the assistance of Dorothy Ann Curran and Gloria Baker in analysis and preparation of this manuscript.
Canadian Geriatrics Journal , Vol. 15 , No. 4 , December 2012