Having that key conversation
Be sensitive and open when patients are unfit to drive
For patients, it can be one of the most painful procedures of all – having their car keys removed from their hand.
When he was in family medicine, Dr. Stephen White of Napanee recalls one patient of about 80 who showed signs of dementia. The man’s daughters had concerns about his driving, and asked Dr. White to raise the topic. The patient himself didn’t recognize the problem. “He probably felt that everyone was against him,” Dr. White says.
After an assessment, it became clear that the daughters’ worries were warranted. By law, physicians who feel that a patient may be unfit to drive for medical reasons have a mandatory requirement to report that to Ontario’s Ministry of Transportation (MTO). While the duty is clear, such reports are stressful for patients and physicians alike.
“We realize that it’s bad news, a big loss of independence, and we feel for them,” says Dr. White, who now works in emergency medicine and is a member of the College’s Inquiries, Complaints and Reports Committee (ICRC). “It’s difficult because you’re also afraid of losing the relationship with the patient.”
As part of Dialogue’s continuing series on communications, we look at the mandatory reporting re-quirement and how to discuss this thorny issue with your patients.
“Unpleasant discussion” is almost inevitable
In Ontario, the mandatory reporting legislation has been in place since 1968, enacted at the request of the medical community. As the MTO explains, doctors were concerned about their inability to per-suade patients who were considered unfit to drive to voluntarily give up their keys.
Driver fitness can be compromised by any number of conditions that will likely impair judgment or psychomotor skills, or cause episodes of loss of consciousness. While physicians might recognize the danger, having the conversation remains difficult. To patients, losing their driving privileges (whether temporarily or permanently) is not only a major inconvenience but it can strike even deeper. It can be equated with a loss of freedom.
“When I was in general practice, I knew this was always going to be an unpleasant discussion,” says Dr. Patrick McNamara, a medical advisor for the College. “Patients argue with you, and they say they’re fine and you’re overreacting.”
Over time, patients might grudgingly accept the consequences. But they can resent the doctor who “turned them in,” another reason why physicians can become anxious about reporting to the Ministry of Transportation.
The number of medical reports to the MTO has been rising in recent years, from 21,000 in 2005 to 40,400 in 2007 to 50,000 in 2010, the last year for which figures are available. Bob Nichols, a spokesperson for the MTO, attributes the increase in part to increased educational outreach to the medical community. Yet some research suggests that physicians are still not making Medical Condi-tion Reports consistently.
In June 2012, Dr. Alex Louie released the results of a review of driving assessments for patients receiving brain radiotherapy at the London Health Sciences Centre’s regional cancer program. Over the study period, only 41% of patients were advised not to drive, and just 30% were reported to the MTO. Among patients who experienced seizures, only 68% discussed driving with their doctor. Although seizures should be automatic grounds for revoking a licence, only 56% of these patients were reported.
“We need more clear and precise guidelines, and more education of physicians, to protect both the safety of our patients and our society,” says Dr. Louie, a Chief Resident in Radiation Oncology and a scientist at the Lawson Health Research Institute.
Nichols notes that the MTO is working to continue to improve doctors’ understanding of their reporting requirements. That includes developing an e-learning module for physicians on mandatory reporting and the MTO review process. (See sidebar below for how the Ministry determines licence status.)
Stay sympathetic but firm
With the issue of fitness to drive so fraught with emotion, the conversation requires a special touch. Five things to remember:
1. Be open.
Some people complain to the College just because they disagree with their doctor’s findings. But the ICRC also receives complaints because the doctor never told the patient about filing a report. “We see this avoidance,” says Dr. White. “Be up front. There’s anger when you tell patients, but if it’s hidden the response could be worse.”
The College’s recently approved policy on mandatory and permissive reporting addresses this in the section on impaired driving. While it’s not necessary to obtain a patient’s consent before making a report under the Highway Traffic Act, the College encourages physicians to inform the patient in advance. In those circumstances where the patient was not informed beforehand, it is recommended that the physician do so after the report has been made.
2. Provide some context.
Don’t just discuss the diagnosis, but the specific medical reasons why the patient shouldn’t be driving, says Dr. McNamara. If someone has had a seizure and is in danger of having another one, talk about what that means behind the wheel. Broaden the discussion too. Fitness to drive is probably only one impact of the patient’s condition. Have the conversation in the context of other implications, to put driving in a larger perspective.
3. Show empathy.
Put yourself in the patient’s shoes to understand their anger and frustration. “Acknowledge what they’re feeling, and talk about how you’ve had other patients in similar circumstances, and you know it’s not easy to live without a licence,” says Dr. White. “You can see yourself in the same position, and know it would be a big loss.”
4. Soften the blow.
Talk about alternatives, perhaps not at the same time you discuss a report to the MTO but at a follow-up. The car is an important part of people’s lives, but over time they might realize that public transportation, taxis, and rides from family or friends can fill their needs (and be cheaper than running a vehicle too). Maybe involve other family members in the discussion. If the family supports your position, that might help the patient to accept the news more readily.
5. Stay firm.
You owe your patients an explanation, but not an argument. “You can’t get into a debate; you have a legal obligation,” says Dr. McNamara.
You can’t get into a debate; you have a legal obligation.
When patients try to make deals – they’ll be extra careful when driving, they’ll only go short distances, they’ll only use the car for work or during the day – don’t fall into a trap. “You’re not bargaining,” says Dr. White. “Whether someone is driving to the grocery store or on Highway 401, they’re putting people’s lives at risk.”
The mandatory reporting requirement for physicians regarding patients who may be unfit to drive for medical reasons is found in Section 203 of the Highway Traffic Act. Section 204 includes similar provisions for optometrists to report visual conditions.
For more on reporting requirements, see the Medical Review Section of the Ministry of Transportation website: http://www.mto.gov.on.ca/english/dandv/driver/medical-review. You can download the Medical Condition Report, or order copies by e-mailing email@example.com or calling 416-235-1773 or 1-800-268-1481.
The Canadian Medical Association publishes a guide called Determining Medical Fitness to Operate Motor Vehicles. It’s available online at http://www.cma.ca, and CMA members are entitled to one complimentary print copy; call 888-855-2555.
How MTO determines licence status
A report by a physician under the Highway Traffic Act will not automatically result in the suspension or down-grading of the
Upon receipt, the Ministry of Transportation (MTO) will consider the details of the individual’s clinical condition reported by the attending physician, using guidelines established by the Canadian Medical Association, and advice from the MTO’s Medical Advisory Committee. Members of the Committee include experts in the fields of neurology, cardiology, psychiatry, endocrinology, ophthalmology, internal medicine, substance abuse, geriatric medicine, and physiatry.
The MTO relies on information provided on the Medical Condition Report to help identify individuals who are at significant risk.
In 2010, 70% of medical reports resulted in an immediate licence suspension.
For individuals who are reported to have a clinical condition that’s well controlled, and who are under physician care, the MTO generally does not suspend the licence. Where stability may be questionable, the MTO may re-quest follow-up medical information or ask the individual to take a driving examination or other appropriate assessments.
The length of a medical suspension varies, depending on the nature and stability of each person’s condition.