Can family physicians evaluate patients’ competence to drive?

Evaluating my patients’ competence to operate motor vehicles often drives me crazy. When I see them arriving with the form in hand, I always wonder whether I am the right person to attest to their abilities. The more so because, whatever the reason behind the need to complete the form, they consider themselves—each and every one—invariably in excellent health, even if at the preceding visit their litany of complaints was endless. I am amazed at the therapeutic power of this piece of paper! But if we trust the results of a survey conducted in 2006,1 I am not the only one to have some doubts.

This month in Canadian Family Physician, Adams and Laycock debate this very question: “Should family physicians assess fitness to drive?” (pages 1264, 1265). Adams2 thinks they should, alleging that family physicians have all the knowledge, skills, and attitudes required for this task, noting especially the global nature and continuity of the care that they provide. Laycock,3 on the other hand, thinks differently. He states that family physicians cannot evaluate the motor, visuospatial, and cognitive skills necessary to operate an automobile, and that their evaluations are not corroborated by road tests.

The question is interesting because, should it happen that family physicians are judged unsuitable to evaluate the ability to operate a motor vehicle, who then should do it? The Ministry of Transportation offices? Occupational therapists who specialize in road tests? Perhaps, but again, we should be able to show proof.

In this regard, the contention that the evaluations of other professionals are superior to those of family physicians is far from being demonstrated. In effect, the ultimate goal (outcome) of evaluating the ability to drive a motor vehicle is not only to identify drivers at risk but also to reduce the consequences of having inept drivers on the road—that is to reduce the number of road accidents and the injuries and mortality they bring about. If you conduct a review of the evidence-based data using the PICO principles, so dear to the gathering of evidence-based data (where the P stands for Population or Patient, I stands for Intervention or Indicator, C stands for Comparator or Control, and O stands for the Outcome of the research), and if you attribute the following key words to your research, P = physicans, I = evaluation of driving, C = occupational therapists, and O = car accidents, you will not obtain any scientific evidence. Not a single study compares the results of those who evaluate driving skills. There is nothing to prove that such evaluation is better done by other professionals than by physicians.

According to one vast meta-analysis4 conducted in 2004 and considered by many to be the document of reference in this area, 8 medical conditions are associated with a higher risk (relative risk >2) of road accidents: abuse of or dependence on alcohol, dementia, epilepsy, multiple sclerosis, any psychiatric condition, schizophrenia, sleep apnea, and cataracts. Everyone agrees that these conditions are managed currently by family physicians. It is certainly true that any of these conditions could be missed in a road test. An alcoholic is not going to turn up drunk for his road test! A patient with sleep apnea can easily pass all the driving tests without showing excessive somnolence. It seems then that family physicians and other professionals have complementary roles in this area.

That being said, I know some family physicians who would willingly give up the responsibility for completing these forms. “One more!” they say, to add to the tens or even hundreds of forms they receive regularly. Many assume this responsibility to render service to patients and to society, often for a derisory fee considering that road tests can easily cost $300 to $1000 if the test is done privately.

Think about it. Unless it can be demonstrated that family physicians are truly incapable of evaluating patients’ ability to operate motor vehicles and that other professionals can do it better, we should be vigilant before changing this way of doing things. What is really at stake should be health and social consciousness rather than professional or corporate interests.

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