MEETING WITH EXPERTS
Ranks 1, 6, 18, and 31: Use of External, Medical Triggers for Medical Reviews -
Physicians are valued sources of information to DMVs. Referrals by personal physicians received a weighting of 3.24, placing it highest in importance of all 64 components weighted in the RVA. As indicated earlier, all 51 jurisdictions accept reports of potentially at-risk drivers from physicians. In the initial survey, at least one jurisdiction reported that physicians and law enforcement are considered “expert” sources, meaning that a licensing action can be made without the DMV requesting additional information (medical history and physician recommendation) from the treating physician. Immediate suspensions are issued in many jurisdictions based on the information provided in an initial report submitted by a physician (e.g., loss of consciousness or other condition that poses an immediate threat to the public). Discussions revolved mainly around the physicians’ responsibility to counsel drivers about their ability to drive safely, and to report their patients only when there was a need to get the DMV involved (i.e., when the patient does not comply with the physician’s recommendations).
Although educating physicians about how medical conditions affect driving performance was rated relatively low (46/64), meeting attendees agreed this was very important and necessary in a model program; it likely fell low in priority in this exercise because it was contained in an area that often gets low priority because of funding and staffing shortages (options for supporting continuing safe mobility). Attendees said physicians need to be educated regarding the State’s reporting requirements and the State’s licensing guidelines for medical conditions and functional impairments. A comment was made by an MAB physician in attendance that many physicians are hesitant to send reports to the DMV because they don’t know what is going to happen to the patients they report. DMVs have found that when physicians understand the DMV process for reported patients, physicians are more likely to report the patients who should be reported. Where used, training in how to profile drivers using Functional Ability Profiles should be provided to physicians. Training in how to complete the driver medical history requests from DMV medical review departments would also be useful to physicians.
Physicians at the meeting agreed the AMA/NHTSA Physician’s Guide to Assessing and Counseling Older Drivers (Wang, Kosinski, Schwartzberg, and Shanklin, 2003) should be required reading for physicians, and that Continuing Medical Education (CME) credits should be offered. Physician education is deemed important regardless of whether reporting is mandatory or voluntary in a jurisdiction. It was recommended by one MAB physician consultant that physicians be required to complete a CME in driver medical education every three years. The hope is that, as physicians become more educated, so will their patients, through various other publications and media. Education must start with the physicians, and it is a never-ending job.
On a related topic, education of the public received a low weight in the RVA (0.84, placing it 62nd out of 64), but received attention during the meeting with experts. Low ratings for this component are related to the fact that this is a new concept for several jurisdictions, which have just begun to explore how to implement activities such as public information and education. One attendee said, “We have convinced people that it is socially wrong to drink and drive. We have convinced them that they must wear safety belts. Nobody presents the idea to the public through commercials or other media that they might not be safe to drive because of a medical condition or functional impairment.” Another reason for low ratings and a barrier is that funding has been appropriated for DUI and safety belt programs, but not for fitness-to-drive. Although the section is not traditionally used for this purpose, a NHTSA representative said a jurisdiction could apply for funding under 23 U.S.C. § 402 (NHTSA grant funding for highway safety programs through the Governor’s Office of Highway Safety) with a particular project in mind for enhancing public safety. It was brought up that the AAMVA Grand Driver program is one of the tools that can be used in any State to implement public education. Two other projects are underway through NHTSA, one called “New Generations” with Iowa DOT and another called “Community Conversations” that will produce materials for educating the public about fitness to drive. Oregon DMV has recently received a grant to work with an ad agency to produce public service announcements. The kit includes radio spots, TV spots, and newspaper ads with the spin, “If you can talk to your kids about sex, you can talk to your parents about driving.”
One MAB physician in attendance highlighted the importance of educating the legislature. Even if there is a public awareness, at some point it comes down to the law, and it can be difficult to get good laws passed unless there is some sort of an education of the body that makes those laws. (Note: in the initial survey, legislation was mentioned by 17 jurisdictions as a barrier to providing more extensive screening, counseling, and referral activities in DMVs).
Referrals by vision care specialists received a weighting of 2.61, placing it second in importance within the set of four components describing external, medical triggers, and 6th out of 64 when considering all components in the third column of the RVA. Several meeting attendees said vision care specialists report drivers in their jurisdictions. Like physicians, their reports provide credible information to DMVs. One attendee remarked that frequently a driver has been required to see an optometrist (because the driver failed the DMV vision screen), and the report came back from the ophthalmologist that the driver has diabetic retinopathy or some other eye disease. That information prompts the requirement for drivers to undergo a medical examination (and have a medical form completed) by their regular physicians.
Referrals by occupational therapists (OTs) and other professionals who conduct driving evaluations, such as certified driver rehabilitation specialists (CDRSs), received a weighing of 1.91, placing it third out of the four components in the set of medical referral triggers, and 18th out of 64 when considering all components listed in the third column of the RVA. Referrals from OTs/CDRSs are among the sources that DMVs consider as valid, removing the requirement for investigations into the credibility of the report. It is probably more common, currently, for a DMV to refer a driver to an OT or CDRS for an evaluation of fitness to drive, than for a report by an OT or CDRS to trigger medical review. However, in a model system where physicians are educated with respect to fitness to drive issues, have good rapport with their patients, and can recommend testing and possible remediation by driving evaluators, drivers may be able to drive safely longer without the need to involve the DMV for medical review. One MAB physician attendee said a team approach that utilizes the treating physician, OTs/CDRSs and the DMV, removes the need for mandatory reporting and allows the physicians and the DMV to be viewed as resources to help people keep driving safely longer, as opposed to agencies trying to take licenses away.
Hospital discharge planners received a weighting of 1.39, placing them least in importance as external medical triggers for medical review in the set of four components evaluated in the RVA, and 31st out of the 64 total components evaluated in the third column of the RVA. In initial survey conducted in this project, 48 jurisdictions said they accept reports of at-risk drivers from hospitals (they were not asked specifically about discharge planners). There was no discussion at the meeting about the utility of hospital discharge planners as external medical triggers for medical review of fitness to drive.