MEETING WITH EXPERTS
Ranks 26 and 27: Use of Internal Triggers for Medical Reviews
Use of internal triggers ranked 9th out of 16 components evaluated in the middle column of the RVA. The four internal triggers evaluated in the RVA were: (1) observations by counter staff; (2) self-reports; (3) driving history (points and crashes); and (4) age. Comments provided by meeting attendees about observations by counter staff and self-reporting are provided below, in addition to the use of age as a trigger, despite the fact that age was ranked in the bottom half of the RVA (54 of 64). Age as an internal trigger produced valuable comments by meeting attendees. Comments regarding the low rating given to points and crashes generally centered around these events as triggering driver improvement requirements, rather than medical review requirements.
The initial survey reported that in 48 of the 51 jurisdictions, observations by counter staff could trigger a medical review of the driver. Comments made by meeting attendees on this topic follow.
One meeting attendee reported that over half of the new cases that come into the medical review unit are referred by the license examiners, who are a front-line method of identifying possible problems. In this jurisdiction, the examiner’s manual has a section on medicals, and MAB physicians conduct training for new hires in what to observe (behaviors, ways of walking, red-flag medications). Another meeting attendee said all their examiners and front-line staff are required by State rules to be trained in when to give the customer a medical report, and when to suspend a license based on a physician’s report.
Interestingly, in the RVA, training of counter staff to recognize signs of impairment was ranked rather low (38 of 64). One MAB physician said the comments received from driver examiners such as “the person couldn't move the car because he/she couldn't feel where his/her foot was, whether it was the accelerator or the brake,” or “he appeared confused or was short of breath” are very helpful during MAB case review.
Use of self-reports was weighted 1.53, placing it second in importance with respect to the four components evaluated in the set of internal triggers for medical review, and 27th out of 64 with respect to all components evaluated in the third column of the RVA. As stated earlier in this report, there are large differences across jurisdictions in the depth of this questioning. Comments provided by meeting attendees regarding the use of self-reporting as a trigger for medical review are provided below.
Several meeting attendees said in their jurisdictions, medical conditions questioning on the license application must be very general due to resistance by ADA. Others countered that if you are asking everyone the same questions, it is not discrimination. A comment was made that some State attorneys general may not want to deal with the political ADA battles that might arise out of requiring drivers to answer questions about specific medical conditions, and that is why the question about medical conditions is very general in those jurisdictions.
A NHTSA representative said according to a lawyer who reviews any ADA licensing questions, a licensing agency may impose a medical standard and/or ask about an individual's disability as long as the information is necessary to ensure public safety. However, the licensing agency must ensure that the medical standard and/or questions are based on real risks (and not on speculation, stereotypes or generalizations about individuals with disabilities or particular medical conditions.) When a medical consensus does not exist regarding whether an applicant/driver with a particular condition or functional limitation poses a real risk to public safety, the licensing agency must base its licensing decision on an individual assessment of whether an applicant/driver can drive safely, taking into consideration the use of adaptive equipment or license restrictions. An individual assessment, among other things, can consist of a road test, review by the licensing agency of additional medical information, and medical or functional testing by the licensing agency (and/or medical personnel acting on its behalf).
Several physicians in the group said they take issue with responses to medical questions triggering the requirement to get a physician’s report. This results in out-of-pocket expenses for the driver and a time requirement for physicians to do an exam or complete papers, when not really necessary. This would be the case for a temporary condition or one from the past that is not relevant to the driver’s current medical status (e.g., people in a car crash in their youth who said they had a loss of consciousness). Other attendees said that they would want to see the physician’s report to make their own decision about whether or not the medical condition affects current fitness to drive.
Several attendees said many applicants lie about medical conditions; they may tell the truth once but will never be honest again once they find out what the consequences of self-reporting are. One attendee used this rationale to say that mandatory reporting by physicians for patients of any age would let the DMV know to take action, instead of relying on faulty driver self-reports. Although people lie, the consensus of meeting attendees is that self-reporting is a valuable internal DMV trigger for driver evaluation because not all people lie on the application.
The use of driver age as a trigger for medical review received a weighting of 1.05, placing it last in importance of the 4 internal triggers evaluated, and 54th out of 64 with respect to all components evaluated in the third column of the RVA. As indicated in the report of the initial survey, age-based testing is allowed in 5 jurisdictions, and 17 jurisdictions require either in-person renewal or have truncated the renewal cycle based on age.
Meeting participants agreed that 5 or even 10 years ago, it was viewed as inappropriate in most jurisdictions to require in-person renewal (as opposed to renewal by mail), or to truncate a renewal cycle as people get older, but that has changed. Several jurisdictions said they had difficulty in the past getting legislation passed to allow truncated renewal cycles and/or age-based testing, but the political climate has changed with the recent older driver crashes that have made national news. It was a consensus of meeting participants that it is appropriate to require in-person renewal and to have shorter renewal periods based on age to give the DMV an opportunity to observe customers for functional impairments and to gather information about medical conditions that could affect driving safety. However, one MAB physician said specifying renewal intervals based on age may not be the way to go, since everyone ages differently. The renewal cycle should be individualized based on the person’s baseline functional status and the nature of his or her medical condition.
With respect to age-based testing, one physician referred to a study that said vision screening and knowledge testing at renewal (every 2 years) were associated with lower fatal crash risk for drivers 70 and older, and that road testing was not associated with lower fatal crash risk for drivers 70 and older (Levy et al., 1995).