Should healthcare professionals breach confidentiality when a patient is unfit to drive?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1505 (Published 31 March 2017) Cite this as: BMJ 2017;356:j1505
All rapid responses
Sokol uses pathos very effectively to highlight the very real dangers of driving when unfit to do so. As anaesthetists we routinely advise patients that they will be unfit to drive whilst their reactions are impaired by residual effects of their anaesthetic drugs - usually for 24-48 hours. We often emphasise this by stressing that their driving insurance will be invalid during this period. Unfortunately, in reality we simultaneously de-emphasise the message by bundling it with a myriad of other important 'do's and 'don't's. Unfortunately also, the newly updated DVLA guidance (Feb, 2017) on fitness to drive fails to highlight the risks (and responsibilities) associated with recent general anaesthesia. This, and that we have little evidence about the extent to which patients choose to follow our advice, or ignore it and are involved in 'accidents', is a matter of obvious concern. Perhaps we should regard 'same-day discharge general anaesthesia' as a notifiable condition and be required to inform the DVLA as a matter or course: then at least data could be collected and collated. Perhaps also, rather than relying on logos, we too should resort to pathos. The tragic story of little Poppy-Arabella and the dangerous driver is a very powerful one.
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The short answer is yes. I am surprised there is any debate. The common good outweighs confidentiality to the individual. I have worked to this principle since I first identified the issue nearly 40 years ago, while working in a rehabilitation unit and, indeed, published on the subject (1). It is good manners to warn a patient that you may report their disability, but if a doctor is aware of a serious problem, fails to report it and someone dies as a consequence I can foresee the possibility that they might be considered an accessory.
In my experience it is sadly the case that one cannot rely on patients to self-report. There are a number of reasons for this. They may feel that their independence is threatened; they may significantly underestimate the degree of their disability both in terms of physical and visual incapacity; they may deny there is a problem (this is especially the case with poor vision, foufor example, hemianopia and sensory inattention following a stroke). Patients with multiple sclerosis or significant brain injury may be disinhibited enough to ignore any recommendations. Some of these cases are recorded in the above reference but, as an example, one patient who had severe clonus had devised a set of blocks affiixed to the pedals into which feet could be strapped.
I have reported a number of patients. It is not, of course, up to a reporting doctor to make a decision on fitness to drive, because that is the remit of the DVLA's medical advisors, but I ask a simple question: how would you feel if a patient you knew was substantially impaired but continued driving, killed a child and you had said nothing?
(1) Winfield J, Bamji AN. Medical fitness to drive. Some problems and some solutions. J Traffic Med 1980, 8, 54-6
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There is a third possibility: set up a system of periodic medical certification for driving license holders, to obtain a renewal. This is done in many countries in Europe. Often, the certification needs to be done by specific physicians, not by the patient's GP or chosen specialist, and after a sight and hearing test. In Italy, for example, this certification is done every 10 years until the age of 50, every 5 years between 51 and 70, every 3 years between 71 and 80, and every 2 years thereafter. Quite simple, really!
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We in the medical field are constantly struggling to balance between privacy (confidentiality) and the greater good for society.
Several examples are quoted in the discussion, and this is one of them. Other notable examples are homicidal patients who confide in their psychiatrists, and disclosing HIV status to potential sexual contacts.
The time has come for the powers that be to come out with a clear cut policy on such cases. I would argue that we should give up some privacy for the greater good of society. It can be easily accomplished by an "opt in" option in terms of privacy for healthcare records. Those who want to keep their records private should be able to make them private, the rest who do not care should have them public.
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I welcome Dr O’Neill’s points regarding the importance of counselling and education (including doctors) with regard to medically unsafe drivers. This appears to be an area where greater efforts are required. With an ageing population increasing numbers of drivers with health problems affecting driving will require more time to be spent providing this, presumably mostly in the GP setting. This adds even more pressures on an already stretched service. It will also add to the workload of the medical section of DVLA, with or without mandatory reporting (MR). He is also concerned about MR causing a break down in patient-doctor trust. In practice I have occasionally found that giving unwelcome advice on this matter within the DVLA regulations and GMC guidelines can also adversely affect that relationship. Similarly the issues of diagnosis and treatment avoidance, and doctor/diagnosis ‘shopping’ are equally possible at present.
I also accept the importance of practicing evidence-based medicine. I am certainly not suggesting that MR replaces education and counselling. However, I remain unconvinced that MR by doctors ‘simply does not work’ in every situation. He cites three articles to support that view. Informative as they are, I remain doubtful. None of them appear to make any distinction between ordinary and vocational/career drivers. It is this latter group who possess the greatest potential to do significant harm if driving whilst unfit.
1. The first, a very small study of 159 patient with epilepsy from the USA, is a survey of the provision of counselling, and continued driving against advice (inter alia) comparing New Jersey, an MR state, and Arizona (non MR). It highlights that counselling levels were poor in both. It states that about 10% of patients continue to drive against medical advice regardless of MR status. It is speculated that the lower level of counselling in the MR state (P = 0.13) is the result of a perception that MR replaces the requirement for this. Perhaps it could be postulated that if the counselling rates had been the same then the level of cessation of driving in the MR state may well have been superior.
2. The Canadian dementia study showed that behavioural disturbances (and gender) were the most relevant factors in determining cessation of driving. This was associated with there being no apparent effect related to mandatory physician reporting. Clearly dementia is a far more nebulous and nuanced disorder than most of the other conditions affecting driving; the authors accepted that the ‘generalizability’ of their results was a limitation.
3. This Australian article is a ‘self-predictive’ survey. This health survey included seeking respondent predictions of behaviour if they hypothetically had obstructive sleep apnoea syndrome. A disappointing 9% (11.4% men, 6.7% women) of respondents predicted that MR would affect their behaviour towards doctors leading to reduced road safety. This should be read in conjunction with the finding that without MR, 3.4 % (4.9% men, 2.0% women) would never self-report to the licensing authority. This study also acknowledges that the behaviour of career drivers requires further evaluation, as does health professionals compliance in MR states.
I accept that mandatory reporting alone would clearly be far from perfect, as is the current system. Unfortunately some drivers may display irresponsible evasive behaviour, with or without MR, and continue to drive against advice and whilst unlicensed. This was clearly demonstrated by the driver involved in the Glasgow bin lorry incident, in which 6 pedestrians were killed and others seriously injured. Alarmingly, he subsequently continued to drive his car after his licence was revoked (4). It is clear that as a result of his persistent untruthfulness the DVLA system of assessment of his fitness as an LGV driver failed (5, 6). However, had he been truthful to doctors about his previous episodes of syncope at the wheel, and with a requirement for MR, it seems highly unlikely that he would have been allowed to be at the wheel of a 26 tonne refuse vehicle on that fateful day.
1. Drazkowski JF, Neiman ES, Sirven JI, McAbee GN, Noe KH. Frequency of physician counseling and attitudes toward driving motor vehicles in people with epilepsy: comparing a mandatory-reporting with a voluntary-reporting state. Epilepsy Behav. 2010 Sep;19(1):52-4.
2. Herrmann N, Rapoport MJ, Sambrook R, Hébert R, McCracken P, Robillard A; Canadian Outcomes Study in Dementia (COSID) Investigators.. Predictors of driving cessation in mild-to-moderate dementia. CMAJ. 2006 Sep 12;175(6):591-5.
3. Elgar NJ, Esterman AJ, Antic NA, Smith BJ. Self-Reporting by Unsafe Drivers Is, with Education, More Effective than Mandatory Reporting by Doctors. J Clin Sleep Med. 2016 Mar;12(3):293-9.
4. https://www.theguardian.com/uk-news/2017/mar/31/glasgow-bin-lorry-death-...
5. https://www.theguardian.com/uk-news/2015/dec/07/glasgow-bin-lorry-crash-...
6. http://www.scotcourts.gov.uk/search-judgments/judgment?id=e916fba6-8980-...
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The obvious answer to the question is yes.
The current, and soon to be updated, GMC advice regarding the confidentiality issues facing doctors in these matters concentrates on the ethical issues. A series of actions is listed for doctors to follow in order to persuade the patient to self-report, and ensure that they themselves are not in breach of the GMC code of practice. To those actions I would have liked to have seen added the requirement to advise the patient that having been instructed not to drive, and to inform the DVLA, he or she should also be told that subsequent driving against medical advice would most likely render their motor insurance invalid.
The GMC guidance, when taken together with the slow workings of the DVLA process, potentially adds unnecessary and unwelcome prolonged risk to not only the driver but also other road users and pedestrians.
The tragic case highlighted here, and the Glasgow bin lorry tragedy, demonstrate that the current system of self-reporting is not fit for purpose.
Common sense dictates that the easiest and quickest way to reduce the risks and delays in the current system is to place a legal responsibility upon doctors to report medically unsafe drivers.
https://www.gov.uk/guidance/general-information-assessing-fitness-to-dri...
http://www.eveningtimes.co.uk/news/13585159.Bin_lorry_crash_driver_enqui...
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While all are deeply sympathetic to the victims of road crashes, it is also important that we practice medicine that is evidence-based and supported by principles of public health. Among the many problems with mandatory reporting of medical conditions relevant to driving is the fact that it simply does not work, whether for epilepsy (1), dementia (2) or obstructive sleep apnoea (3) among other conditions. Indeed, there was less reporting of epilepsy in a state with a mandatory reporting regulation than in a state without one (1). The problem of lack of efficacy is compounded by the potential breach in clinician-patient relationship and trust, which may lead to avoidance of seeking treatment which reduce the risk to drivers and the general public.
The one condition for which further study might be helpful in considering mandatory reporting in terms of scale, relevance and major impact on road safety is that of alcohol and substance misuse and dependence. Worryingly, there is much less research in the biomedical literature on this topic (4), and due consideration would need to be given as to whether current guidelines of relatively long periods of driving cessation in many jurisdictions are appropriate in terms of ensuring congruence between mandatory reporting, effective treatment strategies and a due balance between safety and mobility.
Solutions to reducing the relatively modest impact (in public health terms) of other medical conditions on road safety include public campaigns to remind drivers of their responsibility for monitoring and maintaining their own health as well as following professional advice. This needs to be allied to stringent penalties for driving against appropriate professional advice, as occurred in this tragic case. In addition, it is of concern that traffic medicine occupies such a low or absent profile in medical school curricula (4), and it is important all doctors and related healthcare professionals attain a core competence in assessing medical fitness to drive within their scope of practice.
1. Drazkowski JF, Neiman ES, Sirven JI, McAbee GN, Noe KH. Frequency of physician counseling and attitudes toward driving motor vehicles in people with epilepsy: comparing a mandatory-reporting with a voluntary-reporting state. Epilepsy Behav. 2010 Sep;19(1):52-4.
2. Herrmann N, Rapoport MJ, Sambrook R, Hébert R, McCracken P, Robillard A; Canadian Outcomes Study in Dementia (COSID) Investigators.. Predictors of driving cessation in mild-to-moderate dementia. CMAJ. 2006 Sep 12;175(6):591-5.
3. Elgar NJ, Esterman AJ, Antic NA, Smith BJ. Self-Reporting by Unsafe Drivers Is, with Education, More Effective than Mandatory Reporting by Doctors. J Clin Sleep Med. 2016 Mar;12(3):293-9.
4. Mello MJ, Nirenberg TD, Lindquist D, Cullen HA, Woolard R. Physicians' attitudes regarding reporting alcohol-impaired drivers. Subst Abus. 2003 Dec;24(4):233-42.
5. Hawley CA, Galbraith ND, deSouza VA. Medical education on fitness to drive: a survey of all UK medical schools. Postgrad Med J. 2008 Dec;84(998):635-8.
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Re: Should healthcare professionals breach confidentiality when a patient is unfit to drive?
With advances in both surgery and anaesthesia over 35% of operations are now performed as a day case. As already highlighted, intraoperative medications can remain in the body for 24-48 hours post operatively, as well as this, post operative opioid medications are commonly prescribed and when given to opioid naive patients can significantly impair the patient’s brain. This means that patients taking post operative analgesia could possibly be impaired for days post operatively.
The DRUID study looked at the odds ratio for getting seriously injured or killed whilst under the influence of medicinal and illicit opioid medications. It showed that you have a higher likelihood of being seriously injured after taking medicinal opioids to that of illicit opioids, such as heroin. The odds were worsened if people were >60 years old or young drivers (1). This clearly supports numerous physicians arguments that our patients should not be driving post operatively.
Of course as physicians we advise our patients to not drive 24 hours post operatively, however, in reality we know that some patients do not take this advice, a study performed in 2001 suggested that around 4% of patients drove <24 hrs post operatively (2) . The updated GMC guidelines 2017 state that “in EXCEPTIONAL cases where a patient has refused consent, disclosing personal information MAY be justified in the public interest if failure to do so may expose others to a risk of death or serious harm. The benefits to an individual or to society of the disclosure must outweigh both the patient’s and the public interest in keeping the information confidential.” Proving that a patient will be definitely driving post operatively and not just suspected of driving, is difficult enough without having to prove that the risk to the general public outweighs that of breaking confidentiality. As well as this, what is a definition of an exceptional case? I feel that further guidance is needed.
A blanket rule where we notifiy the DVLA about every patient we have performed a general anaesthetic on would put immense pressure on an already stretch system and would be impractical. Who would notify the DVLA? The Anaesthetist? The Surgeon? All of who, are already busy trying to reduce waiting lists by increasing the number of patients operated on a day,
I agree that more needs to be done to reduce the risk to not only our patients post anaesthetic but also the general public, however further thought is needed in this subject matter due to the multiple ethical issues and more stringent guidelines needs to be implemented with further advice.
(1)Wolff et al. (2013) Driving under the influence of drugs. Retrived from - https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
(2)Correa et al. (2001) Compliance with postoperative instructions: a telephone survey of 750 day surgery patients. Anaesthesia, 56: 481–484. doi:10.1046/j.1365-2044.2001.01524-8.x
Competing interests: No competing interests