Why I may sign your fitness to drive form

“Well, Mr Terry I have some bad news. The results of your tests shows me that it is no longer safe for you to drive.”

“But why, young whipper snipper, you don’t understand, I’ve been driving since before you were born……”

One of the harder things I have do as a GP is to tells someone that they should no longer drive and they need to hand in their license. I have lost a few patients along the way because we have disagreed on their ability or competency.  Generally during a consultation, I consider the patient before me, and sometimes their family. But in this situation, I have a responsibility to consider the wide community. In fact, you also have this responsibility as the F3172 form you gave me to sign for your drive medical stipulates.

“If you hold a Queensland driver licence, or are applying for a Queensland driver licence, you have a legal obligation to notify the department as soon as you become aware of any permanent, or long-term medical condition that is likely to adversely affect your ability to drive safely. “

Driving gives us freedom, flexibility and independence but Driving is a privilege not a right. Here is sobering review from the Victorian Coroner on why this part of my job so important and why I should not to be swayed by desire to keep the you happy.

The rule book I use is the Assessing Fitness to Drive handbook.

Some of these rules are black and white. You can’t drive if you can’t see the third line or 6/24 on the Snellen eye chart even with spectacles.

Other rules seem sensible. For example you cannot drive for 2 weeks after a heart attack, which will be extended to 4 weeks if you needed your chest opened for a coronary bypass graft. If you had a cardiac arrest you cannot drive for 6 months and if you have had an epileptic seizure then in general it is no driving for 12 months. Some decisions may need to involve specialist doctors.

Driving and aging

As you get older, how you process information, your vision, and your ability to move changes.

Vision

  • change focus and see detail such as traffic signs
  • see objects and obstacles such as pedestrians or cyclists
  • deal with and recover from glare such as oncoming headlights or the afternoon sun
  • see things in your peripheral vision
  • adjust your vision when going from light to dark or vice versa

Medical conditions such as cataracts, glaucoma and diabetes can also affect your vision.

Movement

  • muscle strength and speed
  • flexibility and mobility
  • range of movement
  • coordination

These changes, plus health problems like arthritis, can affect the way you drive. For example, you may find it harder to turn the steering wheel, change gears or jump on the brake in an emergency.

Information processing

Consider these challenges,

  • driving at peak hour
  • merging onto a busy freeway
  • changing lanes in traffic
  • travelling an unfamiliar route
  • dealing with a busy intersection or roundabout.

All require

  • visuospatial perception (depth perception)
  • insight and judgement
  • attention and concentration
  • comprehension
  • reaction time
  • memory
  • coordination

Hearing impairment, although recognised as not as critical, can be a hindrance to driving safely.

Not all elderly people have dementia. Dementia is characterised by significant loss of cognitive abilities such as memory capacity, psychomotor abilities, attention, visuospatial functions, insight and executive functions. Some of the tests used to help with screening impaired cognition include the Mini mental State Exam (MMSE) or the  Montreal Cognitive Assessment (MoCA), Trial A and B test, General Practitioner assessment of Cognition  (GPCOG), the clock drawing test and taking history from family and friends.

Dementia may affect driving ability in a number of ways including:

  • errors with navigation, including forgetting routes and getting lost in familiar surroundings
  • limited concentration or ‘gaps’ in attention, such as failing to see or respond to ‘stop’ signs
  • errors in judgement, including misjudging the distance between cars and misjudging the speed of other cars
  • confusion when making choices, for example, difficulty choosing between the accelerator or brake pedals in stressful situations
  • poor decision making or problem solving, including failure to give way appropriately at intersections and inappropriate stopping in traffic
  • poor insight and denial of deficits
  • slowed reaction time, including failure to respond in a timely fashion to instructions from passengers
  • poor hand–eye coordination.

In some instances, it may remain safe for to drive with limitations placed, such as within a certain distance or home or during daytime hours. Having a passenger may not help.

Some people may benefit from having an Occupational Therapist assess driving skill. I have had to do this on a number of occasions usually to prove to someone that they indeed are no longer safe to drive. An OT assessment may not be cheap but it does test practical skills that I am not able to do in the consulting room. The major drawback of an OT assessment is the cost involved which may be several hundred dollars. Dementia Australia has several resources which may be useful.

Currently, in Queensland I am not mandated to report a medically unsafe driver, but in general I will. This may change as in South Australia I had to. Of course, I’m not able to take your car keys off you, but if you continue to drive despite a notification, it is illegal and your insurance will not be valid. As your doctor I am provided protection under legislation when giving information in good faith to the department about your fitness to drive.

Options may include walking, public transport, community buses, taxis, family and friends. Importantly, mobility scooters may not be the solution; they offer much less protection in the event of a collision with a car.

If you would like to listen to a podcast on this subject check out the GP Show.

RACV has a useful summary for older drivers.

Age or health related medical examinations to obtain or renew a licence to drive a private motor vehicle are eligible for a Medicare rebate, whilst a commercial license examination is not.

If you think a motorised wheelchair or mobility scooter may be an alternative you should first read the regulations for these. “In all cases, the person in control of the motorised wheelchair must be capable to safely operate the motorised wheelchair.” But this is self determine as a “medical certificates are no longer a requirement for getting your motorised wheelchair registered.”

 

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Why I won’t be sticking my finger up your bum… well maybe not?

Lets make a couple of things clear first.

If you visit and ask for a check up, I’ll always start with a series of questions. You may be thinking, “Just give me the blood form” but be patient, the questions are an essential part of the consultation. If you answer No, No, No, No, No, etc…… then I’ll move onto examination like listening to your chest, pressing your belly and checking your blood pressure etc. And then maybe some tests as a way of screening for disease.

Screening by definition is looking for absence of bad stuff in someone who has no signs or symptoms of bad stuff. A good example is a screening mammogram for breast cancer. If you tick yes, I have a breast lump, then no screening mammogram for you. That requires a consultation with your GP and potentially a more comprehensive testing regimen which may require extra imaging, a biopsy and a visit to a surgeon. So, the idea of screening is to find the possible bad stuff before it becomes really bad stuff and makes you sick.

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So moving on, who now who gets a finger up the bum?

Once upon a time all men of a certain age were encouraged to attend their GP for annual digital rectal examination (DRE) and prostate specific antigen test (PSA) as a way of screening for prostate cancer. Understandably this may have made some blokes disinclined to come in for any check-up.

For asymptomatic men the Cancer Council, amongst other authorities, do not recommend a digital rectal examination.

Symptoms of prostate cancer include frequent urination, particularly at night, pain when you urinate, blood in the urine and an weakened urine stream. Once prostate cancer spreads it may cause pain in the bones, unexplained weight loss and fatigue. Unfortunately, lots of other things can cause similar symptoms to prostate cancer, such as, sexually transmitted and urinary tract infection and a gradual enlargement of the prostate with with aging that is not cancer, known as benign prostate hypertrophy. There are obviously lots of other things that may cause bone pain, weight loss and fatigue and for those you really should see your doctor.

So what can you do to screen for prostate cancer. Maybe you had a prostate specific antigen (PSA) test? Routine PSA testing for detection of prostate cancer is a controversial issue. New evidence suggests that PSA screening for most men will not provide a survival advantage even if it finds prostate cancer. The Cluster Randomized Trial of PSA Testing for Prostate Cancer trial was run in the UK over 10 years.  This trial of over 400,000 men, aged 50 to 69 years, compared those who had a PSA test to those who didn’t. Not unsurprisingly, more men were diagnosed with prostate cancer PSA group (4.3% versus 3.6%). However there was no significant difference in prostate cancer mortality (0.30 per 1000 person-years for the PSA group vs 0.31 for the control group) after 10 years.

But PSA testing is not really the focus of this blog. If you would like read more look at these links

Cancer Council Australia

“For men at average risk of prostate cancer who have been informed of the benefits and harms of testing and who decide to undergo regular testing for prostate cancer, offer PSA testing every 2 years from age 50 to age 69, and offer further investigation if total PSA is greater than 3.0 ng/mL.”

RACGP

“Whilst the RACGP recommends against prostate cancer screening  we recognise many men will be asking their GPs about screening.”

Now moving back to why I may have to ask to do a rectal examination!

A rectal examination is still part of the examination should you have rectal bleeding, pain or other anal complaints and this includes the 50% of the population who don’t have a prostate.

A rectal exam can find anal warts, haemorrhoids, anal fissures, constipation and prostatitis.

And a recent recommendation from ASHM is that men who have sex with men who are over 50 and are HIV positive should undergo a rectal examination to look for anal cancer. Some suggest this examination even if you are not HIV positive.

Putting some perspective to the incidence of various common cancers.

  • Anal cancer in general population 2/100,000 person
  • Men who have sex with men without HIV 40/100,000
  • Men who have sex with men with HIV  77.8/100,000
  • Bowel cancer 73/100,000
  • Prostate cancer 170/100,000 men
  • Cervical cancer 7.1 cases /100,000 women
  • Ovarian cancer 10.8 cases per 100,000 women
  • Breast cancer 123/100,000 women and 1/ 100,000 men

More cancer statistics can be gleaned from the Australian Institute of Health and Welfare.

So I hope this has made things clearer. If you are overdue for a health check-up go and see your GP, you may not need a rectal exam!

Vitamin B3 and Skin Cancer – a bit more prevention.

A recent study has suggested that vitamin B3 otherwise known as nicotinamide may be able to reduce pre-cancerous skin lesions like actinic keratosis and non-melanoma skin cancers, such as basal and squamous cell cancers.

The Australian Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC) study was run over 12 months and published in the NEJM in 2015. The study gave people who had a high risk of skin cancer 500mg of nicotinamide twice a day. The authors found that nicotinamide reduced non-melanoma skin cancer by a quarter with comparable efficacy against both basal cell and squamous cell cancers. If you want to learn about how nicotinamide may do this have a read of these review articles. Role of Nicotinamide in DNA Damage, Mutagenesis, and DNA Repair and Nicotinamide for skin cancer chemoprevention.

 

Aktinic keratosis or solar keratosis

Squamous cell cancer

Basal cell cancer

Lentigo maligna or malignant melanoma

As with all medical advances, there are some caveats.

The trial subjects were considered at high risk defined as those having had 2 or more non-melanoma skin removed in the last 5 years. In reality that would probably be most of my over 50 year patient here in North Queensland.

The benefit of nicotinamide disappeared once the medication was stopped after 12 months.

Nicotinamide was found to be safe for the duration of this study, although some people did complain of nausea. A smaller dose of 500mg once a day may help those and has been shown to have some benefit albeit less.

The nicotinamide used in this study was donated by Blackmores. Just remember that you need NICOTINAMIDE, not nicotinic acid or niacin, as at that dose you’ll end with facial flushing, headache and hypotension with the latter.

Importantly, taking nicotinamide doesn’t replace the need for protecting yourself from the sun by avoiding being out in the heat of the day, wearing long sleeves and pants, wearing a hat and using sunscreen. The study noted that even for these high risk people who have had skin cancer removed, only 50% used sunscreen. Here’s my hint, to help you remember to use sunscreen.

The study didn’t look at incidence of melanomas, apparently that is next on the authors agenda.

If you recognise any of the spots shown above on your face in the mirror go and see your GP.

May I indulge a short but very sad anecdote from a few year ago. Everyone including the butcher and baker told this bloke to get that ugly spot on his cheek looked at. Instead he put on a band aid and ignored everyone including his wife. Finally, when the spot turned into an even uglier, smelly, ulcer he saw a doctor. Alas it was far too late to save him the squamous cell cancer despite surgery and radiotherapy.


References

http://www.nejm.org/doi/full/10.1056/NEJMoa1506197#t=article

https://www.cancercouncil.com.au/blog/the-role-of-vitamin-b3-in-reducing-non-melanoma-skin-cancer/

https://www.skincancer.org/publications/the-melanoma-letter/spring-2016-vol-34-no-1/nicotinamide

https://www.hindawi.com/journals/jna/2010/157591/

http://onlinelibrary.wiley.com/doi/10.1111/ajd.12631/full

Pictures are from a great skin website from New Zealand called Dermnet

 

 

 

 

 

Trying to understand Medicare #2

What does Medicare Cover?

Rule one – You have to have a valid Medicare card

Rule two – Not everything is covered

Rule Three – GP and Specialists have some different rules. I might leave that for a different blog.  This one if just about GPs.

Rule Four – You have to be alive. You can claim a rebate if I visited and determined you dead, but then that’s when the rebates end!

Rule Five – When you talk with your GP, it is not always safe you assume there is a Medicare rebate for this visit.

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Enough of the rules….

It may be easier to list what Medicare doesn’t cover. And the list is longer than you may think. I have used the most up to date Medicare Benefits Schedule Book Category 8 as the basis of this information.

Firstly, unless there are really special occasions (like a case conference) you need to have a face-to face consultation to access a Medicare rebate.

Telephone consultations, Facebook posts and Skype or FaceTime chats do not have a rebate.

There is no rebate for repeat prescriptions when the patient doesn’t consult with their GP. Many prescriptions used to treat chronic illness last 6 months. If you have a chronic health problem a six month check up may be sensible. After all you service your car regularly.

Non-therapeutic cosmetic surgery doesn’t attract a rebate. So, that annoying mole on your nose, unless it looks like a skin cancer doesn’t earn a rebate when it is removed. Likewise,  Botox for wrinkles doesn’t have a rebate.

Euthanasia and any service directly related to the procedure doesn’t have a rebate.  This one surprised me given that until Victoria’s law is enacted, euthanasia is not legal. This was also listed in the 2014 version of the Medicare Book, so maybe it was written in that brief time euthanasia was legal in the NT.  However, for counselling about euthanasia will attract a rebate.

Medicare rebates are not payable for a compensable injury or illness for which the patient’s insurer or compensation agency has accepted liability. However, whilst the process is pending, a rebate is available. Medicare then seeks reimbursement from the insurer.

Medicare benefits are not available for a medical examination for the purposes of life insurance, superannuation, a provident account scheme, or admission to membership of a friendly society. This also applies to Likewise pre-employment and workplace medicals, and health screening (although there are some exceptions).

Medicare lists a number of specific treatment that it doesn’t rebate for. I’ll list these, although many are things that a GP is unlikely to do. Other’s are areas of controversy in the world of evidence based medicine. Specifically these are

  • chelation therapy other than for the treatment of heavy-metal poisoning
  • the injection of human chorionic gonadotrophin in the management of obesity
  • the use of hyperbaric oxygen therapy in the treatment of multiple sclerosis
  • the removal of tattoos
  • the transplantation of a thoracic or abdominal organ, other than a kidney, or of a part of an organ of that kind
  • the removal from a cadaver of kidneys for transplantation
  • the administration of microwave (UHF radio wave) cancer therapy, including the intravenous injection of drugs used in the therapy
  • cannulation and/or catheterisation of surgical sites associated with pain pumps for post-operative pain management
  • filling or re-filling of drug reservoirs of ambulatory pain pumps for post-operative pain management
  • injection of blood or a blood product that is autologous.
  • endoluminal gastroplication, for the treatment of gastro-oesophageal reflux disease
  • gamma knife surgery
  • intradiscal electro thermal arthroplasty
  • intravascular ultrasound (except where used in conjunction with intravascular brachytherapy)
  • intra-articular viscosupplementation, for the treatment of osteoarthritis of the knee
  • low intensity ultrasound treatment, for the acceleration of bone fracture healing, using a bone growth stimulator
  • lung volume reduction surgery, for advanced emphysema
  • photodynamic therapy, for skin and mucosal cancer
  • placement of artificial bowel sphincters, in the management of faecal incontinence
  • selective internal radiation therapy for any condition other than hepatic metastases that are secondary to colorectal cancer
  • specific mass measurement of bone alkaline phosphatase
  • transmyocardial laser revascularisation
  • vertebral axial decompression therapy, for chronic back pain
  • autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation
  • vertebroplasty

Although some screening programmes like breast cancer and cervical cancer screening are allowed a Medicare rebate, most health screening services are not covered. Medicare lists the following examples where there is no rebate available.

  • multiphasic health screening
  • testing of fitness to undergo physical training program, vocational activities or weight reduction programs
  • compulsory examinations and tests to obtain a flying, commercial driving or other licence
  • entrance to schools and other educational facilities
  • for the purposes of legal proceedings
  • compulsory examinations for admission to aged persons’ accommodation

Specifically, Medicare does recognise the following kinds of health screening

“A medical examination or test on a symptomless patient by that patient’s own medical practitioner in the course of normal medical practice, to ensure the patient receives any medical advice or treatment necessary to maintain their state of health. Benefits would be payable for the attendance and tests which are considered reasonably necessary
according to patients individual circumstances (such as age, physical condition, past personal and family history).”

Medicare then uses some examples which at the bread and butter of primary care in general practice.

  • cervical cancer screening under the National Cervical Screening Program
  • blood lipid estimation where a person has a family history of lipid disorder
  • pathology service requested by the National Heart Foundation of Australia, Risk Evaluation Service
  • age or health related medical examinations to obtain or renew a license to drive a private motor vehicle. Commercial license medical examination is not rebatable, although if you were unemployed my interpretation is it would be.
  • medical examination of, and/or blood collection from persons occupationally exposed to sexual transmission of disease
  • medical examination for a person as a prerequisite of that person becoming eligible to foster a child or children
  • medical examination being a requisite for Social Security benefits or allowances
  • medical or optometrical examination provided to a person who is an unemployed person as the request of a prospective employer

Finally,

Medicare rebates are not paid when a doctor treats his or her practice partner, spouse or children. Medicare also excludes the practice partner’s dependents too.

For a hard earned thirst….

Just finished a hard day at work?

Just put away the lawn mower?

Just been for a big run?

Just powered through a gym session?

Just getting ready to meet the rellies for Xmas bbq lunch?

Have a nice cold glass of water first, then you’ll not be holding onto an cold, empty beer bottle thinking

“Where did that go? I’d better have another!”

 

Remember for healthy Aussie men and women, drinking no more than two standard drinks on any one day reduces the lifetime risk of harm from alcohol-related disease or injury.

If you’d like to know about healthy drinking, have a look here

And for those with a nostalgia for times of old….. not that I have drunk a Vic for a long time!

Slop….

How do you start your morning? I think my idea of having the sunscreen next to the toothpaste reminds met to Slop up each day, because I always, well nearly always brush my teeth! Thankfully, I am yet to brush my teeth with Sunscreen…..

When I do a Skin Cancer Check, I will run through the Sunsmart message. You know slip slop slap. I see that  the Cancer Council has added a couple of extra hints in addition to the original Slip Slop and Slap. I have to confess that I have only realised today that Sid is a seagull. I think the yellow face threw me.

Slip on sun protective clothing that covers as much of your body as possible.

Slop on SPF 30 or higher broad-spectrum, water-resistant sunscreen, at least 20 minutes before sun exposure. Reapply every two hours when outdoors or more often if perspiring or swimming.

Slap on a broad-brimmed hat that shades your face, neck and ears.

Seek shade.

Slide on sunglasses.

I think we are doing a much better job of protecting our skin in these sunny latitudes. I remember my Dad at work laying bricks in the Perth summer sun with just a pair of shorts and boots. He added a hat a bit latter. Now more workers are choosing or are required to wear long pant and sleeves. Long sleeve fishing shirts are trendy. My kids remind me to cover up.

A few statistics from Australian Institute for Health and Welfare to encourage you protect yourself.

  • In 2016, an estimated 13,280 new cases of melanoma will be diagnosed in Australia, and 1,770 people will die from this disease.
  • The rate of melanoma is increasing; from 27 cases per 100,000 in 1982 to 49 per 100,000 in 2016.
  • Some good news is that for those under 40 the rate has dropped from a 13 cases per 100,000 in 2002 to an 9.4 per 100,000 in 2016.

But

  • Between 1982 and 2016, the mortality rate rose from 4.7 deaths per 100,000 to an 6.2 deaths per 100,000.

If you are too busy to see your GP for a skin check, have at a look at this guide melanoma, basal cell or squamous cell cancer. But really make the time to have a skin check.

PS Not endorsing Colgate, Oral B nor Galderma in their post – just the concept!

 

Helpful hint to make your GP consultation run smoother #2

What to wear to a Medical Consultation

I have never worn a white coat as a doctor, but in some countries this the is the expected “uniform”. Really, I mean white is not my colour, although back in 1985 there was a pair of white jeans. They didn’t last long as I seem to attract dirt. It would be even worse in a world of blood, pus, poo and urine!

The aptly titled TAILOR study (that is, targeting attire to improve likelihood
of rapport) was a review of published papers to find out if patient preferred their doctor to wear formal attire. The authors were American but they did review papers from a variety of countries. They concluded “the influence of physician attire on patient perceptions is complex and multifactorial.” And suggested that “patients harbour a number of beliefs regarding physician dress that are context and setting-specific.”

One of the Tailor study authors went onto a write a commentary for The Conversation. His final comment was “While scrubs are appropriate for operating or emergency rooms, we suggest changing into more formal attire to visit patients in the hospital or the clinic. Regardless of the occasion, flip-flops, showy jewelry or jeans simply don’t belong in the hospital, just as scrubs do not belong outside the hospital environment. Especially not in the grocery store.”

In another BMJ article a microbiologist berated junior doctors for not wearing ties.  And heaven forbid facial jewelry. This was frowned upon by the authors of this study. The majority of American patient surveyed gave such jewelry a big thumbs down; “negatively affects perceived competency and trustworthiness.” 

I will stick with comfortable shoes, pushed down socks, shorts and a casual shirt with absolutely no tie. And I may just see if the stud still goes through the hole in my ear.
Mark

Now moving onto patients!

Are there any rules?

Should there be any rules?

What are the expectations?

Doing a PubMed search revealed very little on the subject. Amongst lots of articles (1120 to be exact) they all focused on patient’s perceptions of what health care professional should wear and not visa versa . Maybe there is a PhD in that?

So, here is my thoughts on what will make the consultation run smoother based on experience and chatting with colleagues.

First may I state the obvious,  make sure you are wearing clothing.  Turning up to the consultation naked will have you transported to the nearest psychiatric unit for an assessment of your mental health.

Secondly, don’t feel obliged to wear a suit and tie or even smart casual. Dress comfortably as we may be chatting for a while. I don’t work in a 3 minute appointment clinic and I like to get to know my patients. But you remember all those studies mentioned above, well I am human and despite my intensive training, I will sometimes lapse into making a judgement about you if you turn up in smelly torn jeans, odd socks, and NSFW emblazoned t-shirts.

Now I am not suggesting that I make my patients wear gowns for an examination as is the case in other countries,

My suggestion would be wear what would you to visit your Gran?

Here are some other logical practical suggestions.

1. Consider having a shower on the day of the consultation.

2. Consider wearing underwear and if you do make sure they are also clean.

3. Consider leaving your muddy boots at the front door of the clinic, but have fresh socks available.

4. Consider loose clothing. This is especially important if you have knee or hip pain or have come in for pap (oops… cervical screening test).

5. If I have to listen to your chest, the stethoscope works best on the bare skin. If you have several layers of clothing, some will need to be removed.

6. If you have booked a skin check be prepared to remove shoes, socks and at least some other clothing. Not wanting to make anyone paranoid, but melanomas can develop on places which may not get a lot of sunshine.

7. And, although strictly not clothing, please bring in your glasses and hearing aids.

Have I missed anything??