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.”

 

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!