Easier-to-use fitness-to-drive guide on way from CMA

Barbara Sibbald

CMAJ 1999;160:1752

Few CMA publications are as well thumbed as this guide, simply because an aging population means physicians are being forced to make more and more difficult decisions about Canadians' right to drive. Nationally, the CMA guide has become the doctor's bible in dealing with these issues; the association regularly receives requests for copies of the out-of-print fifth edition.

The sixth edition will sport a new name, Guide for Physicians in Determining Medical Fitness to Drive. Preliminary drafts include a new section on airbags, more consideration of aging drivers, an emphasis on evidence-based background information and much more. All the changes are in the interest of making the "guide medically sound to protect drivers and the public," explains Dr. David Irving, chair of the project advisory group that the CMA assigned to help revise the guide.

"The previous guide was excellent but needed updating," says Irving, who also chairs the medical advisory group of the Canadian Council of Motor Transport Administrators. The new guide is based on both the CMA's 1991 version and the British Columbia Medical Association's 1997 guide.

The CMA first published the booklet in 1977. It is designed to help physicians determine the ability of their patients to safely drive a motor vehicle and to complete a driver's medical examination report.

Irving says the biggest change will likely be an increase in the amount of background information and in advice to help physicians use the guide because "no 2 patients have quite the same condition." A literature search has been conducted as part of the project. Irving, who practises internal medicine and cardiology in Edmonton, said this means that the new guide will contain more evidence-based information.

The project advisory group, which has been meeting since November 1998, includes Irving, Dr. David Smith, medical director of the General Pediatric Clinic at the BC Children's Hospital, Dr. Robert Brison, an emergency room physician at Ontario's Kingston General Hospital, and Dr. Linda Inkpen, a family physician in St. John's.

New legal issues

In addition to the need to add new medical and transportation industry information, the guide also had to be revised because of a changing legal environment. Nine provinces and territories — most recently New Brunswick, Newfoundland and Saskatchewan — now require mandatory reporting of patients who are medically unfit to drive.

There is also increasing concern about legal liability in negligence suits for physicians who fail to report unfit drivers. During the 1990s, 2 Ontario Court of Appeal judgements (Spillane v. Wasserman and Toms v. Foster) found physicians liable for failing to report potentially unfit drivers who were subsequently involved in serious motor vehicle accidents.

The BC courts have also debated the human-rights aspect of revoking the licence of someone who is partially blind. The resulting judgement, which is now being appealed to the Supreme Court of Canada, supported medical opinion that a partially sighted man should be considered unfit to drive. "The guide isn't being redone because of medicolegal issues, but these are a factor and they are included in our draft," says Irving.

The draft edition of the guide has been more widely circulated than ever before. The document has been sent to 116 groups or individuals, ranging from CMA affiliated medical specialty societies to the Canadian Automobile Association, the Toronto Transit Commission, the Muscular Dystrophy Association of Canada and all provincial ministries of transportation. "We're circulating it widely in the hope we can come up with a consensus," says Irving. "But not everybody is going to be happy."

The bottom line, he adds, is to create a guide that is a user-friendly tool for physicians. To this end, the draft contains tables as a supplement to the written text for certain key medical conditions and recommendations, notably those concerning seizures. It also contains an index and more subheadings, plus an expanded appendix with evaluative tools for illnesses related to alcohol abuse and dementia.

The revised guide will list the medical conditions affecting a person's ability to drive in descending order of importance for their association with the risk of causing motor vehicle crashes. The most important risk factor is alcohol abuse — between 35% and 40% of motor vehicle crashes resulting in a fatality involve a driver legally impaired by alcohol.

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© 1999 Canadian Medical Association