Fit to drive? Make sure your patient meets the criteria

Sep 18, 2015

Not sure if your senior patients should still be driving? What about the patient with epilepsy? Don’t let emotion or persistent patients get in the way of your professional judgement. One doctor, in what he later conceded was an error of judgement, certified a patient as fit to drive. Tragically, the patient subsequently killed a pedestrian. The doctor has now been found guilty of professional misconduct.

Assessing fitness to drive

Dr A, a GP with more than 20 years’ experience, had been treating his patient, Mr B, for many years. Mr B was injured when he was 20 and had suffered from post-traumatic epilepsy ever since. Mr B is now in his 50s.

Between 2001 and 2005, Mr B had been allowed to return to a limited amount of driving. In mid-2005 Mr B was involved in two single-car accidents and was required by Queensland Transport to provide a medical certificate to prove his fitness to drive. He visited Dr A to request a certificate, self-reporting that he had been seizure free.

Request for specialist opinion

Dr A noted that this was a ‘difficult situation’. He wrote to Queensland Transport to say that Mr B was due to see a neurologist who would ‘be the best arbiter of whether [Mr B] should be driving or not’. He provided a certificate that said Mr B did have a medical condition, but was medically fit to drive ‘contingent upon authorisation by neurologists’.

The neurosurgeon refused to certify Mr B to drive, noting that Mr B had recently been observed to suffer two seizures (in hospital after one of the accidents) and that he would need to be seizure-free for at least two years before another review. He told Mr B, and wrote to Dr A, that it would be illegal for Mr B to drive before then.

Referral for a second opinion

Mr B was unhappy with the neurologist’s decision and requested a second opinion. Dr A referred Mr B to another neurologist.

The second neurologist also refused to certify Mr B. He stated that ‘there is a high likelihood that at least one of the recent motor vehicle accidents was associated with seizures’ and that his ‘amnesia during seizures makes it very difficult to determine whether (he) will ever be fit to drive a motor vehicle’. He also mentioned that Mr B being seizure-free for two years would need to be corroborated by an independent witness.

Repeated patient requests for review

In late 2005, Mr B again asked Dr A to review his driving suitability but again was referred to the second neurologist. The neurologist, surprised to see Mr B back again in early 2006, reiterated his previous refusal, and sent a letter to Dr A concluding:

‘I explained this clearly to [Mr B] and advised him that I would not be prepared to write a medical certificate for him now or in the future. As difficult as it seems to be for [Mr B], I think it is important that he accepts that he will not be able drive a motor vehicle and arrange his life accordingly.’

However when Mr B again approached Dr A for a certificate in mid-2006, almost 12 months after the last accident, and once again self-reporting that he was seizure free, Dr A agreed to provide the certificate. It is unclear why, after refusing to provide a certificate on many occasions, Dr A decided to provide one now.

In mid-2007, Dr A advised Centrelink that Mr B was at risk of injury to himself or colleagues because of his potential for seizure. But in late 2009, Dr A provided another certificate for Mr B stating he was medically fit to drive.

A tragic outcome

Less than a month later, Mr B suffered a seizure while driving and killed a pedestrian.

The Queensland Civil and Administrative Tribunal found Dr A guilty of professional misconduct, reprimanded him, prohibited him from issuing certificates of fitness to drive, fined him $10,000 plus costs, and required him to attend an education course about dealing with difficult patients.

Key lessons for doctors

Be alert to patient pressure

Doctors, and GPs particularly, can feel pressured by patients to complete certificates in a manner favourable to them. In part this is due to the generally longer relationship which is formed between GPs and their patients – a relationship which often takes on the character of a therapeutic ‘friendship’, but can bring with it a sense of obligation. Also, in light of their experience dealing with government agencies or insurance companies, GPs can feel impelled to act almost as an advocate for their patients in their dealing with such bodies. As the case demonstrates, however, inappropriately acceding to patients wishes in respect of such certification can have tragic outcomes and result in harm to the public and serious censure of the doctor.

Maintaining professional distance

GPs are entrusted by the community with the power, and responsibility, for accurately completing various forms of official certification. This should always be undertaken with complete professionalism and detachment from the influence of friendship. One way doctors can make it easier for themselves to maintain such professional detachment is by creating a formal policy in respect to completing certificates. Such a policy might specify adherence to relevant guidelines, completion of appropriate referrals or testing, possibly completing certificates at a time separate to the consultation, and even submitting them directly to the certifying agency rather than giving them back to the patient. This enables a doctor to make their conclusion honestly, and without the feeling of pressure from scrutiny by the patient.

Such a policy-based approach allows deflecting any anger or hurt feelings associated with refusal or adverse certification, toward the policy rather than the practitioner. Indeed, the doctor can empathize with their patient at the same time as upholding their obligation to make the appropriate certification.

Understand the standards required for certification

Of course, the doctor should also be thoroughly familiar with the current standards of the certificate being completed.

The Assessing fitness to drive for commercial and private vehicles: medical standards for licensing and clinical management guidelines are endorsed by all Australian driver licensing authorities. They clearly explain the role of doctors in assessing and certifying a patient’s fitness to drive. If a GP has any doubt about a person’s fitness to drive, a review by a specialist should be sought.

Showing the patient the relevant part of the guidelines against which they fail can also assist the doctor to maintain professionalism and detachment in respect of the certification, as well as provide an opportunity to educate the patient and counsel them about the importance of such standards.

Learn more

Complete our Risk IQ eLearning course: Managing difficult patients and obtain CPD points or read our fact sheet: Difficult doctor patient relationships.

Watch our Risk IQ webinar: Demands, expectations and complaints: Managing difficult patients and obtain CPD points.

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