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
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
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’.
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
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
Repeated patient requests for review
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.
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.
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
the doctor should also be thoroughly familiar with the current standards of
the certificate being completed.
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
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.
Complete our Risk IQ
eLearning course: Communication strategies for challenging patient behaviours and obtain CPD points or read our fact sheet: Managing difficult patients.
Watch our Risk IQ webinar: Demands, expectations and complaints: Managing difficult patients and obtain CPD
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