Doctor’s View: Aging drivers and public safety: The physician’s role

Following several widely reported incidents in which older drivers caused auto accidents, including one that resulted in the death of a 4-year-old, the elderly driver is increasingly seen as a major public safety concern.

Legislators, policymakers and safety advocates struggle with possible remedies. Many elderly people and their advocates balk at criticism, cite discrimination and cry “ageism.” With our aging population and the motor vehicle as a longtime symbol and tool of our independence, the issue remains a public health concern.

Aging is but one of many factors that can impair a person’s ability to drive. The greatest risk is alcohol, but drugs (including prescription medications), lack of sleep, psychiatric disturbances, diabetes, cardiovascular disease and disorders of the nervous system are among many others. Distractions such as cell phones, personal listening devices and heated conversations also interfere with safe driving.

A key concern in the debate about aging and impaired drivers is the role of physicians in preventing patients from driving, if the patient’s condition or current treatment may impair the ability to operate a motor vehicle.

Federal Highway Administration data indicate that drivers 75 years and older have higher rates of fatal motor vehicle crashes per mile driven than any other age group except teenagers.

Collisions and traffic violations in the elderly population reflect errors of inattention, failure to yield, difficulty maneuvering and driving too slowly. Left turns are notoriously dangerous.

Physiological changes that come with aging eventually affect everyone’s ability to drive. The rate of change in the physical and mental skills required for driving varies from person to person, but aging does take its toll on those critical components necessary for driving: vision, sensory motor abilities, reflexes and cognitive abilities such as divided attention and quick decision-making. Prescription drug use or chronic medical conditions, widely present in the elderly population, may increase impairment.

Many physicians want the ability to reach out to the Registry of Motor Vehicles when patients present a danger on the highways.

Currently, no legal requirement exists for a physician or other interested party to report a possibly unfit driver to the Registry. If an interested party chooses to report such a driver, then the Registry will act on the information, provided it is reported in accordance with prescribed procedures.

This situation leaves physicians with questions about patient confidentiality under existing laws and with potential liability to patients for filing reports and to patients and others for not filing reports.

A bill before the legislature presents a reasonable solution. It would let physicians and other providers file written reports to the Registry about every patient 16 or older who has a cognitive or functional impairment that affects driving ability.

Determining impairment would not be based solely on a diagnosis, but in accordance with guidelines set by the Department of Public Health in consultation with the Registry and its Medical Advisory Board, medical experts and experts on cognitive and functional impairments. These guidelines would define the conditions and impairments that tend to limit a driver’s ability to operate a motor vehicle safely.

At present, a limited review process exists for patients with medical issues that pose potential dangers to their ability to drive.

Physicians have long supported voluntary reporting that protects them from civil liability and that affords help in dealing with patients who continue to drive while impaired. The proposed bill also would shield mandated reporters from civil liability arising from any situation in which a provider did not file a report with the Registry.

Our state medical society several years ago developed an educational program for physicians on how to identify problems of driving impairment and how to address the issue with patients.

The current policy “supports initiatives that improve driving safety, such as periodic re-testing of drivers in increased-risk categories, promotion of alternative modes of transportation, and improved patient education about driving responsibly.”

Balance is in order. When conflict arises between a patient’s right to privacy and a third party’s need to know, resolution should be in favor of the patient’s privacy and confidentiality.

Exceptions to patient privacy should be extremely narrow, as in infectious disease reporting or for patients in psychiatric treatment who make threats of serious harm to an identifiable third party.

The physician-patient relationship is a complex one in which the health of the individual patient must be the physician’s highest priority. But physicians also know that impaired drivers pose a threat to public health, and we welcome the opportunity to balance the patient’s right to confidentiality with public health and safety.

Janet L. Jankowiak, M.D., a geriatric neurologist at Radius Specialty Hospital in Boston, is a member of and advisor to the Committees on Geriatric Medicine and Communications of the Massachusetts Medical Society.

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