Research shows gaps in unfit driver reporting

A new study from Western medical graduate Dr. Alex Louie shows doctors treating patients with brain cancer are unclear about how and when to report a patient's ability to drive.

"It was essentially something we encountered in clinic, in that we saw there was a variable approach that physicians would take, anecdotally, in terms of discussing the issue of driving with patients," said Louie, a scientist at Lawson Health Research Institute and the chief resident in Radiation Oncology at the London Health Science Centre's regional cancer program (LRCP). "It's something where there isn't an exact science, per say, in that where do you draw the line. You may be aware of the requirements but you may not feel it's appropriate. … You're diagnosing them with cancer, telling them what the treatment will be, dealing with the family.

"The last thing on your mind, at least from a practical point of view, is if this person is driving or not."

The study focused on patients with brain tumours and how it compromised their ability to safely operate a motor vehicle due to things such as seizures, loss of reflexes or vision problems. It found 76 per cent of southwestern Ontario physicians caring for patients with brain cancer feel reporting guidelines are unclear.

In a recent survey led by Louie, only three quarters of doctors said they consider reporting brain tumour patients at all. When they do consider reporting, it is usually motivated by legal obligations – even though almost a quarter of the respondents could not clearly define these laws and how they are impacted by them, which are drafted by the Canadian Medical Association (CMA).

In a review of actual clinical practice, the driving assessments for patients receiving brain radiotherapy at LRCP between January-June 2009 were examined. Results show only 41 per cent of patients were advised not to drive, and only 30 per cent were reported to the MTO. Of the patients who experienced seizures – automatic grounds for revoking a license – only 68 per cent discussed driving with their doctor, and only 56 per cent were reported to the licensing authority.

Louie said while brain cancer predispose you to seizures, whether or not a patient will actually have one is difficult to predict. Personally, he informs all his patients dealing with brain cancer there may come a time when the disease may impair their ability to drive.

"You need to engage the patient and make them aware. You can't break that chain of communication," he said.

For him, seizures are clear grounds for reporting a patient to the MTO.

"You need to inform them of the risk. Does it mean we should report all brain cancer patients to be safe? Then where do you draw the line? What if someone has diabetes, what would happen if they get numbness in their feet? So do you then now report all patients with diabetes?"

Where do you draw the line? That's the question lead researcher Dr. David D'Souza, LHSC radiation oncologist and associate professor in the Department of Oncology at Western's Schulich School of Medicine & Dentistry, proposed for this study.

"I see this study as identifying an area of uncertainty to health-care providers that needs clear guidelines," D'Souza said. "As researchers, we started off with what seemed a simple topic.  However, as we delved deeper, we found this is not straightforward. It deals with objectively evaluating the effect of cancer of the brain and the ability to drive, which is not as simple as it sounds."

D'Souza added there are implications for the physician/patient relationship impacting patients' autonomy, livelihood and quality of life.

"This sometimes conflicts with the duty to protect society as a whole," he said. "Hence, it is important to have a conversation with all the key players involved."

CMA guidelines are clear that if a patient has seizures they should definitely be reported. But if the seizures are under control for a period of time, it's grounds to have it reinstated, which adds to the confusion.

"There's a lot of shades of grey with this issue and I think the point of the research is to show that all of this is poorly defined," Louie said. "There's probably no clear-cut answer, but what needs to be done is more research to show who exactly is at risk and what sort of risk society will actually accept in order for people to have their license."

Louie added the bottom line is there needs to be clear guidelines set out, beyond the general legal speak. "It's a big enough health issue, I feel, that it needs to be brought up to get the ball rolling. We need more clear and precise guidelines, and more education of physicians, to protect both the safety of our patients and our society."

Provided by University of Western Ontario