Determining fitness to drive: A troublesome task

As long ago as 1999, the Sup­reme Court of Canada decided in the case of Terry Grismer to instruct all motor vehicle licensing authorities to make fitness-to-drive decisions on the basis of functional capacity, not simply by diagnosis, as had been done previously. 

Mr Grismer was the operator of a mining truck and wanted to continue his employment after a stroke produced a homonymous hemianopsia that eliminated most of his left-side peripheral vision in both eyes. Al­though, sadly, Mr Grismer died while the human rights legal challenge was making its way through subsequent levels of court, his estate pursued the matter to this conclusion. 

In our province, the Office of the Superintendent of Motor Vehicles (OSMV) then began a consultation process and planned for the publication of a new BC Guide in Determining Fitness to Drive to replace the 1997 edition. 

After a long consultation period, in which many doctors volunteered their time, the new edition was published online in July 2010. It was always the intention to also publish a condensed and user-friendly guide for physicians, as the full edition was aimed more toward the needs of regulators. This task has now been delayed until at least 2011, with no announced plan for medical editing and consultation. 

At the time of this writing, the BCMA does not know when and how the new Guide will be implemented. The first reading of Bill 14–The Motor Vehicle Amendment Act, 2010, in part 21, provided for government to set out by regulation the medical conditions or functional impairments that oblige a physician or other health professional to report. 

Doctors can feel uncomfortable balancing the mobility needs of a patient against the potential risk to public and patient safety when considering whether and what to report. In my experience, a lot of the risk is related to the driver’s level of insight. 

A “safe enough driver” is aware of any cognitive limitations and has the judgment and willingness to adapt his or her driving to these limitations. The most dangerous situations are those in which the driver denies or minimizes the reduction in his or her functional ca­pacity and makes no accommodation for it. 

When facing such complex decisions it has been very helpful for BC physicians to know they could contact a medical consultant employed by the OSMV. The OSMV used to have two part-time medical consultants on staff. For the past 10 years, Dr John Mc­Cracken provided this valuable service; however, his contract was not to be renewed. 

The BCMA and the College of Physicians and Surgeons of BC have jointly written to the OSMV to highlight this concern and request a meeting. With the demographics of an aging population and more crowded roadways this is a time that we need more medical consultation available—not less. 

Meanwhile, DriveABLE is the test that the OSMV has contracted with the BC Automobile Association to provide objective information to assist in decision making when there is a concern about cognitive function. The OSMV is also proposing to use SIMARD-MD, a brief pencil-and- paper test, to assist health care pro­viders in rapid screening of patients. This approach has been used in a limited way in Alberta. We await the start of a proposed pilot study in BC. 

Functional capacity is much more than the score on a test—without a mechanism for meaningful and trusted consultation we run the risk of even more rigidity in fitness to drive determinations than existed when only diagnosis was used. The BCMA’s Board of Directors was kept regularly informed during the preparation of the OSMV’s current Guide, but the BCMA was never advised of plans to discontinue the role of medical consultant or the use of medical appeals. 

We need to find a way to address this social and medical issue together and not lose many years of medical “corporate memory” and a spirit of collaboration, as we move ahead. 
—Ian Gillespie, MD 
BCMA President