Driver Test

Safety on our roads is an important public health concern given motor vehicle accident statistics and the prevalence of driving in our society. According to Transport Canada (2010), motor vehicle accidents accounted for 2,227 fatalities, 11,226 serious injuries and a total of 170,629 injuries.

Ensuring drivers with medical conditions are able to drive safely is mandated by legislation and is a responsibility shared by motor vehicle licensing authorities, health care professionals, driver rehabilitation specialists, patients and their families.

In Canada, all physicians have a statutory duty to report patients to licensing authorities if they believe they are unfit to drive. This duty supersedes doctor-patient confidentiality and depending on the province, may be mandatory or discretionary. In Ontario, The Highway Traffic Act was enacted in 1968 out of the medical community’s concern that doctors could not convince medically unfit patients to stop driving. Not surprisingly, patients are very reluctant to give up the independence and freedom driving provides in their daily lives.

When making licensing decisions for drivers with medical conditions, motor vehicle licensing authorities rely on medical reports; expert medical advisors, functional driving assessments and current medical guidelines (i.e. Canadian Medical Association (CMA) Drivers Guide 7th Edition; Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards For Driving).

In Ontario, in addition to vision requirements, basic medical standards that individuals must meet in order to drive are specified as follows: “…an applicant for or a holder of a driver’s licence must not, (a) suffer from any mental, emotional, nervous or physical condition or disability likely to significantly interfere with his or her ability to drive a motor vehicle of the applicable class safely; or (b) be addicted to the use of alcohol or a drug to an extent likely to significantly interfere with his or her ability to drive a motor vehicle safely.” (Highway Traffic Act, s. 14.)

Evidence-Based Resources

The Canadian medical guidelines and standards for driving are excellent evidence-based resources for understanding the breadth and complexity of medical conditions that can affect the ability to drive safely. The CMA Driver’s Guide 7th Edition for example, contains alerts, guidelines, toolkits and questionnaires for a broad range of medical conditions. With respect to driving assessment, The Guide recommends: “A driver with a medical condition that can compromise cognitive or motor skills may require a functional assessment to determine fitness to drive. Any compromise of the ability to perform daily activities should trigger some sort of functional driving assessment.”

Functional driving assessments for drivers with medical conditions are conducted by those experienced in driver rehabilitation and typically involve the following standardized protocol: 1. An in-clinic evaluation by an occupational therapist that includes: history taking and testing of physical abilities, cognitive functioning, perception, vision, road knowledge and driver related insight and judgement; and 2. An on-road evaluation by an occupational therapist and certified driving instructor to assess driving performance on residential, commercial, and highway roads.

Driving assessments conducted under auto insurance accident benefits schedules have been vital for determining fitness to drive, vehicle modifications for patients with a variety of physical impairments, remedial driver training needs for patients with cognitive impairment due to brain injury and designing desensitization programs for patients suffering from driver-related fear due to psychologically traumatic accidents. Driving assessments have also played an important role for evaluating disability and income replacement benefits for those employed in driving occupations.

In Ontario, driving assessments have not been commonly used in the auto insurance system for catastrophic impairment determination. However, considering our obligation to ensure road safety, driving assessments can make a significant contribution in this area. For example, in an evaluation of a patient for Catastrophic determination based on mental and behavioural impairments (i.e. Criterion 8 of the Ontario Statutory Accident Benefits Schedule – SABS), assessors are required to apply the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, 4th Edition, 1993.

A complex and poorly understood process

The AMA Guides note that determining mental and behavioural ratings is a complex and poorly understood process. The Guides direct evaluators of mental and behavioural impairments to indicate and explain, with examples, the impact of the diagnosed psychiatric condition on normal life activities. This involves determining the ability of the patient to function in four major areas: (1) activities of daily living; (2) social functioning; (3) concentration, persistence and pace; and (4) decompensation/deterioration in work or work-like settings. Extreme (Class 5) or Marked (Class 4) impairment must be demonstrated in order to reach Catastrophic threshold under the SABS.

When assessing drivers with mental and behavioural impairments, the CMA Drivers Guide offers important information for evaluators. For example, assessing fitness to drive for psychiatric conditions, it is recommended that all 5 Axes in the American Psychiatric Association DSM-IV diagnostic system be carefully considered and that a Global Assessment of Functioning (GAF) score of less than 50 be used to indicate the need for further assessment.

For psychiatric illnesses, the CMA Drivers Guide states that immediate contraindication to driving includes: “acute psychosis; condition relapses sufficient to impair perceptions, mood or thinking; medication with potentially sedating effects initiated or dose increased; lack of insight or lack of cooperation with treatment; lack of compliance with any conditional licensing limitations imposed by motor vehicle licensing authority; suicidal plan involving crashing a vehicle; an intent to use vehicle to harm others… A patient seen or reported to have any of these problems should be advised not to drive until the condition is evaluated and treated.”

Catastrophic impairment Determination

In the Financial Services Commission of Ontario (FSCO) Arbitration decision A09-001224, the issue of the patient’s ability to drive was relevant to arguments regarding mental and behavioural ratings for catastrophic impairment determination. In this case, the applicant had been employed as a professional truck driver. As a result of the accident, he was reported to have developed (among other quite severe psychiatric symptoms) driving and passenger anxiety, increasing road rage, avoidance of driving during busy times and occasional dependence on others to drive him.

The neurologist for the insurer argued that because the applicant reported he was able to drive, and given the complexity and demands of being able to drive safely, the level of mental and behavioural impairment could not exceed Mild (Class 2) at least for the areas of: (1) activities of daily living; and (2) concentration, persistence and pace, and that it would preclude a Marked (Class 4) impairment for (4) adaptation to work. It was also noted that if any assessor believed the mental and behavioural impairments could affect the applicant’s ability to safely operate a vehicle; this must be reported to the motor vehicle licensing authority.

The arbitrator took a different view and agreed with the testimony of the neuropsychologist for the applicant (who gave Marked impairment ratings in 3 of 4 areas including concentration, persistence and pace).

The arbitrator indicated that: “…driving is an “overlearned” activity – an experienced driver does not typically need to devote much conscious thought to this activity – and this is probabl
y even more accurate for a professional driver like the Applicant. The idea that being able to drive would automatically mean that a person would be placed in the mild impairment category for three of four functional areas seems far too simplistic an approach and not one that is mandated by the Guides. According to the Guides, a person with moderate impairment levels can still have some useful functioning in all four areas of function. A person with marked impairment levels will find useful functioning significantly impeded (but not precluded). Therefore, even at the marked level of impairment, one can expect some useful function in multiple areas of functioning.”

The arbitrator also noted in the decision that the applicant’s licence eventually was suspended pending the licensing authority’s review of further information concerning the patient’s psychological and cognitive condition and his medications.

Role of functional driving assessment

This case illustrates the important role a functional driving assessment could have played in the catastrophic impairment determination process. In this case, such an assessment could have clarified whether the applicant was able to safely operate a motor vehicle and this would have informed the mental and behavioural ratings in each of the four areas of functioning. As well, a driving assessment from a health professional qualified in the field of driver rehabilitation could have provided the arbitrator and the assessors with expert opinions about driving for their decision making.

Although driving is a complex activity involving the coordination of physical, cognitive and emotional abilities, it can be evaluated reliably with current standardized driving assessment protocols. Driving assessments are designed to measure functional driving skills in real time on-road situations. This makes them particularly valuable for assessors, arbitrators and judges who are evaluating the extent and severity of medical impairments. More importantly, however, for road safety reasons, driving assessments should be conducted when impairments due to medical conditions become serious and potentially Catastrophic in nature. 

John Sheard is President of DriveLab and Elana Schneid, B.A. (Hons. Psych), M.Sc., OT, is a Driver Rehabilitation Therapist with DriveLab.