The Impossible Job: Reporting to the Ministry of Transportation

Just today, I spent 30 minutes trying to fill out forms from the ministry of transportation for two of my clients. In these forms, they ask the following questions:

Does this person have any problems with their judgement, attention or cognition? Is there a need for a functional driving assessment?

To answer these questions, I am given only two options, with the expectation I check off just one box: yes or no.

After stewing on these cases and feeling my stress levels rising, I create my own box and check it off: I don't know. I even write in the margin: how am I to know? I do not drive with the patient.

Another impossible, relatively high stakes decision that rests on the clinical judgement of the physician. And though I understand why this is, it is also an unreasonable, unrealistic, impossible ask.

On one hand, we have patients who rely on driving for their quality of life, livelihood and convenience. They experience a mental illness that may compromise this and a physician or nurse is legally obligated to report them to the ministry of transportation in Ontario that will lead to an immediate suspension of their license. Patients, in the throws of their illness are not aware and only when they are more stable, trying to piece together their lives do they realize there is yet another significant hurdle in their recovery: trying to get their licenses reinstated. It is a huge point of contention between physicians and patients, one that can irreparably damage the doctor-patient relationship.

On the other hand, driving is a privilege and not a right. Driving comes with very real risks and when I am deciding whether or not to report a patient of mine to the ministry, I ask myself, would I feel comfortable with this person, in their mental state, driving on a highway alongside me and my loved ones? The risk then seems unacceptable to allow a severely compromised person to continue to drive.

Fortunately, most of the time, the initial report to the ministry of transportation is an easy one. An example of an easy and obvious decision to report would be a psychotic person brought to hospital after driving erratically on the highway. Examples of more difficult cases would be the following: if someone is psychotic, but he has been driving with no concerns noted by family and other witnesses who have seen him drive; Or an aging patient who is slowly declining in their memory and reflexes. Where is the line and how does a physician know when it has been crossed?

But what I struggled with this morning was not the initial reporting to the Ministry. It is the forms after, that patients hope I can fill out as soon as possible, so that they can gets their licenses back STAT. On these forms are questions that are impossible to answer like the questions about cognitive concerns and if a functional driving assessment is needed. I would love to always be able to err on the side of caution and request a functional driving assessment, but reality rears its ugly head. Functional driving assessments are ~$800 and no patient of mine can afford that. I also do not know the specifics of a patient's cognitive status while recovering from a psychosis, nor do I know, when there are deficits, whether or not they would impact driving specifically.

So here I am, trying to maintain a relationship with my patients, who have lost so much already. Here I am, trying to keep these patients optimistic about recovery and on treatment. Here I am, wrestling with the needs of my patients and what deficits I can not know that may or may not impact their driving abilities. This may seem like a small part of patient care, but the anxiety and guilt of the process and its impacts expends so much extra energy that I simply do not have. Now multiply this kind of decision making and these difficult conversations over the many patients that go through this process with me, and I am wasted.

So I will have to create my own answer boxes from now on, to communicate the gray zones we clinicians have to manage in the real world. I will have to repeatedly remind the powers that be (unchanging and inflexible as they are), that we exist between the Yes and the No.