Dr Andrew Gunn has just published a highly entertaining piece on the serious topic of assessing fitness to drive in the elderly.

http://drandrewgunn.com/2013/11/01/the-last-word-on-fitness-to-drive/

I agree with Andrew that the current system has the potential to cause real damage to the doctor-patient relationship and that routine practical testing for older drivers would be a significant improvement. What do you think?  (please comment below)

Anecdotal evidence seems to suggest that some patients will doctor shop with their fitness-to-drive paperwork and lie and/or bully doctors into signing the forms. As a junior GP registrar I felt unprepared to deal with such demanding patients, and on a couple of occasions caved in against my better judgement. One of the most memorable was with “Betsy” (name has been changed).

Betsy was an exceedingly frail 88-year-old who hobbled painfully slowly and breathlessly into my room using her wheelie walker. Her list of medical problems was long and impressive, and included uncontrolled diabetes, heart failure and Parkinson’s. The medical certificate form for her driver’s licence renewal flapped almost comically in her shaking hand. Despite its being patently obvious that she was unfit to cross a road unaccompanied let alone get behind the wheel, I’m ashamed to say that I was bullied into signing the form, for lurking underneath that frail exterior was a very aggressive and manipulative woman. I didn’t sleep well that night, terrified that my cowardice might result in great harm to some innocent road user.

Less than a fortnight later I heard that Betsy had died at the wheel. Imagining the worst and having visions of being hauled up in front of the coroner to explain my negligent action, I spent the next few hours in a state of panic. To my immense relief, I discovered that far from causing an horrific multi-vehicle accident, Betsy had in fact executed a perfect parallel park in town, but failed to alight from her car. Cause of death: massive CVA.

I’ve never gone against my clinical judgement when signing a driver licence medical certificate again, much to the chagrin of several patients.

I’m willing to bet that a fair proportion of us doctors were subject to bullying as schoolkids. Some of us disguised our intellect, played rugby, hung out with the cool kids and went on to become orthopaedic surgeons, but many of us, myself included, found ourselves in the nerdy camp. Orchestra, choir, debating, chess club, maths quizzes and science summer schools were not the kind of extracurricular activities which helped one climb the school social ladder. Add to that a goody-two-shoes attitude, the wrong wardrobe, acne, braces and a few extra kilos, and you get a bully’s pin-up girl – or rather, voodoo doll.

Time went by; we all grew up and I for one relished the idea of living and working in a mature, fair, supportive, adult world. Alas, I was to discover that not all schoolyard bullies grow out of their penchant for pushing others around.

While only a small number of patients attempt to bully us, the ones who do can cause considerable headaches.  Ignoring those who put our physical safety at risk (that’s a whole other topic), the ones who put undue pressure on us to grant their wishes can be more than just unpleasant to handle – their behaviour can result in our treating them inappropriately.

Unfortunately, I did not immediately apply the lesson learned with “Betsy” to other unreasonable demands made of me.  One busy morning, as the only doctor on duty, I was rung by the practice principal’s wife and informed that a “VIP patient” (a close friend of hers) was en route with “something in his eye”. “No care is to be spared!” was her instruction.  I was mildly offended at the insinuation that I spared my care according to whim, but all such thoughts were swept away by the arrival of a distraught wife with her vomiting husband in tow.  I did not need fluorescein to find the foreign body: he had a 2cm diameter bamboo rod protruding from his orbit.  A simple case of ambulance to the nearest hospital, I know, but the patient and his wife flatly refused to be treated at a public hospital, but instead insisted on driving to a private ophthalmologist (there being no private hospital emergency facilities nearby).  After valuable minutes ticked away with my arguing the point, I acquiesced. I had a difficult phone conversation with a local ophthalmologist, hurriedly scribbled a letter and sent the patient on his way.

Later that day, I received a deservedly irate phone call from the ophthalmologist on whom I’d dumped this unstable patient.  It was a metaphorical poke in the eye with a big stick, and I still wince when recalling the dressing down. Luckily, the patient’s outcome was a relatively good one, all things considered.  He lost the eye, but did not suffer any intracerebral complications.

As children we are told, “It’s all fun and games until someone loses an eye.”   It took me a long time to learn this lesson, but learned it I have – I’m no longer a pushover when it comes to bullies.

(Identifying details have been changed to protect patient privacy. Blog post has been adapted from my column “Dealing with bullies” published in MIPS Review Spring Edition, September 2011)