/ / ,» ,, , , - [/34/1 ' ’ / r1 1 f ’V w“ 56 Q [I The Role of Medical Advisory Boards 'n Driver Licensin& 1,44 (DU Hi S 4 , w‘ \ W gg ‘_H\.\__ 1' l . :’ \ ._ 'I‘ r, \ x ‘\ ‘ ‘ N w \\ . \ \x \ ~ _ \ \ . ‘ \, \ \. xv) \ e \ x \ M \ W“ \ ~ ‘ S ‘ \ ‘ \ ‘ _¥7V ,7 \ \ \ \ \ \ \ \ \ A \ ‘ \\ \_ 7 ‘\\ ~ \ . ‘_ \ e ‘- ‘\, ".\ \ ‘ \ \ \\ \\ r . ' ‘ ‘ \* W“. The [Role of Medical Advisory Boards inQriver Licensing J For sale by the Superintendent of Documents. U.S. Governmem Printing Ofice Washington, DC. 20402 . Price 8120 Stock No. 050-003-00252—6 T L 152 .35 l3651 . PUBL ACKNOWLEDGMENTS The National Highway Traffic Safety Administration is grateful to all the organizations and individuals who spent so freely of their time and energy to provide the information that made this manual possible. Of the individuals to be rocognized for their help, the first is Fleming L. Jolley, M.D., Atlanta, Ga, who made available the results of a 1973 Medical Advisory Board survey that he initiated on behalf of the Georgia Board, which was then being organized. Close behind in providing help were Milo Hodgson and Dale Allen, Madison, Wis.; James L. Weygandt, M. D., Sheboygan Falls, Wis.; Paul L. Weygandt, M.D., Akron, Ohio; R. LeRoy Carpenter, and Edward Wehling, Oklahoma City, Okla: A. J. Mirkin, M.D., Cumberland, Md.; Harold A. Fenner, M.D., Hobbs, N. Mex.; William K. Keller, M.D., and Herbert L. Clay, M.D., Louisville, Ky.; and John D. States, M.D., Rochester, NY. Also appreciated was the help of Elmer Brown, Sacramento, Calif; Theodore R. Pinckney, M.D., Washington, DC; James C. Upchurch, M.D., Birmingham, Ala.; Basil Y. Scott, Ph.D., Albany, N.Y.; Thomas Dickinson, M.D., Sarasota, Fla; P.W. Nugent, Atlanta, Ga; D. H. Keirn and James Shulcr, M.D., Tallahassee, Fla.: Gary March. Springfield, 11].; T. E. Banks, M.D., Alexandria, La.; James Fischer, Arthur H. Downing, M.D., and Tina Preftakes, Des Moines, Iowa: Donald C. Lhotka, Chicago, [1].; Larry Wetherby, Frankfort, Ky.; Hon. Richard H. Austin, David Shinn, and John Foley, Lansing, Mich; Donald F. Prince, M.D., Minden, Nebr.; Ruth W. Baldwin, M.D., and Leonard Kestlcr, Baltimore, Md.; Fred M. Patterson, M.D., Douglas Wooten, and Raymond Dean, Raleigh, NC; Harold E. Gillespie, M.D., Richmond, Va.: Robert D. Clinger, Columbus, Ohio; Chester W. Ott and William Wright, M.D., Portland, Orcg.; Otto Lippman, M.D., and James Shuffield, Austin, Tex.; David T. Kirk and Carl L. Klingberg, Ph.D.. Olympia, Wash. Credit is also due staff members of cooperating organizations: Lee N. Hames and Elaine Petrucelli of the American Medical Association; William H. Franey and Arthur A. Tritsch of the American Association of Motor Vehicle Administrators; Robert N. Pierron, who provided editorial consultation on the manual; and James J. McNamara, LL.B., who assisted in preparing the model legislation. Of course, few of the individuals cited above could have provided help without the support and cooperation of the organizations for which they work, so special thanks are, therefore, due many State medical associations and State licensing agencies. Also appreciated is the support of the American Association for Automotive Medicine. Space does not permit the mention of hundreds ofothers who answered numerous questionnaires and telephone inquiries, but their help has not been forgotten. If any major source of help has not been mentioned, the omission is completely unintentional. iii PREFACE This manual represents a compilation of efforts in the State and Federal Governments and in the private sector of thousands of individuals who have attempted to reduce death and injury on our streets and highways by developing and improving methods of identifying and handling medical impairment in drivers of motor vehicles. From the time when licensing jurisdictions first started to see medical impairment as a potential hazard, they realized that medical advice and guidance was essential to good licensing programs and turned to physi- cians for help in judging when an impairment becomes a hazardous risk in driving. From this seeking came medical advisory boards (MAB’s) as we now have them. For convenience and the saving of space, such boards will be identified throughout this manual as MAB’s, or simply as boards. In order for this manual to present a picture that is not completely fragmented by hundreds of footnotes listing exceptions and differences, an MAB is defined as an officially recognized medical group, established either by law or by administrative fiat, for the purpose of advising the driver licensing agency on the medical aspects of driver impairment in all the major medical specialties. Such boards can provide a tremendously valuable service to licensing agencies, driver license applicants, and society in general. The purpose of this manual is, therefore, to encourage both the establishment of such boards and the improvement of those already in existence. The results of more than 2 years of discussions and correspondence with licens- ing and medical personnel throughout the country, as well as a study of a large number of documents and literature on the subject, are presented as succinctly and accurately as possible. The original intention had been to produce a manual similar to one that the US. Department of Health, Education, and Welfare produced in 1967, in which MAB programs of seven States (Florida, Kentucky, Maryland, New Jersey, North Carolina, Oregon, and Pennsylvania) were featured in detail. That manual undoubtedly spurred quite a number of other States to start boards, and by 1974 there were boards in all States except three, albeit many of them existed only on paper or on some unofficial basis. As cited in the Acknowledgments. Dr. Jolley of Atlanta did a mail survey of licensing agencies and made available the information he obtained. This was valuable but did not provide nearly enough information, especially concerning the input of State medical associations and State departments of health. In 1974 the American Medical Association, the American Association of Motor Vehicle Administrators, and the American Association for Automotive Medicine conducted a mail survey to these two organizations as well as the licensing agencies ofeach State. These three agencies were chosen since all are usually involved to some extent in most States in the operation of a medical advisory program. A tremendous amount of information was gathered. but the responses from the three agencies varied considerably and in some cases was found to be contradictory. As a result, it was necessary to make on-site visits, to contact by telephone, or to engage in considerable follow-up correspondence with those persons in the various States who had responsibilities for driver licensure or who otherwise participated in the process. Thus, despite consider- able advance help on this project from various sources, it probably could not have been completed without the financial grant received from the National Highway Traffic Safety Administration. It should be emphasized that cooperation for the most part, from licensing jurisdictions particularly, was excellent, but there were exceptions, and specific questions were not answered. Information, therefore, is unfortunately incomplete for some States. As the information gathered for this project was evaluated, it soon became apparent that the presentation of the programs in a number of States would, for a number of reasons, not be as valuable as the development and presentation of a model program. Basically, even the best existing boards have some bad features, and some of the worst have some good points. Then, too, as will be discussed, some of the best-appearing boards on paper may not work very well. Obviously, there is no intention to indicate that the seven States used as good examples in the 1967 manual are no longer worthy of praise, since five of those States are carrying on as well as or better than they did in 1967. One of the other two no longer has an advisory board, as defined for purposes of this manual; the other one continues to use medical panels only for convulsive, metabolic, and cardiovascular disorders. Similarly, there is no implication that the model proposed will solve all the problems connected with the medical aspects of licensing or even that it is the best way of doing it in any individual State, but only that it provides a convenient framework on which any State can build a good program, best suited to its own individual needs. It has been deliberately simplified and generalized for this purpose. In addition to a model MAB, this manual contains a model law to help establish a board, and it provides useful associated information. It is hoped that this and the rather detailed state-of—the-art review of what exists at present will be helpful in showing the value many States place on their MAB’s. Finally, the manual contains a list of recommendations that seem to be a logical step in improving the handling of impaired driver license applicants in the future. Publication of these recommendations, or for that matter anything in this manual, does not imply endorsement by the sponsors or by the US. Department of Transportation. But it is hoped that each jurisdiction will find something ofvalue in this manual to start an MAB program or to improve the one it already has. vi THE ROLE OF MEDICAL ADVISORY BOARDS IN DRIVER LICENSING CONTENTS PREFACE ............................................................. v PART I INTRODUCTION ........................................................ 1 BRIEF HISTORICAL PERSPECTIVE ........................................ 2 STATE OF THE ART ..................................................... 2 ORGANIZATION AND OPERATION ..................................... 4 Legislatively Constituted Boards ..................................... 4 Appointment and Membership ................................... 7 Specialty Groups Representation ................................. 7 Size of Board ................................................ 8 Length of Term .............................................. 9 Number of Meetings ........................................... 9 Remuneration ............................................... 9 Responsibilities and Functions ................................... 9 Legal Protection .............................................. 10 Anonymity and Confidentiality .................................. 1 1 Three Boards in Detail ......................................... 1 1 Maryland ............................................... 1 1 Oklahoma ............................................... 12 Texas .................................................. 13 Administratively Established Boards .................................. 13 Two Boards in Detail .......................................... 15 North Carolina ........................................... 15 Wisconsin ............................................... 16 PART 11 INTRODUCTION ....................................................... 17 MODEL MEDICAL ADVISORY BOARD ...................................... l7 Rationale for Medical Advisory Boards .................................... 18 Establishment ........................................................ 18 Board Appointments .................................................. 19 Size ..... - .......................................................... l9 vii Composition ....................................................... 19 Length of Service ................................................... 20 Remuneration ..................................................... 20 Number of Meetings ................................................. 20 Functions and Responsibilities ................................. » ........ 21 Legal Considerations ................................................ 22 Summary ......................................................... 23 MODEL MEDICAL ADVISORY BOARD LAW ................................ 25 SIMPLIFIED SCHEMATIC FLOW CHART OF MODEL LICENSING PROCEDURE FOR HANDLING MEDICAL IMPAIRMENT .................................. 28 MODEL FORMS ....................................................... 29 PART III INTRODUCTION ...................................................... 43 THE NEED FOR CRITERIA .............................................. 43 PHYSICIAN REPORTING OF DRIVER IMPAIRMENT ......................... 45 MODEL REPORTING LAW .............................................. 47 CHRONIC VIOLATOR .................................................. 48 DWI SCHOOLS ........................................................ 48 MEDICAL REVIEW BOARD .............................................. 49 IN-PERSON RENEWAL ................................................. 49 TRAINING DRIVER EXAMINERS, DRIVER IMPROVEMENT ANALYSTS, AND HEARING OFFICERS ............................................... 49 TELESCOPIC DEVICES AND DRIVING .................................... 51 PART IV RECOMMENDATIONS .................................................. 53 BIBLIOGRAPHY ....................................................... 55 viii INTRODUCTION A license to drive is extremely important to millions of our citizens. It is not the pur- pose of this manual to argue whether such a license is a right or a privilege, but it is quite obvious that the public as a whole has a right to protection from death, injury, and property loss caused by drivers—fin this case, impaired drivers. Thus, even if the license to drive is interpreted as a right, society can withhold such a license when there is adequate reason to believe that the individual involved has an impairment that can be expected to create an un- reasonable risk upon our streets and highways. Ever since driver licensing agencies started to check, even in a most rudimentary fashion, the physical and mental capacity of drivers to carry out the task of operating a motor vehicle safely, many of these agencies have tried to improve the means of identifying those medical conditions that are likely to be a hazard. Most persons involved in the licensing process agree that a program of having all driver license applicants examined by physicians is a logical way to discover potentially hazardous medical conditions—it would, at the very least, take a burden off the licensing agency. Such thinking led directly to various experiments: one State, Pennsylvania, started a program in 1960 in which every driver license applicant had to have a medical examination by a physician before being licensed and on every renewal. On a random basis, more than 2,000,000 drivers were examined in Pennsylvania in the next few years. For a number of reasons, including difficulties caused by sheer numbers and the expenses involved. the project was discontinued. There was, perhaps, an even more compelling reasonirethe program was deemed unjustified in view of the comparatively small number of hazardous medical conditions found in persons who had had no prior evidence or even suspicion of any existing medical problem. Although mass examination efforts apparently do not meet the cost effectiveness criterion of most legislators (and the public that elects them), such a criterion does not take into account the pain and suffering that result from motor vehicle crashes that might have been prevented. However, the realities of State and Federal budgets and the apparently low sense of value that society places on these particular deaths and injuries establish definite restraints on how much can be done. Although it is not our purpose here to question why society demands a great deal more financially, and in training. from, for example, an applicant for a beauty operator’s license than it does from an applicant for a license to manipulate a heavy, complicated piece of machinery at high speed on congested highways, it is definitely within the scope of this project to present ideas and suggestions that can improve the licensing process—Aparticularly as they relate to medical advisory boards. Since medical examinations for all applicants does not seem to be practical at this time, a viable alternative is to examine drivers when the medical findings are higher. This, of course, makes it necessary for the licensing agency to make medical judgments, a task in which it needs help. And this can best be provided by a medical advisory board. 231-660 0-77 -2 1 Not only can MAB’s give advice and guidance concerning the high-risk groups with which the licensing agency should concern itself, but they can, in addition, help it make decisions concerning individual applicants within those groups. It can develop guidelines for its own use, for the use of driver licensing personnel in screening for driver limitation, and for the use of the applicant’s physician. It can act in a liaison capacity between the licensing agency and individual physicians and can develop medical forms to use for a vast variety of medical problems. In general, as its name implies, a board can act in a truly advisory capacity. BRIEF HISTORICAL PERSPECTIVE Although it was not until the 1900’s that formal, legislatively authorized and financed medical advisory boards began to spread throughout the country, many States had used advisory plans of some sort for at least a quarter of a century. In fact, as early as the 1930’s States had begun to establish somewhat formalized advisory mechanisms, most of them concerned primarily with epilepsy. Some States, such as Oregon, had begun to take advantage of medical knowledge provided by their State Health Department; others used the services of dedicated individual physicians. From that early period many licensing administrators felt that the laws that mandated them to license drivers implied that they not license individuals who could not drive safely. In fact, about half of the States used this as a reason for setting up advisory systems to help them determine who should or should not be licensed. Most of these systems were informal, rather haphazard arrangements, and their very existence depended almost solely on the personal motivation of a few dedicated individuals. Formal medical advisory boards began to spring up, however, largely as a result of a conference sponsored by the American Association of Motor Vehicle Administrators and the US. Public Health Service in 1958, of workshops in 1060 and 1961, and of a National Conference on Medical Aspects of Driver Safety and Licensing,jointly sponsored by these two organizations and the American Medical Association. In 1967 a federal standard was promulgated, giving considerable impetus to the establishment of such boards as part of State highway safety programs. By the late 1960’s 47 States had set up some type of medical advisory system. At present, 40 States have a medical advisory board, and five States do not. Seven of these 40, however, have boards that are inactive or are not yet fully operational. This manual discusses in detail the state of all these boards as well as that of the District of Columbia MAB. STATE OF THE ART The 1967 manual “Medical Advisory Boards for Driver Licensing” went a long way in influencing States to establish medical advisory boards and in aiding those States that had boards to make them more effective. Likewise, the adoption of the highway safety standards in that same year bolstered this effort by requiring States to establish some form of medical advisory channel to assist driver licensing agencies in developing criteria and guidelines relating to physical and mental impairment. In the past 5 or 6 years, however, a number of MAB’s have become ineffective or inoperational, or have completely dis- appeared, and the medical activities in licensure have been allowed to retrogress. But in a few States the medical advisory operations have become much stronger and much more effective in aiding the licensing agency in this important phase of driver licensure. Much credit is due individual physicians and licensing officials whose enthusiasm, leadership, and dedication to automotive safety have resulted in strong, functioning MAB’s. Thus, the medical advisory board picture, with the exception of a few outstanding States and a spurt of activity in the past year in which one State passed MAB legislation and another reactivated its board, has shown a slackening of interest. Apparently, quite a number of the boards that were instituted never got off the paper that created them, and others have slowly disintegrated. Such slackening has been due to a number of factors, including the following: medical society budgetary retrenchments that have reduced activities, generally in the field of traffic safety1 (the American Medical Association itself abolished its committee on medical aspects of automotive safety); the change in emphasis from the preventive aspects of traffic safety in the late 1960‘s and early 1970’s to an interest in emergency medicine; retirement or change of a chairman who had not built up a large enough base of interested members and who had tended to serve as a one-man MAB; personality conflicts between licensing administrators and the medical profession; or simply lack of interest or understanding of the role of medical impairment in driver licensure on the part of the licensing administrators on the one hand and the medical profession on the other. In addition, the Federal-Aid Highway Act of 1976 prohibits the US. Department of Transportation from imposing sanctions against States that have not enacted legislation to comply with the highway safety standards requirements. It is too early to tell what effect the Congressional removal of the enforcement provisions of the Federal highway standards will have on further reducing the initiative of States in regard to medical advisory boards, but it is known that the standard requiring motorcycle helmet usage has already been rescinded by seven States. At present, 10 States (Alabama, Arkansas, California, Connecticut, Idaho, Montana, New Hampshire, New Jersey, Oregon, and Washington) do not have medical advisory boards. Until June 1976 the Alabama State Medical Association Committee on Traffic Safety served in this capacity through administrative agreement, but organizational changes within the medical society caused the committee to drop this driver license advisory function. Similarly, in California, the State medical association committee on automotive safety served as the MAB since 1969, but it has not functioned in recent years. Arkansas considered legislation to establish a board, but the legislation failed in the General Assembly. Similar legislation is being contemplated in Idaho, although a bill has not yet been submitted. Montana remains inactive in this area. The five States that do not have MAB’s as defined for purposes of this study, have set up some informal arrangements for physician evaluation ofquestionable cases on which the licensing agency does not feel qualified to make a determination as far as the driver’s medical impairment is concerned. It is interesting to note that in Oregon 3 medical advisory board was established by law in 1954, but in recent years the board has become inoper- ational even though the law has apparently never been rescinded. This is the case also in Arizona, Massachusetts, and West Virginia where no mention was made of any medical input into the licensing process even on a quasi-formal basis. 1In a number of states, however, the medical society committee on automotive safety still functions as the medical advisory board to the licensing agency. Connecticut and Oregon rely upon the State Health Department for medical evaluation either directly through staff or an ad hoc consultant in the particular medical specialty, who then reports the findings to the licensing agency. In Oregon the department of health has lent support in getting passage of legislation requiring mandatory physician reporting to the health department of certain medical conditions potentially hazardous to driving and has been instrumental in developing some guidelines for evaluating individual cases. In New Hampshire the licensing agency has access on a limited basis to physicians through the State medical association. For specific cases involving alcohol abuse, it relies upon the department of health’s alcoholism section for advice and guidance. New Jersey does not have a medical advisory board, but in 1963 two medical panels were created, one on convulsive disorders, which has since added diabetes, and the other on cardiovascular disorders. Washington’s program is somewhat more comprehensive in that the licensing agency retains on a part-time basis a physician consultant to evaluate the more difficult cases that cannot be screened out by the licensing agency using the guidelines established some time ago with the Washington Medical Association Vehicle Safety Committee. In addition, the licensing agency has access to researchers who are able to conduct studies using the statistics on impaired drivers gathered through the medical surveillance program. Of the 40 State medical advisory boards, 33 are functioning to some degree of effec— tiveness.2 It is interesting to note, however. that of the six boards having the most active programs, only three of these are legislatively constituted boards; the remaining three are organized through administrative fiat. Conversely, the majority of boards that serve primarily as arbitrators between a license applicant and the licensing agency, or the license applicant’s physician and the licensing agency, were established by statute but have not progressed much beyond the elementary functions as outlined in the laws creating them. Organization and Operation Of the 40 States that have functioning medical advisory boards, 27 boards are estab- lished by legislation and 13 through administrative agreement (Table 1). Seven of these 40 are medical advisory boards only “on paper”; 5 are by law, and 2 are by administrative agreement. Five of the 7 are completely inactive, and the other 2, Illinois and Ohio, have only recently been reconstituted and have not yet become fully operational. MAB’s have been grouped by category in Table l for discussion purposes. In addition, a numerical rating has been assigned to each—categories 2, 3, and 4 refer to functioning boards regardless of how they are constituted. It should be exphasized that assigning a rating is meant in no way to denigrate any State medical advisory program, since some States given a lower rating have some excellent features whereas those given a 4 are by no means beyond improvement. LEGISLATIVELY CONSTITUTED BOARDS Table 2 is an index to all the information that follows concerning legislatively consti- tuted boards where State laws were made available to the project investigators or where information was learned through on-site investigation, correspondence, or telephone survey. 2Althouth not a Statejurisdiction, the District of Columbia’s MAB program is discussed as part of the State of the Art. It does not, however, appear in the statistical totals given. Present status of medical advisory boards Table 1. usetts ‘0 arolina Note. 7— Current status of MAB’s in all 50 States and the District of Columbia and how they were established. The following numerical rating devised for purposes of this study indicates their level of operations: 0 A No MAB. 1 * Board exists“on paper” but is inactive or not yet fully operational. 2 — Board serves primarily as arbitrator in individual cases. 3 7 Board sets general medical policies and develops forms, in addition to its arbitrator role. 4 w Board is structured uniquely and has expanded its overall activities to encompass many aspects. Those States that have no MAB but have access to medical personnel either through the State medical association or the State health department are indicated by 00. a MAB established by administrative order in ‘ 1965; disbanded in July 1976. L Not yet fully operational. b MAB established by administrative order in d Law enacted in 1954 and never rescinded; 1969 but has not functioned in recent years. however, MAB does not function at present. Table 2 — Provisions of State Laws Establishing MAB’s ('oiidnei husniess Medical Health Year law How members Length oi Confidentiality I-iinetions society department State enacted Membership appointed rerin Meet (‘oirrspondrncr Remuneration Illllllllllll) .v\non_\nn|,\ oI iiilormaiton del'incd liaison liaison Ari/ona I968 7 M.[).'s minimum State health .I yr \ I'\[i\‘llsi‘s only Yr\ No Yes Yes Yes commissioner (‘olorado W73 II M.l).'s. specialities (lovernoi s w \" Lsprnsi's only My Yes Yes listed. I () I) Delaware W70 R members nnnnnuni Seueiary to department \“ None Yes YL\ Yes Yes Yes in addition, I 0 I). ol linhlie s‘al'ety and I ophthalmologist used as consultants in all Vision cases Honda I975 | I M.I).‘s. I () I). Stale cabinet 4 \l ‘\"| Yes Yes Yes Yes Yes Georgia I975 7 members:1 ('oninnssiniiei ot X" I'sprnsrs only Yrs Yes Yes Yes PlIhIlt s.iIety IllUlllIII\ Hanan I969 i M I).\ lllllllmum‘ Governor \ I\pCII\L'sUl1I\ \o \o Ym specialities listed Illinois |07S 9 M.l).‘s X" Yes Yes Yes Indiana l967 I0 nieinhers total. (inveinoi 4 _\i ‘t is.“ d.i\ i Yrs Yes including I () I). 4 )l rsprnws and I attorney. Osteopath may serve. Kansas 1069 < members. Secretary ot \ NB IIIs'l‘lIIIIl including I 0.1)., revenue specialities listed Kentucky 1904 At least 3 MI) 's i ('oiriiiiissioner ol | yr \" Yrs Yes Yes pllhIIL’ health piihhc \RIICIY \Ilhu‘el I} \r commissioner i to re piihlie sateiy appouil commissioner inrui Louisiana I‘JbX Ht members, Governor \ I \penses onl) \o Yes \‘o Yes Including 4 () I) ‘s. Ia has 4 ICIUUIIJI boaids Maine 1963 Yes Yes Yes Maryland I947 45 members. hoth Motor vehicle I yr \ Sit! nierniig Yrs \o Yes Yes Yes M.I).‘s‘ and ().|) ‘s \‘UIIIIIIISMUIICI \liIVlcil [U ls“ .Ippoinl- Ilk‘lll Massachusetts I‘I74 Nevada I972 .l M.I).‘s Director oI motor \oue Yes vehicles New Mexico I‘llxl .I M.I).'s None Y L\ ()luo I974 ()klahiima I967 7 members. 4 h) pllhlle health ,\' \oiir Yts Y rs Yes" Yrs Yes specialities listed commissioner .l h) qudIIL’lIV‘I public saletv eonnrussionei Oregon NSHIh I"rins_v|vania [076 I} members l’i. Secretary oI Yes Yes Yes i.e., M.l).'s as transportation IiiIIows 7 M.D.'s, I ().I)., and 5 representatives of various state agencies Rhode Island l968 5 M.I).‘s, including Governor S.“ meeting Yes 4 specialities teserpt es as listed I I puhlie ntliem health physician meinhei) ex ot'l‘ieiu South Dakota I074 7 members X“ N'oiir Yes Texas I970 84 members, Ilealth commissioner 2 )l X" Yes Yes Yes Yes Yes including 3 members ().l).'s rotate Utah 1068 imemhers 4 by .siate health X SIS inrelnig 0 Yes Yes Yes director espenses I by public safety commissioner Vermont I068 x“ None No Yes Virginia 1068 7 M I).\ Governor 4 )r $40 day + \o Yes Yes Yes espcnses West Virginia 1974 5 members, including Governor 3 yr X SIS/day + I ().I). expenses Wyn-rung W73 IS members, (‘mnnnssinner oI’ I'spenses only Yes Yes Yes including I 01), public safety dBy practice. I’law was nevei rescinded; mi MAB at present. Space does not allow more than a sampling of examples when discussing specific provisions of State laws; however, Table 2 facilitates this. Having a board established by statute does not necessarily mean a specific law has been enacted to set up a board and clearly define its functions and responsibilities, although this is true in at least 18 states: Arizona, Colorado, Delaware, Florida, Georgia, Hawaii, Indiana, Kansas, Kentucky, Louisiana, Nevada, Pennsylvania, Rhode Island, Texas, Utah, Virginia, West Virginia, and Wyoming. In some cases the legal authority of the motor vehicle administrator to set up a board is specified in existing legislation that authorizes the administrator to seek medical advice and counsel in evaluating cases involving medical im- pairment and in establishing guidelines relating to driver limitation. For example, in one case the law states: “In deciding whether to issue or deny a license, the Commissioner (of Motor Vehicles) may be guided by opinion of experts in the field of diagnosing and treat- ing the specific physical or mental disorder suffered by an applicant.” In some States the medical advisory board is known by another name. In Georgia and West Virginia, for example, the legislation specifically calls for a “driver license advisory board.” In Indiana it is “the medical advisory commission,” and the Kentucky statute calls for a “medical review board.” This latter should not be confused with a duly constituted appeal board, such as that in North Carolina, whose decision concerning licensure is binding upon the licensing agency. The Nevada law says simply a “medical board” shall be ap- pointed. The functions and responsibilities of advisory groups, as defined by the laws in these various States, however, are basically the same as for other medical advisory boards, regardless of their title. Appointment and Membership There are a variety ofways in which MAB members are appointed and operate. In some States, a slate of nominees is solicited from the State medical association. In others, State health agencies are asked. The Indiana law stipulates that “members of the commission shall be appointed by the governor from a list of nominees presented for his consideration by the disciplines indicated (neurology, cardiology, ophthalmology, otolaryngology, ortho- pedics).” This, presumably, could include recommendations from medical specialty organizations (e.g., American Association of Neurological Surgeons and American Associa- tion of Ophthalmology). In Delaware the law specifies that “the chairman of the Board shall be the Executive Secretary of the State Board of Health”: in Oklahoma the State health commissioner serves as the executive secretary of the board. In a few states nomina- tions are made by various State health groups or State departments such as: Vermont, Department of Mental Health; Florida, Department of Vocational Rehabilitation; and Pennsylvania, Governor’s Council on Drug and Alcohol Abuse. Membership varies almost as much as the appointments. In Vermont and Pennsylvania the State health commissioner is a member, and in Kentucky the commissioner of public safety is authorized to serve. Specialty Group Representation In some cases the law stipulates the specialties to be represented on the MAB. The Hawaii law establishes a five—member board as follows: “At least one of the members shall be a psychiatrist, at least one shall be a specialist in cardio-vascular disease, at least one shall be an ophthalmologist, at least one shall be an optometrist, and at least one shall be an ortho- pedic surgeon.” In Colorado “the Board shall be composed of the following: (b) one Colorado licensed optometrist; and (c) (i) eight Colorado licensed physicians, including at least one physician qualified in each of the following: (ii) internal medicine (iii) psychiatry; (iv) neurology; (v) physical medicine; and (vi) ophthalmology.” The Rhode Island law lists the medical specialties to be represented, which include a public health physician. “The medical board shall consist of a physician in general practice, a neurologist, a psychiatrist, and an orthopedic physician . . . and a physician from the Rhode Island department of health designated by the director of health who shall serve ex officio.” In other States the law is not specific concerning membership. For example, “under the provisions of Title 46.] of the Code of Virginia, there is hereby created a Medical Advisory Board for the Division to consist of seven qualified and practicing physicians appointed by the Governor.” The Arizona law states simply that “members appointed shall represent various medical specialties.” In those States in which the law is not specific about membership, specialties other than the major ones involved in driver limitation are often successfully represented: for example, the Maryland Medical Advisory Board is chaired by a pediatrician. Pennsylvania’s motor vehicle code contains one of the most comprehensive sections on membership. It calls for 13 members with representatives from the department of trans portation department of justice, Governor s council on drug and alcohol abuse, department ot health, Pennsylvania State police, and one each of the following physicians: neurologist, cardiovascular surgeon internist gener 1al practitioner ophthalmologist psychiatrist, ortho- pedic sur,geon and optometrist. It should be noted that 4 ot the 13 need not be physicians. In a number of States the law allows for other than physicians to serve as bona fide board members. In the majority of cases the law specifically names optometrists who are licensed to practice in the State and are recommended by the State optometric association. In at least one State, Indiana, in addition to an optometrist, an attorney and an osteopath are members. Size bf Board In addition to listing the medical specialties to be represented, stipulations have been established, either by law or through administrative practice, 011 the number of board mem- bers. These vary from as lew was3 (Nebraska) to as many as 84 (Texas). When a specific number of board members rs mandated by law, it is usually an odd number. It should be mentioned that in most cases 111 which the law stipulates a minimum number of members, by practice the 111embership has been enlarged to make it more representative of the major medical specialties involved in automotive medicine. Length of Term Less than one third (eight) of the State laws stipulate the length of service of board members, which ranges from 1 year (Kentucky) to 4 years (Florida, Indiana, and Virginia). When initial appointments are made for 4 years, these are staggered to maintain contin- uity on the board. In only one State (West Virginia) is there any indication of how new appointments are made, but it can be assumed that other States follow the same format as for initial appointments. It can also be assumed that members can succeed themselves in— definitely since none of the State laws studied for purposes of this manual prohibited it. Number of Meetings A number of medical advisory boards meet on a regular basisimonthly, bimonthly, quarterly, biannually~but many act through correspondence. Most of the legislation is not specific concerning meetings, and by practice, this is usually left up to the discretion of the chairman or is dependent on the amount and urgency of business for the board’s attention. Several boards conduct most of their business by mail but meet at least once a year with the licensing agency personnel, primarily to review, in a general way, overall procedures for evaluating cases referred for medical reasons. Two notable exceptions to this practice are the Maryland and Texas MAB’s, which are discussed in detail below. Remuneration Some State laws clearly stipulate the remuneration board members shall receive. In every case in which the law is specific, members are reimbursed for their out-of—pockct expenses, primarily for traveling to and from meetings. In addition, some States pay a small honorarium (Indiana~$25.00 per day; West Virginia—$35.00 per day; Maryland-$50.00 per meeting). In Rhode Island, the law states: “Members of the medical board shall receive, as compensation for their services thereon, thirty—five dollars ($35.00) per meeting, except for the ex officio members; provided, however, that no member shall receive more than three hundred fifty ($350.00) dollars per annum pursuant to this section.” The Arizona law states that “no compensation shall be paid for serving on the medical advisory board, provided that each member shall be paid mileage and subsistence expenses from the Arizona highway fund as may be allowed by law in traveling from his regular place of residence to and from meetings of the medical advisory board or from his regular place of residence to and from the place where he discharges his duties.“ Responsibilities and Functions Most State laws establishing medical advisory boards are rather detailed in discussing makeup and administrative operations, but only a small number outline in detail the specific charges and responsibilities of MAB’s. Functions and responsibilities of medical advisory boards vary tremendously from State to State, and this variation is not necessarily related to whether the board is legisla- tively mandated or organized administratively. Most State laws are very generally written, charging MAB’s with the overall responsibility of advising the commissioner of motor vehicles on medical criteria and vision standards. This mandate is usually interpreted to en- compass all medical aspects of licensure, including evaluation of individual applicants on their physical and mental capability to operate a motor vehicle safely, especially when this 231-660 0 - 7'7 - 3 9 dictum is not specifically stated. Within this broad framework, however, a medical advisory board is able to be as active or as dormant as it sees fit. In addition to the overall charge to the MAB, in a very few States optional activities are suggested. The Colorado Board may become involved in related activities, such as de- veloping regional or local medical advisory committees and giving special attention to medical referrals involving abuse of alcohol or other drugs, including special rehabilitative treatment. In Arizona, the medical advisory board may conduct studies, including recom- mendations, for the purpose of suggesting medical standards for licensure, training programs for driver examiners, certification procedures for licensing programs, and research in the field oflicensure and examination. Georgia’s MAB program was legislated in 1975, although it was established initially through executive order in 1973. Special note is made of the text of that order because it incorporated some of the most important functions of a medical advisory board: “ORDERED: That there is‘created and established a Driver License Advisory Board for the purposes ofadvising the Governor, the Commissioner of Public Safety and the Board ofPublic Safety on matters concerning driver licensing and high- way safety. The Board is specifically directed to submit recommendations for driver license examination criteria and licensing procedures related to physical and mental ability, and to evaluate the same on a regular basis. The Board should recommend screening procedures for use by driver license examiners to identify promptly driver license applicants whose physical or mental abilities are questionable. When requested by the Commissioner of Public Safety, the Board should ad— vise the Commissioner whether or not a licensed driver or applicant is physi— cally or mentally qualified to be licensed. The Board may formulate its advice from records and reports or may cause an examination and report to be made by one or more members of the Board or any other qualified person.” (Italics are added to emphasize functions spelled out in the executive order.) Legal Protection One important issue that has a direct bearing upon how effectively an MAB can oper- ate is the provision to hold board members immune from legal action resulting from their recommendations. A number of State laws are specific about granting this protection. The Utah law states: “Members ofa medical advisory board shall incur no liability for recom- mendations, findings, conclusions or for other acts performed incidental to members/zip on a board. ” (added). In the Texas statute this protection is extended to “all other persons making examinations for or on recommendation of the members of the Board.” In both Florida and Georgia a similar provision is included: “Members of the board and other per- sons making examinations shall not be held liable for their opinions and recommendations.” The question ofimmunity for physicians and others who are authorized or required to report medically impaired individuals is discussed later. Many licensing administrators believe that immunity for MAB members can be as- sumed even when a state law does not specifically provide for 1t, on the basis that the board 10 only evaluates an individual’s ability to meet certain physical and mental criteria and does not, in fact, grant, restrict, or deny licensure-by law, that is the motor vehicle administra- tor’s responsibility. Even when a board is asked for a recommendation, its role is strictly advisory and its recommendation is not binding on the licensing agency. Anonymity and Confidentiality Numerous licensing personnel and physicians who were queried felt very strongly that MAB members should remain anonymous so that they are not harrassed or unduly plagued by individuals whom they have evaluated; yet not a single State statute made available for this study provides for anonymity. This is handled in a number of States as a matter of ad- ministrative policy. Of course, this anonymity is not valid when a board member is required to appear in court and testify concerning his/her observations and findings regarding an in- dividual referred for evaluation. One State (Delaware) provides by statute that board members not be required to testify in person: “To maintain confidential the identities of the members of the Board and its vision consultants, they shall not be required to appear in court. If the qualifications of the members or consultants to make recommendations are challenged in court, the Secretary (of Department of Public Safety) shall give the court brief professional biographies outlining the training and experience of each member and of each vision consultant.” Assuring confidentiality of information concerning reports received or made by medi- cal advisory boards is an important issue, but it does not seem to present a major problem for licensing agencies even when this is not specifically addressed in the statute. When it is contained in the law, in every case the law clearly states that information received in con- nection with evaluating individuals for licensure is for the confidential use of the board and/ or department and cannot be divulged or used as evidence in any court transactions except as provided by other sections of the law, in transactions directly related to suspension, re- striction, or denial of a driver’s license. Three Boards in Detail Of the 27 States with legislatively mandated boards, 3 (Maryland, Oklahoma, and Texas) are unique and warrant special discussion. Maryland. Maryland was the first State (1947) to establish a medical advisory board to assist the motor vehicle administration in evaluating medically impaired individuals for licensure. Since its creation, the board has expanded not only in size and operation but in overall scope of activities. The board at present consists of 45 members, recommended by .the State medical association and appointed by the motor vehicle administrator; member- ship includes optometrists. Board members serve for 1 year and are subject to reappoint- ment. The Maryland Board personally interviews all drivers who are referred to it for medical reasons by the licensing agency. To implement this ambitious practice, the board is com- posed of smaller regional groups, all of which function the same and none of which has jurisdiction over the others. This not only makes the system possible from a practical view- point but also precludes the necessity for applicants to travel great distances to be evaluated. 11 Each regional branch has representation of the major medical specialties and follows the same operating procedure in evaluating driver license applicants. Meetings are held twice weekly at the motor vehicle administration office in Glen Burnie, and monthly or semi- monthly in the other locations around the State. Members alternate attendance at the meet- ings, with one of each specialty: a) neurologist, neurosurgeon, or epileptologist; b) psychia- trist; c) internist, cardiologist, or endocrinologist; d) orthopedic surgeon or physiatrist. Each member is compensated for attendance at meetings and for any court appearances that may occur as the result of an appeal. When the licensing agency has reason to believe a condition exists that might impair an applicant’s driving ability, the applicant is required to submit certain medical information as well as an authorization for release of records and information from physicians or hospitals that had treated applicant for his medical condition. When all appropriate information is received, it is summarized and sent to the MAB, along with the applicant’s case history, be- fore the applicant’s personal appearance before the board. The MAB has the authority not only to interview the applicant but also to conduct certain tests, such as that for reaction time, to enable it to evaluate more effectively an in- dividual’s functional capability. In addition, the board has access to the driver’s crash and violation records. A primary objective of the board is to urge medically impaired individuals to seek proper medical help to get their conditions under control. Individuals are therefore seen at various intervals to reevaluate their conditions, and licensure can be recommended at a sub- sequent time when the medical condition has improved. The Maryland MAB has established specific guidelines to aid physicians in advising patients with certain potentially dangerous driver limitations. These guidelines have been distributed to all Maryland physicians to orient them concerning these medical problems. In addition, the board has developed medical report forms to facilitiate the work of the physi- cians who are asked to evaluate medically impaired drivers. The greatest drawback to the Maryland program is that it does not require in-person renewal, and consequently, the licensing agency must rely primarily on self-reporting by im- paired drivers on their license application, information from family or friends, courts, law enforcement agencies, hospitals, and voluntary reporting by physicians. If studies such as those by Waller and West hold true in Maryland, large numbers of impaired drivers un- doubtedly go unidentified, even though a significant number are referred (13,461 during 1975) and do get into the system where they can be controlled. Oklahoma. The Oklahoma Medical Advisory Committee, as it is named, was estab— lished by law in 1967 through the cOOperative efforts of the Oklahoma Medical Associa- tion, Oklahoma Department of Health, and the Oklahoma Department of Public Safety. The MAB consists of seven members, who serve anonymously, with at least one representative from the following medical specialties: internal medicine, vision, ortho- pedics, neurology, and psychiatry. Four members are appointed by the State commissioner of public health and the remaining three members, by the commissioner of public safety. The MAB meets quarterly and receives no compensation for its services. The organization of the Oklahoma MAB is unique in that it has a physician executive secretary who is the commissioner of public health. The MAB secretary meets weekly with 12 members of the driver improvement bureau to review individual problem cases and thus has to refer only a limited number to individual board members and an even smaller number to the MAB as a whole. Because of this system, the MAB has had time to fulfill its essential function of establishing medical policy and developing guidelines by which the licensing agency, with the guidance of the board’s executive secretary, can make its determinations without having to use the valuable time of the board members to serve unnecessarily as arbitrators in individual situations. The board is also available for appeal cases and, in addi- tion, has served to establish better liaison with the medical profession generally. In its deliberations the board has paid special attention to high-risk groups, such as the problem drinker and the habitual offender, and it has formulated broad definitions and guidelines to aid the licensing agency in more effective handling of these cases. In addition, the board studied what effects, if any, referral to the MAB had on medically impaired drivers, and in 1973 it published research comparing an individual’s driving record before and after MAB. Texas. The Texas Medical Advisory Board has been operational since 1970 and is ad- ministered jointly by the department of public safety and the department of health. At present the board consists of 84 members, 3 of whom are optometrists. The board meets weekly in Austin and San Antonio, and the members are scheduled on a rotating basis, so that at least three attend each meeting and none is overburdened with numerous meetings. The Texas MAB reviews about 15,000 applicants each year. In light of this large number of medical referrals, the MAB has promulgated and published a comprehensive “Texas Physician’s Guide for Determining Driver Limitation.” These guidelines specifically list a number of medical problems related to driving safety, and they stress functional capac- ity of the driver. The guidelines were developed, in part, to meet the need for improvement of standards used in evaluating different classes of drivers-7*passenger-carrying driver, commercial driver, and private vehicle driver, and to orient physicians about what to look for when evaluating patients for driver impairment. The board is also involved in a study similar to the Oklahoma one; comparing driver records before and after the MAB evaluation should yield some important statistics. ADMINISTRATIVELY ESTABLISHED BOARDS The 13 MAB’s established by administrative fiat are free to function arbitrarily because they are not governed by specific legislative guidelines. The two exceptions are the Missouri MAB, which was appointed in 1974, and the North Dakota board appointed in 1966, both of which unfortunately are not operational. The primary function of 5 of the 13 MAB’s has been to serve in the advisory role of evaluating individual problem cases. Licensing personnel in these States, however, felt that although these boards may not be as active as some others, their functions were extremely valuable in providing the licensing agency with medical input in areas in which lay driver examiners were not qualified to make valid decisions. The remaining six administrative MAB’s all function rather effectively, and because they are different, each is discussed briefly. They do share a commonality, however, in that all have broadened their activities beyond those of arbitration, such as developing medical l3 report forms and promulgating basic guidelines regarding specific medical impairments to enable licensing agencies to make determinations without having to send all cases to the MAB for review. In addition, in all but one State, the MAB has an effective relation with the State medical association, which has been helpful in getting recognition of the impor- tance of medical advisory operations in driver licensure. In four of the six States (Iowa, Nebraska, North Carolina, and Wisconsin), a committee of the State medical association serves as the MAB. In all States except Nebraska where automotive safety comes under the purview of emergency medical services, these are auto- motive safety committees. Nebraska MAB, however, maintains good rapport with the emergency medical services committee by having its chairman attend MAB meetings; ex officio members of the Nebraska Safety Council and Nebraska Highway Patrol also attend. Of significance also is the board’s involvement in attempting to get legislation enacted con- cerning release of medical information on impaired drivers. In addition, the Nebraska Board is in the process of reevaluating some of its guidelines, especially those regarding persons with epilepsy. For all intents and purposes, the Iowa Medical Society Sub—Committee on Safe Trans- portation has redefined its functions to serve as the MAB at the request of the motor vehicle administrator, and its emphasis on other activities in automotive medicine has been de- creased. The lowa Board, operating since 1966, has been active in developing general guidelines to aid the licensing agency in screening out those drivers with obvious medical impairment. When a driver or applicant is not satisfied with the licensing agency’s decision, the case is re- ferred to the MAB, along with any appropriate medical reports. To insure complete anonym- ity of individual board members, the Iowa Medical Society serves as a clearinghouse for review of all cases and returns the board’s recommendations to the department of public safety. Individual applicants may appeal the licensing agency’s action after MAB review, but this has been rare. The Iowa Board conducts most of its work through correspondence but does meet occasionally with the licensing personnel, sometimes in conjunction with other State medical association committees or State agencies that have overlapping interests. Other than North Carolina and Wisconsin, whose programs are presented below in detail, the two remaining States, Michigan and New York, and the District of Columbia are administrative MAB’s that are not official parts of the State medical association, but in all three cases they function effectively. The District of Columbia’s medical advisory program has been operating for more than 20 years. It is unique in that in addition to a functioning MAB, it has a full time medical officer who is authorized to interview all impaired individuals referred by the licensing agency and to conduct physical examinations when advisable or necessary. On the basis of the individual’s own physician’s report and the observations and examination of the medical officer, a large number of individual cases are screened out in light of existing medical policy without having to be reviewed by the entire board. Through a federal grant several years ago, the licensing agency conducted statistical research on driving records before and after MAB review, which should be of interest to all concerned with automotive crash causation. The Michigan MAB program, formally called “Medical Evaluation and Advisory Group,” was initiated by the licensing agency in 1970, and membership was solicited from medical specialty organizations within the State. The board is composed of three subcom- mittees representing all the major medical specialties involved in driver limitation, and each 14 subcommittee acts independently within its own particular area of expertise. The MAB has been instrumental in developing guidelines and report forms for vision, metabolic disorders, and cardiovascular diseases. In addition, the licensing agency has available to it consultation and support from various State health agencies and university health facilities. The New York medical advisory program functions on two levels. In 1968 a com- mittee was established within the health department to address the overall problems of licensing impaired drivers. This highway safety medical committee is composed of a number of subcommittees representing specific medical specialties. Individual problem cases are screened initially by licensing staff versed in medical limitations, and if the case cannot be resolved, it is referred through the health department to individual physicians, usually sub- committee members or other specialty State agencies, such as the department of mental hygiene, for medical evaluation. The highway safety medical committee acts not only in developing guidelines for the licensing agency but also in proposing and supporting needed legislation in this area. The New York program benefits also from input and support of the medical society’s committee on accident and injury prevention, especially through overlap- ping membership. Two Boards in Detail The MAB programs in North Carolina and Wisconsin have been quite successful with- out the benefit of legislation. In fact, serving in the dual capacity of State medical associa- tion automotive safety committee and of medical advisory board has given medical advisory activities access to new avenues of approach and personnel with varied but related interests. In both States the committees are extremely active in continuous surveillance of legislation and administrative practices that have implications for automotive safety. These activities include issues such as licensing telescopic lens wearers, immunity for physicians who report seriously impaired drivers, and alcohol testing of automotive crash victims, all areas in which an MAB has a valid interest but, functioning independently, may not always have the necessary administrative backup to become involved. North Carolina. In 1964 the North Carolina Medical Society, working with the North Carolina Division of Motor Vehicles, established a program to evaluate medically impaired drivers. The medical society’s traffic safety committee was assigned, in addition to its other activities, to serve as the medical advisory committee to the licensing agency. In that capac- ity it developed general guidelines and administrative policies concerning the licensure of impaired drivers and, in addition, recruited physicians to serve on medical consultant panels to review individual cases in specific medical specialties. In 1968 another dimension was added when the licensing agency asked the State board of health to assume administration of the program. It continued basically as previously established except that a physician was appointed as medical adviser to serve as overall coordinator between the various agencies involved. An individual identified as having a medical impairment is required to submit a report from a personal physician, which is screened first by the licensing agency and then by the medical adviser. If a decision cannot be reached, the case is submitted to the medical panel for that particular disorder. On the basis of the recommendations of the panel members, the medical adviser reports the findings to the licensing agency for its decision. In addition to its MAB, North Carolina has a very elaborate review mechanism when an individual appeals the decision of the licensing agency (see “Medical Review Boards”). 15 Excellent liaison has been established among the licensing agency, medical association, and health department as well as with other agencies and individuals directly or indirectly involved in licensure. This has played an important role in the success of the North Carolina program. Wisconsin. The State medical society’s committee on safe transportation serves at the request of the division of motor vehicles as the medical advisory board for all matters re- lated to medically impaired applicants and drivers except epilepsy, which is handled by a separate medical review board. This board for applicants with epilepsy should not be equated with a review board such as the one used in North Carolina, since this Wisconsin Board is similar to its MAB except that it handles a single condition and was established by legislation. It varies from the Wisconsin MAB in that it is authorized to interview applicants in person. It consists of 14 physicians who are specialists in epilepsy; they serve on a rotat- ing basis. The medical review board has facilitiated a better understanding not only with epileptic drivers but also between individual examing physicians and the licensing agency. The MAB has served since 1969 and has been very active in developing medical report forms based on functional capability and in providing screening guidelines for the licensing agency. In addition, the MAB has used the State medical journal as an educational medium for orienting the State’s medical profession concerning problems such as the potentiating effects of prescription and over-the—counter drugs on driving. The licensing agency for the past several years has retained a physician on a part-time basis to evaluate problem cases in light of policies established by the MAB and to send to the board only those relatively few cases that cannot be easily resolved or that present new problems on which no current policy exists. This method has been very effective and has freed the MAB to concern itself with overall problems and issues and to provide a frame- work for the licensing agency. In addition, a number of driver improvement officers have been actively engaged in evaluating the crash and violation records of medically impaired drivers who have been re- viewed by the MAB. It is hoped that some important information will soon be available. 16 INTRODUCTION The presentation of a model medical advisory board and a model medical advisory board law is the result of careful evaluation of the material discussed factually in Part I. The commentary and recommendations presented are likewise based on that evaluation. Although any commentary on these matters as well as any recommendations cannot help being subjective and containing some bias of the sponsors, organizations, and individuals who provided information, and of the individual authors, it is hoped that any unintentional bias will be slanted only toward achieving the overall goal of licensing drivers whose physical and mental capacities allow them to drive safely and of withholding or restricting the licenses of those who present a risk to safety. A MODEL MEDICAL ADVISORY BOARD In attempting to present a board that can be used as an example or model for all States, it is clearly realized that no one plan, no matter how ideal, can possibly serve the variety of problems that different States have. These differences are perhaps most apparent between States with large populations and those with small, but even States with similar populations have different needs, different abilities, and different philosophies. However, it should be pointed out that some individuals in the licensing process, as perhaps in many other areas of our society, often tend to use “we are different” as an excuse for carrying out procedures that are possibly outmoded and inferior to those used elsewhere. As mentioned in the Preface, the 1967 manual “Medical Advisory Boards in Driver Licensing” presented programs as they existed in seven States. This method of presentation was excellent for what was then a comparatively new idea in most States, and interested States could simply select a program that seemed to fit their needs. Unfortunately, none of those plans was (or pretended to be) perfectvieven the best had some weak featuresiyet States tended to adopt one of the seven without change. Even worse, some States adopted one of the plans but then eliminated certain features without replacing them with anything else, which resulted in a board that could function only in a limited fashion. The plan here, therefore, is to present a model medical advisory board that is believed to incorporate good features of many existing boards. It has been simplified and reduced to basics-most such plans will tend soon enough to change and become more complicated to fit particular needs. Since it cannot possibly fit every need of every State, and certainly does not claim perfection, it should be adapted, not adopted. This model is literally a skeleton that can be used to develop a board that is appropriate for any individual State. To understand the model, one must first clearly understand why medical advisory boards are needed. And this need is by no means universally acceptedm—some medical people 17 231-660 0 - 77 - 4 do not fully realize the role of human impairment in the ability to operate a motor vehicle safely, and some licensing people do not realize that a medical advisory board can be of great help in the licensing process. Some of the former do not appreciate the preventive medicine aspects inherent in the driver licensing process, and some of the latter do not see the potential benefits of medical input. Rationale for Medical Advisory Boards The single most importantjustification for having an MAB is that it can help the licens- ing agency with the task of identifying individuals with potentially serious driver impair- ment. This does not mean that the board, itself, must necessarily do the identifying. In fact, if the board provides the licensing agency with proper criteria, screening aids, and good advice in general, the board will have to deal personally with a comparatively low number of individuals. This is not to denigrate the individual evaluation phase of the board’s activity, because it is an extremely crucial step in controlling impaired drivers and, in many cases, getting and keeping those drivers under proper medical care. Driver impairment is involved in a significant number of crashes, and if alcohol impair— ment is included, the number rises substantially. In terms of identification and control, licensing agencies do not have the necessary resources to handle all these cases. A great variety of medical problems are involved, and it is not economically feasible to have the necessary medical specialists on staff permanently. Obviously, an MAB could not handle all license applicants in even a small state, but with proper screening of applicants by the licens- ing agency, the board will not only be able to evaluate those applicants referred through the screening process, but will have the time to do some of the other activities discussed herein. From an educational viewpoint, MAB’s can serve a very useful purpose in orienting the medical profession concerning the role of driver impairment in crash causation. It can, for example, work through the State medical association in getting mailings out to the associa- tion’s members, and it can get information on its activities published in the State medical journal. The overall value of an effective medical advisory board program cannot be overesti- mated. These benefits are discussed throughout this description of a model board. The material that follows is in part a rationale for the model medical advisory board law. In addition, it offers numerous suggestions and ideas about how an effective identifi- cation and evaluation program can be carried out. Establishment The medical advisory board should be established by law. Although there are unde- niable advantages in being established administratively, the legal route seems to be best for the following reasons: a) a board is not so likely to become inactive when an active, moti- vated chairman retires or otherwise is no longer available; b) a board cannot become in- active so easily when there are personality conflicts, changes in administration, or any other situation that might be used as an excuse; c) immunity from suits for the physician who serves on the board and for the physicians who report driver limitation is usually easier to provide than for an administratively appointed board; d) it is easier to justify many of the board’s activities when it has legal status; and e) legal establishment can likewise have in it provisions for protecting the anonymity of its members and the confidentiality of the board’s deliberations. l8 Board Appointments The board should be established as an arm of the driver licensing agency, and appoint- ments should be made by the administrator of that agency (e.g., department of motor vehicles, department of state, or department of public safety). This does not, however, preclude cooperation and participation by the State medical association, State health department, and other appropriate agencies without whose support the program would not function. In fact, the administrator should solicit the advice of the department of health and should select members from a slate proposed by the State medical association. This insures that the physicians asked to serve are recognized by their own profession as being competent in a particular medical specialty and are in good standing with the medical com- munity. If an optometrist is selected, the advice of the State optometric association should be sought. Size Even in the smallest States, the board should consist of at least nine members. This makes it possible to have the primary medical specialists involved and helps to assure that a sufficient number are available at every meeting, thereby avoiding unnecessary delays in board decisions. Large States, which have a heavy workload, should have at least 25 for the same reasons; if there are regional boards in different parts of the State, it would be advis- able to have double or even triple that number. The Texas Board has 84 members who serve on a rotating basis, and Maryland has 45. An odd number of members is recommended to preclude a tie when voting on important issues concerning the board’s operation or on evaluation of individuals; although unanimous, or near unanimous, decisions are usually more often the case for most MAB’s. Composition The MAB should have at least one neurological, cardiovascular, and ophthalmological specialist. These three specialties are considered crucial, since most of the driver limitations that require board action fall into those areas. Beyond these three, the motivation of the physician is more important than the specialtywthe board can be filled out with other physicians, such as psychiatrists, internists, orthopedists, and family physicians. The only non-physician that should be considered is the optometrist. A number of States allow other than physicians to serve as bona fide board members. Although it may be helpful to have the advice and counsel of an attorney, for example, it should be obvious that only physicians are qualified by training and experience to make determinations concerning an individual’s physical or mental condition (with the exception that an optometrist is qualified to make determinations regarding visual functions that are measurable through testing). An ideal situation would be to have the State medical association committee on auto- motive safety, or at least several of its members, serve on the medical advisory board. This would give the board access to information and expertise in the entire field of automotive safety and would allow an active board to broaden its objectives. In addition, it would provide a direct channel to the medical profession; it would undoubtedly enhance the board’s stature if it would be officially recognized by the State medical association as a legitimate and necessary committee. Unfortunately, most State committees have been abandoned in recent years, although in one State (Ohio) a committee has recently been appointed. Also, the American Association for Automotive Medicine published a pamphlet on this subject that provides helpful hints on getting a committee appointed. l9 It might also be helpful to ask the department of health to recommend a public health physician versed in epidemiology. This would give the board some expertise should it wish to conduct research on individuals in the medical evaluation program. There are many in- trinsic benefits in seeking recommendations from both public and private State agencies, especially medical associations. Not only does it insure broad-based cooperation in, and liaison with, the MAB program but, most important, gives recognition to the preventive as- pects of automotive medicine, which in recent years have taken a back seat to emergency medical services or other considerations. Length of Service The term of appointment should be long enough for the member to become thorough- ly familiar with the functions and activities of the board and to be able to provide a worth- while amount of service at least 4 years. In addition, two renewals should be allowed in order to take advantage of a good member’s abilities and service. It would be well for the administrator to review the record of each member before reappointmentwthe member’s attendance at meetings, motivation, and so forth. Those who do not contribute should be replaced. It is advisable for board members to be appointed on a staggered basis so that the entire board will not be completely new each term. There are certain obvious advantages in having the same members reappointed, especially when they have developed an effective program; however, when those individuals, for one reason or another, sever their relations with the MAB, the entire program suffers or even collapses completely. It is a good idea, therefore, to keep alert and active by adding and orienting new members. In addition, this process should help to have a broader base of members of the medical profession who know and understand licensing problems, and it can provide a general rapport with the profession that not only will be helpful to the licensing agency directly but will aid in getting support for legislation if needed. Remuneration It is recommended that board members not be paid for their services other than out—of- pocket expenses, such as for traveling to and from board meetings, meals, and lodging if necessary, and perhaps a small honorarium. In fact, there is a strong feeling that paying board members might have a negative effect by attracting individuals who like to have their names appear on letterheads but who lack the motivation to do a good job. Proposed legis- lation to establish medical advisory boards in a number of States has been defeated in recent years primarily because the bills contained provisions for excessive funding. It seems to work best to “pay” motivated board members by having the licensing agency provide the board with an efficient staff, good meeting facilities, effective screening so that the board does not waste time with applicants who should have been handled routinely by the licensing agency, and perhaps an occasional sincere letter of appreciation. The latter need not be handwritten but should not look like the thousands of form letters the licensing agency handles continuously. Number of Meetings Even a board with a small number of referrals should meet at least four times a year. If the board is to serve the licensing agency efficiently, it cannot conduct all its business by correspondence or even with an occasional meeting (see “Functions and Responsibilities” below). 20 Although regular meetings should not be held simply because a meeting was scheduled, boards can and should, in addition to their advisory functions to the licensing agency, spend time in orienting the profession concerning the medical aspects of driver licensing and the role physicians can take. Furthermore, issues continually arise on which the MAB should take a stand; for example, physician reporting of driver impairment and licensing of wearers of telescopic lenses, both of which are discussed later. Also, the MAB can provide scientific background in controversial, or at least public, issues, such as the wearing of helmets by motorcyclists, the use of safety belts, and passive protection (air bags) for motorists. Functions and Responsibilities Much of the legislation that established present MAB’s does not outline their functions and responsibilities except in a general way. It is surprising that when functions are given, they often are related more to evaluating individual license applicants than to providing ad- vice and guidance as the title medical advisory board implies. Yet, this is one of the areas that, when neglected, can often result in having a board grow dormant. Thus, functions and responsibilities should definitely be included in the enabling legislation, which should not only allow the board to become involved in certain activities but should encourage those activities. There are certain advantages in generalized legislation, but the mandate can also give an excuse for one side or the other to use for not doing things. One of the most important functions of an MAB should be to serve in the capacity that its name impliesxadvisory to the motor vehicle administrator on all medical aspects of driver licensure. Although it is important that a licensing agency have some means for ob- taining expert medical opinion on specific cases that are questionable or on those for which no policy exists, an MAB should not devote all of its time to this function. This can and should be handled by trained examiners or driver improvement analysts who are able to interpret guidelines and policies as set down by the board. It is strongly urged that newly established boards, or ones that are being reconstituted, not devote a great deal of time debating medical criteria. There is no question that criteria are badly needed in fact, this is discussed in detail in another part of this manual- but no single board has the manpower, resources, or expertise to conduct the research to develop such criteria. Until basic, long-range research is undertaken, much valuable time will be wasted by board members who are not able to resolve these problems. Furthermore, it is not necessary for any one board to spend a great deal of time developing guidelines and procedures since, for the most part, this information is already available through other MAB’s or from the scientific literature. It is hoped that this manual, and the references it recommends, can be helpful in aiding an MAB along these lines. One very useful function that an MAB can perform is developing medical forms for physicians who evaluate individual applicants. These forms should be simple and concise; they should be returned to the MAB directly or to a physician who works with the licensing agency, rather than to a lay examiner or licensing administrator. Physicians generally are more likely to cooperate if they are able to report to another physician. The model forms that are included in this manual ask for only a minimum of informa- tion. Much more could be added, depending on the degree of specificity required by the MAB and the amount of administrative backup available to it. As indicated earlier, MAB’s are encouraged to become active in many more activities than individual applicant evaluations. One valuable service a board should be active in is the training of driver examiners to recognize signs and symptoms of driver impairment. This 21 will make it easier for the examiner to screen out those individuals who obviously should not drive or should be restricted, and it is one means of significantly reducing the number of cases referred to the MAB for evaluation. Training courses should be developed and con- ducted by MAB’s, using the medical orientation forms developed by the American Medical Association and the American Association of Motor Vehicle Administrators; these forms are available from the U.S. Department of Transportation. In fact, orientation courses should likewise be developed for driver improvement analysts and hearing officers. This would not only reduce the number of board referrals but would also educate other groups of individuals involved in the licensing process and help to raise the overall professionalism of the system. The medical advisory board has an extremely vital role to play in orienting the general physician population to the importance of medical impairment in crash causation. For ex- ample, the medical report forms that the individual’s personal physician is asked to com- plete, if effectively written, could serve as one tool for bringing to the physician’s attention the need to identify a medical problem, to remind the patient to adhere to the medical regimen (especially in not taking prescription and over-the-counter drugs), and to caution the patient regarding the use of alcohol. Another important activity for a board, especially if it is supported by the State medical association, is to have published regularly in the State medicaljournal information on the board’s operations, research studies that the board may conduct on impaired drivers, and other types of information that would be of general interest. Likewise, an MAB can spend some time in developing educational approaches and materials for the general public to make it more aware of the implications ofdriver impair- ment and to encourage impaired individuals to seek medical help. Where applicants are evaluated in person, as in Maryland, the board has an excellent opportunity to discuss with the individual the extent of the impairment and what can be done. Activities such as these in which an individual is made to feel that personal safety and welfare are important would go a long way in establishing public support ofMAB operations. Although it may not be feasible at present, every board should have as one of its goals research to evaluate its own effectiveness in identifying medically impaired drivers. This could be done by contrasting driver crash and violation records before and after MAB review. Studies of this type would be extremely valuable, especially if mileage exposure were known, since this is one of the most serious gaps in our knowledge of this area of licensing. It must be filled if medical advisory board effectiveness in reducing highway carnage is ever to be measured. MAB’s should require that all persons referred for medical evaluation be interviewed in person by the board. This would not only allow the board to get first—hand information about the individual but would give the board an opportunity to evaluate the degree of im- pairment from a functional viewpoint. In addition, it would afford an opportunity for the board to educate the individual about the particular disorder and to provide a better under- standing of the importance of evaluation. This rather ambitious recommendation obviously could not’be handled by a board if the licensing agency does not have a good screening program. Also, to do this, the board would have to have regional branches so that neither the board members nor the applicants appearing before the board would have to travel great distances. Legal Considerations Medical advisory board members should be granted legal immunity from all suits arising out of performance of their board duties, and the law should clearly stipulate this. 22 The majority of physicians would feel more comfortable knowing that they are protected legally from risk of court action even though immunity can usually be assumed because their decisions are strictly advisory. In addition, immunity written into the law would be more effective in obtaining physicians’ cooperation in the MAB programs. In the same vein, information provided to the board for the purpose of reviewing individ- ual cases should be for the confidential use of the licensing agency in making its determina- tion concerning licensure, and the providers of this information should likewise have the same legal protections. Obviously, the information is admissible in a court hearing if the licensing agency’s decision is appealed, but the law should clearly state that such informa- tion cannot be used for any other purpose. Summary It cannot be emphasized enough that a viable, effective medical advisory board is only as good as the individuals involved in the program. This is true even when the board is legislatively mandated. For this reason an MAB program demands support and cooperation from all concerned agencies and individuals but especially from State licensing departments and State medical associations. 23 MODEL MEDICAL ADVISORY BOARD LAW IN THE GENERAL ASSEMBLY STATE OF A Bill for an Act to Establish a Driver License Medical Advisory Board to the Motor Vehicle Commissioner; Function and Responsibilities of Board; Confidentiality of Reports, and Immunity from Legal Actions. Be It Enacted by the Legislature of the State of Section 1. For purposes of this Act: (a) The term “Commissioner”1 means the Motor Vehicle Commissioner of this State; (b) The term “Department”2 means the Department of Motor Vehicles; (c) The term “Board” means the Driver License Medical Advisory Board established under Section 2 of this Act. Section 2. (a) There is hereby created within the Motor Vehicle Commissioner’s Office a Driver License Medical Advisory Board for the purpose of advising the Commis- sioner concerning the medical aspects of driver licensure. The Board shall consist of at least nine members, appointed by the Commissioner, eight of whom shall be physicians licensed to practice medicine in this State and representing the medical specialties of neurology (or neurological surgery), in- ternal medicine, psychiatry, ophthalmology, cardiovascular medicine, orthopedics, and general medicine (or general Surgery); one member shall be an optometrist licensed to prac- tice optometry in this State and recommended by the State optometric association. The physician members of the Board shall be appointed from a slate of nominees submitted by the State medical association in consultation with other appropriate State health agencies and medical specialty organizations. The Board shall be appointed initially as follows: three members to serve two-year terms, three members to serve three-year terms, and three members to serve four-year terms: thereafter appointments shall be for four-year terms, and vacancies shall be filled by appointment for the unexpired portion of the term. The Commissioner shall designate the Chairman of the Board. Board members shall serve without compensation but shall be re- imbursed for necessary expenses incurred in performing their duties. Such payments Shall be made from funds appropriated to the Commissioner’s office. 1The term “Commissioner” used throughout this model bill should be replaced, as necessary, in any particular State, with the title of the appropriate State official having authority over driver’s licenses. 2The term “Department” used throughout this model bill should be replaced, as necessary, in any particular State. with the title of the appropriate State administrative agency having authority over driver’s licenses. 25 The Board shall meet at least four times a year and may hold such special meetings as are necessary to fulfill its responsibilities described under Section 2(b) ofthis Act. A majority of the Board shall constitute a quorum. Section 2. (b) The Board shall have the following responsibilities: (I) advise the Commissioner on medical criteria and vision standards relating to the safe operation of motor vehicles; (2) recommend to the Commissioner procedures and guidelines for licensing individuals with physical or mental impairment; (3) initiate the development of medically acceptable report forms; (4) direct research of medically impaired individuals; (5) recom- mend a training course for driver examiners in the medical aspects of licensure; (6) spear- head efforts to orient the general physician population as well as the public in the medical aspects of driver licensure; (7) assist in the development of regional medical advisory boards; and (8) evaluate individual problem cases that require more than one opinion or that cannot be screened out in light of guidelines established by the Board. The Board may formulate such advice from records and reports or may cause a physical examination and written report to be made by a physician or optometrist of the applicant’s choice, licensed to practice in this State, or by one or more members of the Board. The individual licensed driver or applicant may cause a written report to be forwarded to the Board by a physician or optometrist of his choice licensed to practice in this State, and such report shall be given due consideration by the Board. The Board shall exercise its option ofinterviewing in person any driver or applicant whose ability to Operate a motor vehicle safely cannot be ascertained through written reports or records. Section 3. Reports or records, received or made by the Board or any of its members, or by the Commissioner’s office, pursuant to this Act for the purpose of assisting the Commissioner in determining whether a person meets the physical or mental standards to be licensed as a driver are for the confidential use of the Board and the Commissioner’s office, and, except as may otherwise be specifically required by Federal statute, such reports or records shall not be divulged to any other person; Federal, State, or local government; or private entity, or used as evidence in any trial; provided that copies of such reports or re- cords shall be provided, upon demand, to the licensed driver or applicant to whom they relate or to his authorized representative, and, provided further, that such reports or records may be submitted in proceedings under [insert reference here to sections of the State statutes that set forth administrative procedure regarding notification to driver or applicant of sus- pension, restriction, revocation, or denial of application for license; right to an administrative hearing; procedure on hearing; and right ofjudicial appeal] , and any person conducting an examination or submitting a report or records pursuant to this Act may be compelled to testify relative to same in such proceedings. Section 4. The Commissioner shall give fair consideration to any opinion, reports, records, or recommendations of the Board or of private physicians or optometrists licensed to practice in this State and submitting same pursuant to this Act; however, all such opin- ions and reports shall be solely advisory and not binding on the Commissioner. Any person under review who refuses to admit to an examination or con- sent to provide information, or both, shall as a matter oflaw be considered unqualified to operate a motor vehicle until such time as the individual complies with the Board’s requests and the Board can make its findings and recommendations to the Commissioner. Section 5. No civil or criminal action may be brought against the Board, any ofits members, the Commissioner or Commissioner’s office or its employees, or any physician or optometrist licensed to practice in this State, for providing any reports, records, examina- tions, opinions, or recommendations pursuant to the Act. In addition, any other person 26 acting in good faith and without negligence or malicious intent in making a report to the Commissioner’s office pursuant to this Act shall have the immunity from civil liability that might otherwise be incurred or imposed. Section 6. Meetings of the Board in which reports received for the purpose of deter- mining the medical condition of an applicant are considered are closed sessions, since those reports are confidential under Section 3 of this Act. Section 7. A person whose driver’s license has been suspended, restricted, or revoked or whose application for a driver’s license has been denied shall have the right ofjudicial appeal of such action, as provided under [here insert reference to appropriate sections of State law relating to judicial appeal of administrative decisions] . No person shall be allowed to drive in violation of any suspension, restriction, revocation, or denial of application while any such appeal is pending. Section 8. All laws or parts of laws in conflict with this Act are hereby repealed. Section 9. If any provision of this Act is held by a court to be invalid, such is validity shall not affect the remaining provisions of this Act, and to this end the provisions of this Act are declared severable. Section lO.This Act shall become effective (date) 27 SIMPLIFIED SCHEMATIC FLOW CHART OF MODEL LICENSING PROCEDURE FOR HANDLING MEDICAL IMPAIRMENT (Read from Top to Bottom) Driver license applicant (New, renewal, special) A D l} Written quiz. interview by driver V examiner or driver analyst, a visual E * screening, and sometimes a be- R hind-the-wheel test. May request further medical information. I I License is denied, revoked, Applicant is licensed or restricted V Applicant may appeal i7 Medical advisory board May see applicant in person May request further information V Applicant is licensed v QZHMZmOHF n _ License is denied, revoked, or restricted I Applicant may appeal1 I The courts License is denied, revoked, or restricted ~ Applicant is licensed I Licensing agency may appeal V lLicensing agencies can make use of hearing officer system in the hope that an appeal to the court will be unnecessary. 28 MODEL FORMS The only forms in this manual are those that are designed to obtain information from physicians. Although obviously important in the licensing process, the literally hundreds of administrative forms, letters to the applicant, legal forms, and so forth usually are not of immediate concern to MAB’s and therefore are not a part of this manual. An exception is the crucially important initial letter to the physician. The sample forms illustrated are brief and deliberately contain only questions sufficient to elicit the basic information needed to make an evaluation. Some MAB’s may wish to devise forms that are more detailedicertain- ly, medical evaluation requires as much good information as possiblevbut at some point there must always be a compromise between forms that provide information in great detail and the cooperation of physicians, many of whom will not take the time to complete lengthy forms. Especially irritating to physicians are the duplication of information often required in multiple forms as well as the filling in of information on conditions not related to the primary reason for the examination. Therefore, as noted in the letter, the physicians are asked to complete only the form for the medical condition in question but, naturally, are asked to fill other forms if they find other conditions that present a potentially signifi- cant hazard in driving. It would be well to include on the forms a summary of State standards in MAB policies if these have been established, such as is shown on the back of the sample vision form. It is possible that showing the cut-off points the licensing agency uses in making its decision to license or not license might cause physicians (in the interest of protecting their patients) to be less than candid in their recommendations. However, if physicians are asked for medical evaluations of their patients who drive, they are entitled to know what standards exist and what is expected of an individual in order to meet the qualifications for licensure. Some States require an applicant to fill out a health history questionnaire. While this may elicit a great amount of information, it is not of much value unless a physician follows up on the leads it provides. Also, although it may be an advantage for the applicant’s physi- cian to have the health history done in advance, many physicians prefer to use their own form with which they are familiar. Undoubtedly, the initial questionnaire (usually 15 to 20 questions) that the applicant fills out when applying for a driver’s license should be expanded to have the applicant provide a health picture that is a bit more complete but still not involve a three or four-page form. The redesigning of this initial form would be an extremely worthwhile activity for MAB’s in most States. 29 DEPARTMENT OF MOTOR VEHICLES State of (date) Re: (applicant’s name) Dear Doctor: The above named individual is required to undergo a medical examination to determine whether the physical and mental standards to be licensed in this State are met. Your report will be reviewed by this agency before the applicant is licensed. It should be emphasized that State statutes make the Administrator of this agency responsible for the licensing ac- tion and that your medical report is strictly advisory. State statute also provides you with legal immunity against possible legal action resulting from your cooperation. In addition, please be assured that your report is for the confidential use of this agency solely for the purpose of determining eligibility for licensure. In order that we may be properly informed about medical conditions that might impair safe driving ability, will you kindly complete the attached medical form and return it in the enclosed self-addressed envelope. Although this particular form is of major concern in this case, if your examination reveals other conditions that in your professional opinion, might present a hazard to driving safety, please submit that information also. In addition, the Physician Recommendations form must be completed. The professional fee for this examination should be charged directly to the applicant. The form authorizing you to release the medical information is for your protection it should be signed by the applicant and kept in your files. If you do not provide the requested informa- tion, the applicant will be required to obtain it from another physician. The Department of Motor Vehicles is taking this action in the interest of the public’s safety as well as that of the individual applicant. We appreciate your assistance in this program. Respectfully yours, , M.D. Driver Licensing Consultant .(or Chairman, Medical Advisory Board) Attachments Medical Report Form Physician Recommendations Form Return Envelope AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I hereby authorize the release of my medical history to the Department of Motor Vehicles for the purpose of determining my eligibility for a driver’s license by (name of physician or hospital providing information) . (signature of applicant) (date) 30 DEPARTMENT OF MOTOR VEHICLES State of (date physician completes form) PHYSICIAN RECOMMENDATIONS FORM Please complete the entire form and return it with the completed medical report form in the enclosed self-addressed envelope. ON THE BASIS OF MY EXAMINATION, I RECOMMEND THAT THE APPLICANT: A. Be restricted to E] daylight driving. (explain reason) [:1 driving with corrective lenses or prosthesis. (specify) D driving a non-commercial vehicle. [:1 other. (specify) E] B. Be given a road test to demonstrate ability to drive safely. D C. Have further medical examination before being licensed. (specify) D. Have periodic medical examination and evaluation at least every E] 6 months I: 12 months E] 18 months 1:] 24 months C] Other (specify) How long have you treated this patient? Date of visit preceding this one: Reason OTHER COMMENTS: ********** Being duly licensed to practice in the State of ,I certify that I have examined this applicant on (date) (signature) Medical License No. Office Telephone No. 31 DEPARTMENT OF MOTOR VEHICLES State of MEDICAL REPORT FORM Vision without with present field of vision color vision lenses lenses (in degrees) (circle) RE 20/ 20/ yes no LE 20/ 20/ yes no BE 20/ 20/ yes no Corrective lenses will [:1 will not [:1 improve vision. Treatment will [:1 will not El improve vision. Other eye disorders or abnormalities: (describe) Is the condition progressive? Yes [3 No C] Prognosis or remarks: Is the applicant taking any medication? Yes C] No D If “yes, ” specify type and dosage. (signature of physician or optometrist) (address) (date) 32 SUMMARY OF VISION SCREENING STANDARDS FOR DRIVER LICENSING Vision with no progressive abnormalities or diseases of the eye: a. Better than 20/404full driving privileges b. Between 20/40 and 20/70—daylight driving only c. Worse than 20/70-—not eligible Vision with progressive abnormalities or diseases of the eye: a. Better than 20/404full driving privileges b. Between 20/40 and 20/604daylight driving only c. Worse than 20/60inot eligible Drivers with vision of 20/100 or worse in one eye and in the other as follows: a. Better than 20/407full driving privileges b. Between 20/40 and 20/50—rdaylight driving only c. Worse than 20/507not eligible Peripheral vision a. 1400 or more~full driving privileges b. Between 1 10” and 1400 isubject to review by medical advisory board e. Less than l 100 --not eligible (NOTE: This is a sample of criteria used by one State to determine visual ability to drive safely. It is shown here not as a model as far as the standards are concerned, but putting it on the back of the Medical Report Form is an idea that would help to orient physicians about what that State considers necessary for safe driving. It is far preferable to asking the physician whether or not the applicant should be licensed or merely asking what the appli- cant’s condition is without letting the physician know whether an applicant with that condition is likely to be licensed or not licensed.) 33 DEPARTMENT OF MOTOR VEHICLES State of MEDICAL REPORT FORM Cardiovascular Conditions Does the applicant have symptoms of heart disease while sitting at rest? 2. Is the applicant able to do normal housework or gainful employment? 3. Does the applicant have pain (angina) or obvious dyspnea when walk- ing about on a level surface? 4. Does the applicant have a history of fainting spells caused by rhythm disturbance? 5. Does the applicant have a history or evidence of peripheral claudica- tion on walking on a level surface? Does the applicant have a known aortic or ventricular aneurysm? 7. Does the applicant have diastolic hypertension usually over 1 10? (If “yes,” give details about symptoms and treatment) 8. Does the applicant have any of the following: syncope, vertigo, infarction? (give details) 9. Does the applicant take medication regularly for a cardiovascular condition? (explain) 10. Does the applicant have a pacemaker? 1 1. Has the applicant had heart or blood vessel surgery? When? COMMENTS: (signature of physician) (address) (date) 34 El DDDDDDD§ DC! [I DDDDDDDg DE] DEPARTMENT OF MOTOR VEHICLES State of MEDICAL REPORT FORM Neurological Conditions YES 1. Does the applicant have a history of seizures, convulsions, blackouts, dizzy spells, or loss of consciousness? (describe) [:1 2. Does the applicant have a history of aura preceding seizure? I] (describe) 3. Is the applicant on medication? (specify type and dosage) [:1 4. Is the applicant reliable in taking medication and following medical regimen? Has the applicant been seizure free for at least one year? 6. Has the applicant evidence of any limiting or progressive neurological deficit (e.g., multiple sclerosis, parkinsonism, muscular dystrophy, muscular atrophy)? (describe) If “yes,” is the applicant under regular medical care? DUE] PROGNOSIS/COMMENTS: (signature of physician) (address) (date) 35 NO EIIZIEI DEPARTMENT OF MOTOR VEHICLES Department of MEDICAL REPORT FORM Metabolic Conditions 1. Is the applicant being treated for diabetes? If “yes,” specify: E] Insulin dosage and type 1:] Oral medication dosage and type 2. How long has the diabetes been under control? 3. Is there a history of adverse reactions (e.g., shock, coma)? (describe) 4. If the applicant has adverse reactions, is there a history of aura preceding the episode? Does the applicant have associated visual disorders? 6. In your professional opinion, is the applicant reliable in adhering to his medical regimen? 7. Does the applicant have any other metabolic disorders that might impair his driving ability? (explain) COMMENTS: YES DUDE! NO [:1 USED (signature of physician) (address) (date) 36 DEPARTMENT OF MOTOR VEHICLES State of MEDICAL REPORT FORM Mental and Emotional Conditions Has the applicant in the past three years demonstrated homicidal, suicidal, or assaultive behavior? (describe) Does the applicant exhibit tension, tremulousness, anxiety, depression, hostility, bizarre behavior, paranoia, serious impairment ofjudgment, confusion, hallucinations, or delusions? (describe) Has the applicant been hospitalized in the last three years for any mental or emotional condition? (explain) Hospital Address City Date (s) of admission Date (3) of discharge Reason for admission Has the applicant ever been treated (other than in a hospital) for emotional or mental illness? (give details, including diagnosis) Does the applicant now show evidence of any emotional instability or mental illness? (describe) Does the applicant manifest side effects from prescribed medication that might affect driving ability? (give details) 37 YES NO 7. Does the applicant demonstrate any mental retardation? (give details) 8. Does the applicant have sufficient regard for his/her personal safety as well as that of other drivers and pedestrians to drive safely? (give details) 9. Is the applicant likely to act on sudden impulse without regard for the consequences of the behavior? (describe) 10. On the basis of your examination and/or knowledge of this applicant, do you recommend periodic psychiatric examination? If “yes,” at what intervals? COMMENTS: (signature of physician) (address) (date) 38 YES NO COMMENTS: DEPARTMENT OF MOTOR VEHICLES State of MEDICAL REPORT FORM Musculoskeletal Conditions Has the applicant an amputation or skeletal deficit that can interfere with safe driving ability? (give details) Does the applicant use a prosthetic device? (explain) How long has the applicant been using the prosthesis? Does this device provide adequate compensation for driving safety? Has the applicant any paralysis,joint stiffness, reduced physical dexterity, or limitation of motion sufficient to interfere with driving safety? (give details) Is the condition stable? Does the applicant have muscular coordination sufficient to drive safely? (signature of physician) (address) (date) 39 YES CID CID NO DD CID DEPARTMENT OF MOTOR VEHICLES State of MEDICAL REPORT FORM Alcohol or Other Drug Dependence YES 1. Is there evidence or personal knowledge of addiction, habituation, D or abuse of alcohol or other drugs? (give details) 2. Has the applicant ever been treated for alcoholism or drug [:1 dependency? (give details including when and where) 3. To your knowledge, has the applicant discontinued the use of alcohol or other drugs? 4. Is the applicant on any non-drug therapy (c.g., AA, psychiatric)? 5. Is the applicant on any medication or maintenance therapy (e.g., antabuse, methadone)? 6. At this point in therapy, is the applicant sufficiently responsible and dependable to drive safely? Comment on anything in the applicant’s emotional adjustment that might be a driving hazard. DUDE 7. What is the applicant’s general physical condition? (signature of physician) (address) (date) 40 NO DUDE] INTRODUCTION There are a number of factors related to medical advisory board activities that often have a significant role in the success or failure of boards. These factors have not been dis- cussed under the “Model” section because most boards and many licensing people do not ordinarily see them as part of the board’s role. As they are discussed and emphasized individ- ually here, however, it is believed that their importance will be recognized. THE NEED FOR CRITERIA The establishment of medical criteria to be used in determining who should or should not be licensed to drive is ordinarily beyond the capabilities of a medical advisory board. Such a task requires painstaking, scientific research that obviously is difficult, or impossible, for a volunteer board. Because most medical conditions do not readily lend themselves to precise, predictable cutoff points that indicate who can drive safely, research in this area is especially difficult. The truth of this can be seen in the fact that very few real criteria have been scientifically established since people started driving motor vehiclesjust over three- quarters of a century ago. Even in the area of vision, perhaps the area seemingly most amenable to being meas- ured, the criteria used are more or less arbitrary agreements that have been handed down through the years. In fact, there is considerable disagreement among the States concerning the visual acuity standards, ranging as they do all the way from 20/40 to 20/100. Even when allowing for State prerogatives, if the criteria were really scientifically established, there should not be that much difference. Or consider cardiovascular criteria that set a specific blood pressure reading as being the cutoff limit for licensure. Here, again, there is little scientific evidence to prove that drivers start having significantly more motor vehicle crashes at the point selected unless that point is set so high or so low that it will affect only a very small number of applicants. Some States have completely arbitrary, albeit seemingly logical, criteria concerning epilepsy. These criteria usually consist, in part, of the length of time since the last seizure, ranging from 3 months to 2 years or more. Those upper levels are getting lower through the years (the American Medical Association’s “Physician’s Guide for Determining Driver Limitation,” for instance, has changed its standard from 2 years to 1 year within a decade), but as far as scientific evidence is concerned, there is little more reason for lowering the standard than for raising it. With diabetes, in some States, the criterion consists of whether or not the patient is “on insulin.” One might question if the absence of lapses of consciousness or state of shock 41 would not provide a better criterion, whether on insulin or not. The insulin rule, however, may be an excellent guideline, and this is the area in which an MAB can best use its ex- pertise. Although the distinction between guidelines and criteria may seem to some to be semantic, for purposes of this manual, aguideline has been established on the basis ofex— perience, common sense, interpolation from allied information, and perhaps even on some statistical evidence. Criteria,_ however, must come from scientific study which indicates that driving can definitely be shown to be more hazardous beyond such and such a cutoff point. For instance, 20/40 may indeed be such a cutoff point, but for it to be a legitimate criterion, research has to show that it is significantly safer than driving with 20/50. The same must be done to prove that drivers with a peripheral field ofless than 140°, for example, are really significantly more hazardous than those who are not able to meet that level. To give another example, it may be perfectly logical, and probably scientifically sound, to require a driver of a commercial vehicle to have two arms and two legs, but such a requirement ignores compensatory action on the part of the driver or the use of prostheses. Thus, licensure must be based on scientific criteria but must also take into consideration functional ability to overcome certain handicaps. For some areas of medicine, criteria will be extremely difficult, or impossible, to establish at our present state of knowledge and experience. Mental and emotional diseases are a prime example, for which it may be necessary for a long time to be satisfied with the judgmental efforts of physicians. Ajudgment is not the most desirable thing to use as criteria, but it is the best available at this time for many mental and emotional conditions. In other medical areas, however, much can be done. In the cardiovascular area, for instance, it will be difficult, but a great deal has been learned from the work evaluation clinics about the role of work stress and heart disease. Undoubtedly, similar techniques can be used to determine what the stresses of driving do to an individual who has already suffered from a certain amount of cardiovascular trauma. From such research, criteria can be established. It is possible for criteria to come from statistical evaluation of motor vehicle crashes, but this type of research ordinarily gives evidence, for example, only that persons with a particular condition are over-represented in a sample of particular kinds of crashes. Al- though this is valuable information, it does not establish that all individuals or indeed any individual license applicant will crash. However, when the statistical evidence is strong enough, the licensing department is certainly justified in using it as a criterion. At any rate, it behooves all persons interested in the licensing process to put time and effort into encouraging research on the part of both public and private sectors for the purpose of establishing scientifically defensible criteria for licensing. This will not only improve the licensing process but will be needed in the near future even to continue the licensing process. It seems quite certain that it will become more and more necessary for the licensing agency to prove that its standards are necessary to insure that individual can drive safely. As mentioned earlier, many standards now in use seem, and very likely are, logical and needed to keep our highways and streets safe, but they will have to be proven! This would be difficult, or impossible, with many of the criteria now being used. Thus, the need for scientifically defensible criteria is not only desirable, but it may soon be critical. 42 PHYSICIAN REPORTING OF DRIVER IMPAIRMENT Another of the associated factors that affect how a medical advisory board operates is the controversial issue of whether physicians should report their patients who have a medi- cal impairment that is likely to present a serious hazard on the highway. In 1975 and early 1976 the American Medical Association and the American Associa- tion of Motor Vehicle Administrators conducted a series of four regional conferences on this subject. Although there was no complete agreement on whether physician reporting of driver limitation should be voluntary or compulsory, there was consensus that the medical profession has a vital role in the identification of medically inpaired drivers. It was generally felt that to be really successful the reporting program had to be compulsory. One of the biggest deterrents to reporting is the fear of being sued by a patient for giving out confiden- tial information; compulsory reporting laws, in fact or by implication, largely negate this fear. In addition, compulsory reporting laws usually help preserve the confidentialitv of medical records and guarantee that the information reported be used exclusively for the purpose of determining fitness to operate a motor vehicle safely. The most compelling reason for physician reporting of driver impairment is that many impaired drivers remain undetected unless brought to the attention of the licensing agency by a physician. A serious drawback is that there is a lack ofdefinitive information showing the relation of medical impairment to crash causation, and even less is known concerning the cutoff point at which a specific impairment is likely to become a hazard to safe driving. Without these criteria, physicians are reluctant to suggest that someone may be a hazard on the highway. Whether one agrees or disagrees with the concept of physician reporting, licensing agencies certainly need this kind of cooperation from the medical profession. Even when driver examiners are trained to recognize signs and symptoms of medical conditions that might affect safe driving, they are not physicians or diagnosticians and, in most cases, cannot make a valid judgment concerning degree of impairment. More important, some States do not have in-person renewal for driver licensure, and the examiner, no matter how well trained, has no contact whatsoever with drivers after the initial licensure process. In these cases especially, it is extremely important that medically impaired drivers be brought to the attention of the licensing agency as soon as possible and be brought under medical care and supervision for the protection and safety of themselves as well as others on the high- way. It is interesting that the conference on physician reporting brought out that increas- ingly physicians are becoming liable for not reporting serious impairment to the licensing agency. In at least two cases in which the physician was required by law to report epileptic drivers to the licensing agency and failed to do so, the physician was successfully sued after the epileptic driver was involved in an automobile crash. Whether a State enacts a law requiring physicians to report driver impairment or only grants immunity to physicians for doing so voluntarily, it should be emphasized that no legislative program will be successful unless it is accompanied by a broad-based educational campaign aimed not only at the physician who is responsible for reporting but also at the driving public who must understand the physician’s responsibilities in response to such legislation. Such an educational campaign would be an extremely valid and worthwhile endeavor for a medical advisory board to initiate and encourage. A number of physicians have expressed the opinion that other sectors of society, such as schools, welfare agencies, courts, and police, should also report impaired drivers. Many of these groups do indeed have the opportunity to see and report such drivers, but most of the registrants at the aforementioned physician reporting conferences felt that the dangers of such reporting of medical conditions by non-medical persons outweighed the good that might result. All agreed, however, that the police should report persons who were in a vehicle crash in which the driver seemed to have a lapse of consciousness, cardiovascular “accident,” or other condition that made him/her lose control of the vehicle. Because this issue is so controversial and because it has such an important bearing on the operations of the medical advisory board, a model physician reporting law, which States can adapt to their own particular needs and requirements, follows. 44 MODEL REPORTING LAW IN THE GENERAL ASSEMBLY STATE OF A Bill for an Act to Authorize Physicians and Optometrists to Report Driver Impair- ment to the Motor Vehicle Commissioner; Confidentiality of Reports; and Immunity from Legal Actions. Be It Enacted by the Legislature of the State of Section 1. For purposes of this Act: 1 (a) The term “Commissioner” means the Motor Vehicle Commissioner of this State; (b) The term “Department”2 means the Department of Motor Vehicles; (c) The term “Board” means the Driver License Medical Advisory Board. Section 2. Any physician or optometrist licensed to practice in this State and having knowledge of any applicant’s or licensed driver’s mental or physical impairment is autho- rized to report such knowledge to the Commissioner’s Office or to the Board. The report shall be in writing giving the name, date of birth, and address of any person over 15 years of age having mental or physical impairment that could affect such person’s driving ability. Section 3. (a) The reports authorized by this Section shall be confidential and used solely for the purpose of determining the qualifications of any person to operate a motor vehicle on the highways. (b) No civil or criminal action may be brought against any physician or optometrist who is requested to evaluate an applicant or driver for potential driver limita- tion when referred to that physician or optometrist by the Board or the Department. (c) This immunity from legal action is extended to any physician or optometrist who provides the information authorized herein. ((1) In addition, any person acting in good faith and without negligence or malicious intent in making a report to the Commissioner’s Office pursuant to this Act shall have the immunity from civil liability that might otherwise be incurred or imposed. Section 4. Any report made pursuant to this Act shall only be admitted in evidence in action regarding the revocation, suspension, cancellation, or denial of a driver’s license 1The term “Commissioner” used throughout this model bill should be replaced, as necessary, in any particular State with the title of the appropriate State official having authority over driver’s licenses. 2The term “Department”used throughout this model bill should be replaced, as necessary, in any particular State with the title of the appropriate State administrative office having authority over driver’s licenses. 45 and shall not be considered a public record provided that the report shall not be excluded on the grounds that the matter is or may be the subject of a physician~patient privilege or similar privilege of rule against disclosure. Section 5. The State Department of Health and the State Medical Association acting jointly shall furnish physicians and optometrists authorized to report pursuant to this Act educational information describing disorders and diseases that may affect a person’s ability to operate a motor vehicle safely. Section 6. All laws or parts of laws in conflict with this Act are hereby repealed. Section 7. If any provision of this Act is held by a court to be invalid, such invalidity shall not affect the remaining provisions of this Act, and to this end the provisions of this Act are declared severable. Section 8. This Act shall become effective (date) CHRONIC VIOLATOR The Oklahoma Medical Advisory Board is the only board known to define within its guidelines the category of chronic violator as a medical problem. Individuals are placed in this category when they have had three or more license suspensions and fail to respond to warning letters or to the usual methods of help offered by the department of public safety, such as personal interviews and driver improvement school. When a driver is placed in this category, the individual must provide to the medical advisory board the results of extensive psychological and psychiatric testing, including examinations to determine whether the driver is emotionally capable of handling a motor vehicle safely. The medical advisory board evaluates drivers in the chronic violator category as it does drivers with any other medical impairment. The inclusion of the chronic violator category under medically impaired drivers is an excellent and innovative idea, and it is recommended to all States. Although its inclusion might increase the number of persons referred to the MAB, it identifies a potentially high— risk group of drivers who obviously have little or no regard for their own safety or the safety of others. DWI SCHOOLS 3 Although MAB’s do not have authority to send applicants to a DWI school, they certainly can recommend this as one of the actions on the part of the applicant that the board feels might improve the applicant’s condition. The applicant whose condition had to be reevaluated by the board 6 months or 1 year later might well take such a recommenda- tion seriously. The same sort of results might apply to a recommendation to join Alcoholics Anonymous or some other rehabilitative agency. Of course, if the individual is an advanced alcoholic, any such recommendation would have to include complete medical evaluation and treatment. 3Various abbreviations are used to indicate schools or rehabilitation courses to which persons who have been arrested for driving illegally while intoxicated are sent (usually by the courts): DWI Driving While Intoxicated, DUILiDriving Under the Influence of Liquor, and the like. 46 MEDICAL REVIEW BOARD The medical review board is an appeal mechanism for an applicant whose license has been denied for medical reasons. This should not be confused with a strictly advisory board that is merely titled “review” in some States. As far as is known, the medical review board exists only in North Carolina and in Ohio, although the latter covers only neurological dis- orders involving loss of consciousness or muscular control. In a number of States a hearing officer acts in somewhat the same capacity, although such officials do not have the final authority to rule on licensing cases, as do the North Carolina and Ohio review boards whose decisions are legally binding on the motor vehicle commissioner. According to North Carolina law, the review board shall consist of the commissioner or his authorized representative and four persons designated by the commission for health services who shall be either members of the commission or physicians duly licensed to prac- tice in that state. The review board may require in-person appearance of the license appli- cant and of witnesses, by subpoena if necessary. The board shall pass upon admissibility of evidence and shall not be bound by common law or statutory rules of evidence that prevail in courts of law; its actions are subject only to judicial review. An applicant or licensee who has been denied a license pursuant to a hearing before the board may not file a new application until the expiration of 2 years after the date of such denial by the board. In Ohio, if an individual who is subject to episodic impairment of consciousness is denied a license after certification by a physician to be seizure—free for a least 1 year, he/she is entitled to a hearing. For this purpose, three—man review boards are appointed by the Governor, and one or more members of each board shall be a physician qualified in the diagnosis and treatment of episodic disorders of consciousness or muscular control. In its deliberations the review board considers the extent and duration of medical control of the condition, whether the person is dependable in following a medical regimen including taking medication, and other relevant information. It should be pointed out that these statutory powers make the medical review board separate and different from a medical advisory board. In fact, North Carolina also has a functioning medical advisory board, and in Ohio an MAB has recently been reconstituted. IN-PERSON RENEWAL In-person renewal of licenses can be ofgreat value. Of course, the value of the re- newal appearance depends upon what is done at the time of the renewal. As mentioned in the section on training examiners, there is not much value in having trained examiners if they do not have the opportunity to spend some time screening the applicant. It would also be of value at this time for the examiner to have available the traffic records of the appli- cant. Applicants with bad records could immediately be sent to a driver improvement analyst before the license is renewed. TRAINING DRIVER EXAMINERS, DRIVER IMPROVE- MENT ANALYSTS, AND HEARING OFFICERS Another of the factors related to medical advisory boards is the ability of the driver license examiner to identify signs and symptoms of conditions that are potential hazards as far as safe driving is concerned. In many, if not most, States the chiefsource ofinformation about driver impairment comes from the applicant, and that primarily from what is admitted on a brief questionnaire. 47 Not only is this inadequate from the point of view of uncovering unsafe drivers, but it is unfair in that the applicants may through ignorance of their condition report unneces- sarily. In this latter situation, it not only may prevent the applicants from driving but may cause a lot of unnecessary expense on their part and loss of time on the part of the physi- cians to whom the applicants are sent. A trained examiner who has contact with the applicant could prevent much of this unnecessary hardship. The main reason for examiner training is, of course, to make the examiners more competent in the screening process, and to help them recognize signs and symptoms. The examiners should in no way try to diagnose medical conditions but only to use signs and symptoms of such conditions as a guide in determining who should be sent to a physician for further evaluation. Realizing the need and the value of such training, the American Medical Association and the American Association of Motor Vehicle Administrators, with financial help from the Highway Users Federation and the Wisconsin Department of Transportation, produced an educational package for licensing agencies to use in orienting driver examiners. Consist- ing of five videotaped lectures by nationally recognized medical specialists and a self- teaching manual, the package was purchased by 21 licensing jurisdictions, an indication of the need licensing administrators feel for examiner education. Seeing its value, also, was the National Highway Traffic Safety Administration of the US. Department of Transportation, when in 1976 that organization, with the cooperation of the American Medical Association and the American Association of Motor Vehicle Ad- ministrators, updated and upgraded the original package and made it available to each State. One of the biggest assets of the new package is that it is on 16 mm color film, which avoids many of the difficulties of the original videotape. The main interest in discussing the examiner training is in its relation to medical ad- visory boards. Obviously, having better educated examiners will, on the one hand, prevent unnecessary referrals to the board and, on the other, present to the board those cases that need evaluation or about which there is a conflict between the applicant’s physician and the licensing agency. Better educated examiners are also more able to use intelligently the criteria that active medical advisory boards produce and to understand certain medical pro- cedures that the board develops for handling impaired drivers. At any rate, this type of examiner orientation cannot help improving the driver selec- tion process in weeding out applicants who are medically unfit and, on the other hand, making certain that all applicants who can drive safely will be licensed. In addition, any type of examiner training or education will undoubtedly raise the professionalism of the entire licensure process. It might be of great benefit for States to select certain qualified examiners for special training in handling applicants with certain conditions, such as aging, cardiovascular conditions, diabetes, epilepsy, and so forth. Of course, the only way these benefits can accrue is with face-to-face meetings between applicant and examiner, and this requires the applicant to appear in person at the examining station—mot only for the initial license but for all renewals as well as when he appears as a result of being reported or otherwise called in. The same benefits to be gained from training examiners apply equally, if not more so in many cases, to driver improvement analysts and hearing officers. One State, Michigan, actually sends its analysts to a private agency for training, especially in regard to handling applicants who have problems with alcohol and other drugs. 48 TELESCOPIC DEVICES AND DRIVING The use of telescopic devices while driving has become a controversial issue in recent years. Driver licensing officials in many States have been confronted with the problem of whether they should license an individual who is able to pass the visual acuity standards with the aid of a telescopic device but who does not have the required acuity when driving without the device. Since wearers of telescopic devices use them for only short periods while driving, the problem for licensing officials, legislators, and the general public is obvious. Accordingly, it becomes a problem for the medical advisory board. In fact, a national conference on the subject, sponsored by the American Medical Association and the American Association of Motor Vehicle Administrators, recommended that “wearers of telescopic devices and other low-vision applicants” should be evaluated by the medical advisory board. The conference recommended also that medical advisory boards should initiate development of special examination forms, training courses, and educational materials for low-vision license applicants. Finally, and probably most impor- tant, the AMAAAMVA conference recommended that no individual should be licensed to drive unless able to meet the State’s legal requirements for visual acuity wit/tout the aid ofa telescopic device, but it urged that further research be done. In recommending that highly motivated wearers of telescopic lenses and other low- Vision applicants be selected to take part in a carefully controlled, scientific, long-range study, the conference expressed the great need for criteria to evaluate the safe-driving ability oflow-vision applicants. A medical advisory board can do much to promote such research in its State and should take responsibility to see that it is carried out in a scientific manner. 49 RECOMMENDATIONS Recommendations are, of course, inherent in the discussion of a model medical ad- visory board, a model legislation, and a number of associated factors. At the risk of some repetition, the recommendations that follow cover a large number of different facets. Also, some of these recommendations, as some of the material throughout this manual, may seem to relate only tangentially to MAB’s, but those who have worked closely with MAB’s realize the value of some of these related factors, even though they may come to the fore only occasionally. 0 The first, and without question the most important, recommendation is that criteria be established for the various medical conditions that can affect driving safety. In the absence of such criteria, the development of which requires time, money, staff, and research capabilities, MAB’s can develop general guidelines for determining driver limitations. 0 Every State should have a medical advisory board that is active and functioning according to the suggestions made in this manual. 0 Such boards should be established or, if already in existence, be strengthened by legislation based on and containing at least the general provisions of the model law in this manual. 0 Since State licensing agencies usually cannot get actively involved in directly promoting legislation, MAB legislation should be spearheaded by State medical associations, in close consultation with the licensing agency. 0 In consideration of the above recommendation, it is suggested that State medical associations invite the chief driver license examiner or one of his aides to sit in on medical committee meetings that deal with the medical aspects of automotive safety. 0 Conversely, States that do not have a medical advisory board, or at least do not have one that functions well, should ask the medical association to appoint some interested physician to serve as a liaison at licensing agency staff meetings when medical aspects are being handled. 0 While in-person review of applicants may be difficult under some State situa- tions, it is recommended that every MAB have at least a modified in-person review set up to allow it to review in person at least those applicants with the most troublesome medical problems. 0 The licensing agency should manage the operation of the MAB. It should appoint an intelligent, highly motivated member of its staff to act as permanent secretary for the board. 51 The licensing agency should make active use of its MAB~it is far better to have the board complain of being overworked than to have it die because of lack of activity. It would be advisable for the licensing agency to employ a physician part time to screen selected medical records and to determine cases to go to the MAB. Traffic violation records should be available to the licensing agency and, if not, certainly to the MAB for making its decisions. Drivers who are chronic violators (habitual offenders) should be considered as having a medical problem and should be evaluated by the MAB. The State medical association should be encouraged to participate not only in MAB activities but in licensing activities in general; when the medical association has a committee on the medical aspects of traffic safety, that committee, or at least some of its members, should be the ones to take part in these activities. The State medical association should be encouraged to orient its physician mem- bership about its role in licensure, especially in getting off the road patients with conditions that are likely to be hazardous. In followup to the above recommendation, physicians should accept a moral obligation to the public to report to the licensing agency patients who do not respond to the physician’s advice to refrain from driving. Legal immunity should be provided to encourage the physician to cooperate in reporting, at least, the conditions potentially the most hazardous to driving. 52 BIBLIOGRAPHY Carpenter, R. L., & Margo, M. K. Oklahoma’s Medical Advisory Committee for driver licensing. Oklahoma State Medical Association Journal 621396-98, 1969. Determination of need for medical evaluation in driver licensing, American Medical Associa- tion, Journal of the American Medical Association 203:880-881, 1968. Driver licensing guidelines for medical advisory boards, U.S. Department of Health, Education and Welfare, Public Health Service, Washington, DC: US Government Printing Office, 1969. Driving stresses change the ECG in cardiac cases, Medical Tribune, March 17, 1968, pp. American Association for Automotive Medicine. Guide for Medical Association Committee on Traffic Safety. Morton Grove, 111.: 1975. Hames, L. N. The role of medical advisory boards in driver licensure, Traffic Digest Review (Northwestern University, Evanston, 111.) February 1972, pp. 13—17. Instructions for examining physician to determine physical fitness of drivers engaged in interstate of foreign commerce, Federal Highway Administration, Bureau of Motor Carrier Safety. Washington, DC: 20590, 1970. Lippman, 0. Texas Medical Advisory Board aims for safe driving. Texas Medicine 67: 1 18- 121, 1971. AMA Committee on Medical Aspects of Automotive Safety. Determination of need for medical evaluation in driver licensing. Journal of the American Medical Association, 203:880-881, 1968. AMA Committee on Medical Aspects of Automotive Safety. Physician’s guide for deter- mining driver limitation. Chicago, 111.: American Medical Association, 1973. American Association for Automotive Medicine. Guide for Medical Association Committee on Traffic Safety. Morton Grove, 111.: Health and Safety Associates, 1975. American Industrial Health Association Committee. Medical evaluation of the commercial- vehicle driver 7 A guide for the industrial physician. Journal of Occupational Medicine, 8:274-279, 1966. Carpenter, R. L., & Margo, M. K. Oklahoma’s Medical Advisory Committee for Driver Licensing. Oklahoma State Medical Association Journal, 62:396-398, 1969. Driving stresses change the ECG in cardiac cases. Journal of the American Medical Association, 200:24, 33, 1967. Federal Highway Administration, Bureau of Motor Carrier Safety. Instructions for examining physician to determine physical fitness of drivers engaged in interstate or foreign commerce. Washington, DC: 1970. Hames, L. N. The role of medical advisory boards in driver licensure. Traffic Digest Review (Northwestern University, Evanston, 111.), February 1972, pp. 13-17. Lippman, 0. Texas Medical Advisory Board aims for safe driving. Texas Medicine, 672118-121, 1971. 53 Medicine, 67:118-121, 1971. The Maryland Medical Advisory Board. Glen Burnie, Md.: State of Maryland, Department of Motor Vehicles, 1967. Proceedings: National conference on the aging driver, American Medical Association and American Association of Motor Vehicle Administrators, 1974. Morton Grove, 111.: Health and Safety Associates, 1974. Proceedings: National conference on current problems in driver licensure, American Medical Association and American Association of Motor Vehicle Administrators, 1971. Chicago, 111.: American Medical Association, 1971. Proceedings: National conference on telescopic devices and driving, American Medical Association and American Association of Motor Vehicle Administrators, 1976. Morton Grove, 111.: Health and Safety Associates, 1976. Proceedings: Physician reporting of driver limitation, American Medical Association and American Association of Motor Vehicle Administrators, 1976. Morton Grove, 111.: Health and Safety Associates, 1976. Texas Department of Public Safety. Texas Guide for Driver Limitation. Austin, Texas, 1975. U.S. Department of Health, Education, and Welfare. Driver licensing guidelines for medical advisory boards (U.S. Public Health Service Publication No. 1996). Washington, DC: U.S. Government Printing Office, 1969. U.S. Department of Transportation. Medical advisory boards. Traffic Laws Commentary, 1(1), March 1972. Committee on Medical Aspects of Automotive Safety. Visual factors in automobile driving and provisonal standards, American Medical Association. Archives of Ophthalmology, Vol 81:865-871, 1969. Wade, E. H. A review of 4,000 driver license applicants medically evaluated in North Carolina. Raleigh, NC: North Carolina Department of Motor Vehicle Driver License Division, 1967. Waller, J. A. Chronic medical conditions and traffic safety. New England Journal of Medicine, 273:1413-1420, 1965. Waller, J. A. Medical impairment and highway crashes. Journal of the American Medical Association, 208:2293-2296, 1969. Waller, J. A. Medical inpairment to driving. Springfield, 111.: Charles C. Thomas, 1973. West, 1., et al. Natural death at the wheel. Journal of the American McdicalAssociation, 205:266-271, 1968. Medical advisory boards for driver licensing, U.S. Department of Health, Education and Welfare, Public Health Service, American Association of Motor Vehicle Administrators and American Medical Association, March 1967 (out of print). Medical evaluation of the commercial-vehicle driver—A guide for the industrial physician (Rep. No. 5). Journal of Occupational Medicine 82274-279 May, 1966. North Carolina Motor Vehicle Laws, 1973 Supplement, Department of Transportation and Highway Safety, Raleigh, NC, 1973. 54 Pennsylvania Motor Vehicle Code, Pennsylvania Department of Transportation, Harrisburg, Pa., 1976. Physician’s guide for determining driver limitation. American Medical Association, Chicago, 1973. Proceedings: National conference on the aging driver, American Medical Association and American Association of Motor Vehicle Administrators, 1974.: Morton Grove, 111. Health and Safety Associates, 1974. Proceedings: National conference on current problems in driver licensure, American Medical Association and American Association of Motor Vehicle Administrators, 1971. Proceedings: National conference on telescopic devices and driving, American Medical Association and American Association of Motor Vehicle Administrators, 1976. Pub]: Health and Safety Associates, Inc., PO. Box 222, Morton Grove, Illinois 60053. Proceedings: Physician reporting of driver limitation, American Medical Association and the American Association of Motor Vehicle Administrators, 1976. Publ: Health and Safety Associates, Inc., PO. Box 222, Morton Grove, Illinois 60053. State driver’s license manual (available in almost every state). Texas guide for driver limitation, Texas Department of Public Safety, Austin, Texas, 1975. Maryland Medical Advisory Board, State of Maryland, Department of Motor Vehicles, Glen Burnie, Maryland, August 1967. US. Traffic Laws Commentary, “Medical Advisory Boards,” US Department of Trans- portation, Volume 1, No. 1, March 1972. Visual factors in automobile driving and provisional standards. American Medical Assr :iation. Archives of Opthalmology, 1969. Wade, E. H. North Carolina Department of Motor Vehicle Driver License Division—A review of 4,000 driver license applicants medically evaluated in North Carolina, 1967. Waller, J. A.: Chronic medical conditions and traffic safety. New England Journal of Medicine 273: 1413-1420, 1965. Waller, J.A.: Medical impairment and highway crashes. Journal of the American Medical Association 20822293-2296, 1969. Waller, J. A.: Medical impairment to driving. Springfield, Charles C. Thomas, 1973. West, 1., et a1: Natural death at the wheel. Journal of the American Medical Association 205:266-271, 1968. 55 U.S. GOVERNMENT PRINTING OFFICE: 1977 Ow 231-660 ‘ A .J '"I' v" 22-, ‘ 'Iy‘.‘ _ +".'“'.. . ’1)! "V L I Fir- .— . I h’d- ‘ I .‘ "4 LI; _ Lo_'| ' .D ‘3‘" DOT HS 802 013 March 1977 US. Department of Transportation National Highway Traffic Safety Administration Traffic Safety Programs 400 Seventh Street SW. Washington, DC. 20590 CDEHEE‘W7H