Like all good stories, this one starts with two friends are sitting at a bar. Let’s call them Tom and Larry. They’ve known each other for years, and are at their weekly Monday night football meet up at their neighborhood bar. This time though, Larry has had more than a few too many drinks and clearly won’t be able to drive home safely. He’s unsteady on his feet and slurring his words. Tom offers him a ride home, offers to pay for a cab or car service, counsels him on the dangers of driving while intoxication but despite his best efforts, Larry insists upon driving himself home. Tom tells himself that he has counseled Larry, told him all the risks, so when Larry drops his keys onto the floor as he stumbles his way to the door, Tom picks up Larry’s keys and hands them over. On Larry’s drive home, he crosses the center line and hits an oncoming car, resulting in serious injury not only to himself but also to the other driver.
Is Tom at fault? Sure, he wasn’t driving the car, but he handed car keys to someone he knew wasn’t safe to drive, was a danger to himself and others. And even if you can’t attribute any blame to Tom for his actions, or in this case, lack thereof, how do you think Tom feels about his role that night? What kind of emotional burden will Tom have to carry, knowing that his actions might have prevented two people from being seriously injured? How would you feel if you were in his shoes?
I can tell you. Because, I am Tom.
When a patient comes to the hospital after having been involved in an accident, we remove their clothes and package up their belongings until it is time for them to go home. Then, when they are medically ready to leave the hospital, we give them back their personal effects, which almost always include their driver’s license and car keys. And we do this, regardless of how or why their accident occurred.
Doesn’t sound like a problem to you? Let’s compare it to this situation. A patient comes to the hospital after having sustained a gunshot wound. Again, we remove their clothes, but while packaging up their belongings a gun is found. Law enforcement suspects that gun has been involved in a crime, has been an instrument in the harming of an another individual, and they confiscate the gun. When that patient is medically ready to discharge, we don’t return their gun.
But when a patient has been involved in a car accident due to intoxication, addiction, or medical condition, we do return their keys. And in contrast to the gun, which at the time of confiscation is only suspected to be involved in a crime, as a trauma surgeon I know when one of my patients committed a crime because I have the results of their alcohol and drug screen. As physicians, we know when our patients have seizures, are prescribed narcotics, are battling addictions, have driven and continue to drive under the influence, and yet – we can’t protect them, or you, beyond what Tom was able to do for Larry – counsel and give advice.
Of course not, doctors can never disclose patient conditions because of doctor patient confidentiality, right? Not true. In fact, there is already precedent that when the public’s safety is at risk, certain conditions, when diagnosed by a doctor, must be reported to county or state health departments or the Centers for Disease Control. Of course the irony of this is, I can and have to tell the state health department if my patient gets diagnosed with Chlamydia but I can’t tell anyone if my patient has had three car accidents this year due to being under the influence of alcohol or drugs.
Although chlamydia is a sexually transmitted disease that can have long lasting effects if it isn’t treated, it doesn’t come close to having the same public safety impact of impaired driving. Approximately 40,000 people died last year due to motor vehicle accidents. Over 25% of these were related to alcohol, but that doesn’t even account for accidents due to medical conditions, narcotics, or illicit drug use. In fact, in 2016 almost 12 million people drove under the influence of illicit drugs. And I can tell you right now, there are a bunch of doctors who knew about it. But, the rules and laws regarding the reporting of individuals unsafe to drive varies drastically by state and situation, and the vast majority of states use ambiguous, vague language about when a physician may be able to report, without any standardized or clear processes to do so. With the dramatic rise of opioid addiction and the expanding number of elderly drivers (50% increase since 2009) in this country, motor vehicle accidents, injuries, and deaths are only going to increase. And with this increase comes the growing emotional burden of front line physicians who treat people with injuries, people they know shouldn’t be driving, and yet, at the end of the day, have to hand them their keys.
But, it doesn’t have to be this way. We, as physicians can do more to protect our patients, and the public. But we need the clear means and mechanisms to both protect not only our patient’s confidentiality, but also their life. As a society, as a medical community, we need to prioritize safety on the roads and treat it for what it is: a public health issue – a cause of preventable death in this country. As such, we all need to engage our government leaders in discussion for new legislation and processes which will allow us to better serve our patients, and the public.