Section 1

Introduction

Following the example set by the Canadian Medical Association (CMA) guide on the evaluation of fitness to drive since publication of the 1st edition in 1974, nearly a half century ago, this 10th edition continues to provide current, practical information for health professionals who have determined that a patient has a condition that may affect their fitness to drive. In consideration of this orientation, clinical information on the diagnosis and evaluation of the various medical conditions has been kept to a minimum to allow the health professional rapid access to guidance on the effects of the given conditions on fitness to drive.

This edition incorporates the latest recommendations of the Canadian Cardiovascular Society (CCS), to be published in 2023. It also profits from the series of systematic literature reviews conducted under the auspices of the Monash University Accident Research Centre and published in the 3rd edition of its report entitled Influence of Chronic Illness on Crash Involvement of Motor Vehicle Drivers (Charlton et al., 2021) (often referred to as the “Monash Report”).

All sections in this guide have been revised by their respective authors, and references are provided within each section to enable the interested reader to further their knowledge as desired. It is also intended that the references will facilitate the justification for medical standards for fitness to drive if those standards are challenged, a situation that is increasingly frequent for licensing agencies.

The 7th edition of this guide recognized that a landmark legal ruling in British Columbia, known as British Columbia (Superintendent of Motor Vehicles) v. British Columbia (Council of Human Rights) or simply the Grismer decision, identified the right of Canadian drivers to have their licence eligibility determined on the basis of an individual functional assessment, rather than exclusively on the basis of a diagnosis, with a corresponding responsibility for licensing authorities to accommodate drivers wherever possible, within safe limits. This accommodation can often be achieved with appropriate licence conditions or restrictions or vehicle modifications, which may be based on a physician’s recommendation. Physicians should be aware of the need to review patients’ medical fitness to drive according to an assessment of their overall functional capacity, including their ability to accommodate medical and physical deficits. Physicians should also consider the possibility of synergetic effects of multiple medical conditions, as well as aging or other circumstances, on their patients’ overall functional capacity and fitness to drive.

The principle is that the functional effects of the medical condition, rather than the diagnosis alone, determine licence status in most cases. This principle is examined in detail in Section 2, Functional assessment — emerging emphasis.

Many of the recommendations in this guide are the same as the standards found in similar documents, such as the Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards for Drivers (CCMTA, 2021). The CCMTA standards were developed in meetings of the medical consultants and administrators from each province and territory who are responsible for advising the motor vehicle licensing authorities on medical matters and safety in driving. The standards are revised annually by that organization’s Driver Fitness Overview Group, and the majority are adopted by the provincial and territorial motor vehicle departments. This process achieves a uniformity of standards across Canada, with the result that a driver licensed in one province or territory can easily exchange their driver’s licence in the event of a move to another province or territory.

To minimize impediments to commercial drivers who must cross the Canada–United States border, an agreement has been reached whereby each country recognizes the medical standards of the other country. The only exceptions concern insulin-treated diabetes, epilepsy, hearing deficits, and drivers with medical waivers. Canadian commercial drivers with these conditions and those with a medical waiver cannot cross the border into the United States with their commercial vehicles. This agreement has been under revision for some time, and it is possible that the final document will modify these restrictions. Should this come about, this guide will be modified to reflect the changes.

Non-commercial drivers and commercial drivers who are driving non-commercial vehicles are not subject to the same restrictions.

A Scientific Editorial Board composed of five member physicians and a physician editor-in-chief continued the work they began with the production of the 8th and 9th editions of the guide. Where possible, an evidence- based approach was used, although medical standards for driving will always contain some consensus-based recommendations, since some situations do not lend themselves to an evidence-based approach. For example, the vision section remains consensus-based, as no cut-off points for visual acuity or visual fields based on crash risk have been established.

However, the evidence for medical factors in crash risk is improving. The Scientific Editorial Board was aided in the preparation of this guide by a review of recent scientific reports for each section. Interested readers are referred to the latest edition of the Monash Report (Charlton et al., 2021), which remains the most complete and detailed review of the evidence supporting medical standards for drivers at the time of publication of this guide. The US National Highway Traffic Safety Administration (NHTSA) document Driver Fitness Medical Guidelines (NHTSA, 2009) is another useful publication that contains both extensive references and an analysis of the literature. In addition, the CCS “risk of harm” formula, first included in the 7th edition of this guide to support its recommendations, has been retained in this edition. However, the recommendations throughout this guide remain largely empirical and reflect the fact that the guidelines presented here are based on the consensus opinion of an expert panel supported by a careful review of the pertinent research and examination of international and national standards, as well as the collected experience of a number of specialists in the area. They are intended to impose no more than common sense restrictions on drivers with medical disabilities. This guide is not a collection of hard-and-fast rules, nor does it have the force of law.

Physicians are regularly called upon to evaluate medical fitness to drive. Traditionally, this occurs when a patient arrives with the driver fitness form from the licensing authority. However, in many parts of Canada, driving is a daily activity, and the potential effects of a medical condition on driving capability should be a consideration for everyone, regardless of age or whether they have a driver fitness form to be completed. For instance, a person with newly diagnosed diabetes should receive counselling on the Diabetes Canada recommendations for drivers, along with advice about diet and exercise. This observation applies to all medical conditions and to all patients with a driver’s licence, although very few physicians routinely inquire about licence status.

Every physician who examines a patient to determine fitness to drive must always consider both the interests of the patient and the welfare of the community that will be exposed to the patient’s driving. During the examination, the physician should not only look for physical disabilities, but should also endeavour to assess the patient’s mental and emotional fitness to drive safely. A single major impairment or multiple minor functional defects may make it unsafe for the person to drive. Adaptations to the vehicle or changes in driving habits allow compensation for most physical limitations; however, in most cases, cognitive limitations are not amenable to compensation.

Likewise, physicians should be aware of their responsibility or legislated requirement to report patients with medical conditions that make it unsafe for them to drive, according to the jurisdiction in which they practise. Physicians should also be aware of the circumstances in which patients are likely to function. For example, the extreme demands related to operating emergency vehicles suggest that drivers of these vehicles should be cautioned that even relatively minor functional defects may make it unsafe for them to drive in emergency conditions.

Motor vehicle crashes during the period preceding the COVID-19 pandemic killed about 2,000 people in Canada each year and injured another 160,000 (Transport Canada, 2022). By contrast, the number of deaths in Canada directly attributable to COVID-19 was, at the time of writing this section, more than 32,000 over the first 2 years of the pandemic (Statistics Canada, 2022). Because driving activities were sharply curtailed by pandemic restrictions, road crash fatalities were lower than usual over the same period.

Most motor vehicle crashes involve people between the ages of 15 and 55 years, and crashes are a leading cause of death and disability in this group. Major contributing factors to crashes involving younger people are alcohol, speeding, and poor judgment, including driving inappropriately for weather and road conditions and failing to use safety equipment. Older drivers are involved in proportionally fewer crashes than younger drivers, but they are more likely to die in a crash, principally because of increased frailty.

Anything that physicians can do to encourage safe driving by their patients has a positive public health impact. Questions about drinking and driving and seat belt use should be considered at least as important as questions about smoking behaviour. The prevention of motor vehicle crashes has at least as great an impact on population health as trauma programs that treat crash victims. The health of commercial drivers is also an important consideration, given their long hours on the road, the consequences of a crash involving their loaded vehicles, and their vulnerability to metabolic disease, fatigue, and stimulant use. It is imperative that physicians understand the increased risks associated with obstructive sleep apnea, cardiovascular diseases, addictions, and other conditions that may reduce driver fitness.

The motor vehicle licensing authorities have the power to issue and suspend licences. Legislation in the provincial and territorial jurisdictions stipulates that these authorities can require licensed drivers to be examined for their fitness to drive. “Fitness” is considered to mean fitness in the medical sense. The provincial and territorial motor vehicle licensing authorities have the final responsibility for determining licence eligibility, and fitness to drive is a major determinant of eligibility. The recommendations of the CMA outlined in this guide are meant to assist physicians in counselling their patients about the effects that their medical conditions will have on their fitness to drive and how to minimize these effects. The guide will also help physicians in determining whether a person is medically fit and in identifying conditions that will likely disqualify a person from holding a licence.

It should be remembered that driving is a privilege, not a right. Just as physicians are required to maintain their “fitness” to practise medicine, drivers must maintain their fitness to drive and be prepared to demonstrate their fitness if it is in doubt.

The classification of drivers’ licences takes into account any specialized training or knowledge that may be required of the driver. For instance, driving an articulated truck requires specific training that is not required for driving a car; similarly, driving a taxi requires detailed geographic knowledge of the area that may not be required for driving the family car. These additional factors are reflected in the various classes of licences. Usually, holders of Class 1 to 4 licences (for driving heavy vehicle combinations, buses, trucks, emergency vehicles, and minibuses) are referred to as “commercial” drivers, and those holding any other class of licence (for driving automobiles, motorcycles, mopeds, scooters, three-wheel motorcycles, and tractors) are referred to as “non-commercial” drivers. In some jurisdictions, taxi drivers are considered commercial drivers, whereas in others they are considered non-commercial drivers.

Because this guide is intended to provide physicians with guidance on the determination of fitness to drive, rather than the classification of drivers in the licensing system, and because driving activities are an important factor in this determination, the Scientific Editorial Board has decided that this publication will use the terms “non-commercial” and “commercial,” rather than “private” and “commercial” as was the case in past editions.

Consequently, commercial drivers are those drivers whose job necessarily includes driving as the pivotal activity, whereas non-commercial drivers are everybody else. Thus, a sales representative who must drive to meet customers and a taxi driver who is transporting paying customers are considered “commercial drivers,” while a physician using a car to make house calls is a “non-commercial driver,” since there is no requirement for the physician to use a motor vehicle for transportation.

Physicians should assess their patients for fitness to drive in terms of the context in which they will be driving and advise them accordingly. Obviously, for a patient with a known risk of a medical event, the risk of the event occurring while the person is at the wheel will be much greater if the person spends much of the day at the wheel than if the person rarely drives.

The motor vehicle licensing authorities require a higher level of fitness for commercial drivers who operate passenger- carrying vehicles, trucks, and emergency vehicles. These drivers spend many more hours at the wheel, often under far more adverse driving conditions, than drivers of non-commercial vehicles. Commercial drivers are usually unable to select their hours of work and cannot readily abandon their passengers or cargo should they become unwell while on duty. Commercial drivers may also be called upon to undertake heavy physical work, such as loading or unloading their vehicles, realigning shifted loads, and putting on and removing chains. In addition, should the professional driver suffer a collision, the consequences are much more likely to be serious, particularly when the driver is carrying passengers or dangerous cargo. People operating emergency vehicles are frequently required to drive under considerable stress because of the nature of their work. Inclement weather, when driving conditions are less than ideal, is often a factor. This group should also be expected to meet higher medical standards than non-commercial drivers.

It should also be borne in mind that operators of heavy machinery, such as front-end loaders, may hold a Class 5 (non- commercial vehicle) licence, rather than the higher classes of licences normally required for commercial drivers. Alternatively, a patient with this class of licence may be a commercial traveller who drives thousands of kilometres a week in an automobile.

If, after completing a driver’s medical examination, a physician is undecided about the patient’s fitness to drive, the physician should consider arranging a consultation with an appropriate specialist. A copy of the specialist’s report should accompany the medical form when it is returned to the motor vehicle licensing authority. Alternatively, physicians may consider referring a patient to a driver assessment centre if a functional assessment is beyond the scope of the examining physician.

A medical examination is mandatory for some classes of licences. The licensing authority may base a final decision regarding a driver’s licence eligibility on the examining physician’s opinion. When the report differs significantly from previous reports submitted by other physicians or conflicts with statements made by the driver, the motor vehicle licensing authority will often ask its own medical consultants for a recommendation.

Ultimately, it is the licensing authority, not the physician, that makes the final determination of eligibility. Some jurisdictions have ceased to ask the physician’s opinion as to the driver’s fitness to drive, since it can be difficult to extrapolate office observations to actual driving conditions. In these jurisdictions, the physician’s responsibility is to provide accurate information that will permit the licensing authority to make the appropriate decision. Obviously, awareness of the individual jurisdiction’s approach and standards is essential for any physician who is assessing and evaluating patients’ medical fitness to drive.

Most medical school curricula spend little, if any, time on driver evaluation. As a result, most physicians have only a passing knowledge of many of the aspects discussed in this guide. Although the guide can be useful in aiding physicians to become familiar with evaluating drivers’ fitness, availability of and participation in formal continuing medical education programs are essential if physicians wish to improve their knowledge of the subject. The benefits of interaction with a knowledgeable physician who can explain how the licensing authority applies the principles described in this guide and in the CCMTA Medical Standards for Drivers , as well as the particularities of the respective jurisdiction’s rules and regulations, cannot be duplicated by reading a printed document.

Some Canadian jurisdictions already offer such continuing education programs, which have proven popular with physicians (Dow and Jacques, 2012). Physicians are encouraged to attend such programs if available in their respective jurisdictions or to request them if not available.

As noted above, driving is considered a privilege. As such, in most jurisdictions, patients are responsible for paying for all medical reports and laboratory examinations carried out for the purpose of obtaining or retaining a driver’s licence, even though the examinations or tests may have been requested by the motor vehicle licensing authority. In other jurisdictions, examinations for some drivers, such as seniors, are insured services, or it is the responsibility of drivers’ employers to cover such costs. Functional evaluations are often at the driver’s cost.

In most Canadian jurisdictions, the cost of medical examinations of drivers for whom the periodicity of their medical examinations is mandated by law or regulation is covered by the jurisdiction’s medical insurance agency.

Drivers’ licences are divided into classes according to the types of motor vehicles that the holder is permitted to drive. The classifications can vary across jurisdictions, and graduated licensing systems have been instituted in some jurisdictions. In this guide, therefore, licences and vehicles are classified generically, and readers should refer to the provincial or territorial classification when necessary (see Appendix B for contact information). The CCMTA defines seven classes of licence, described in detail in its standard Driver Licensing Classification (CCMTA, 2020):

• Classes 1 to 4: Commercial classes of driver licence.
• Class 5: Required to drive a passenger vehicle.
• Class 6: Required to drive a motorcycle.
• Class 7: Learner/instructional driver licence.

This guide is produced as a service to CMA members; however, the CMA and the CMA Group of Companies do not have the capacity to comment on or respond to questions related to clinical issues arising from the work of the content experts.

Physicians who have comments and suggestions about the guide’s recommendations are invited to contact us at [email protected] or toll-free at 888-855-2555.