Driving After Musculoskeletal Injury: Addressing Patient and Surgeon Concerns in an Urban Orthopaedic Practice

Chen, Vincent BS; Chacko, Aron T. BS; Costello, Frank V. JD; Desrosiers, Nicole NP; Appleton, Paul MD; Rodriguez, Edward K. MD, PhD

Journal of Bone & Joint Surgery - American Volume: 01 December 2008 - Volume 90 - Issue 12 - p 2791–2797
doi: 10.2106/JBJS.H.00431
The Orthopaedic Forum

1Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215. E-mail address for E.K. Rodriguez: ekrodrig@BIDMC.Harvard.edu

2McCarthy, Schuman, and Coombes Associates 61 Russ Street, Hartford, CT 06106

Article Outline

Patient and public safety concerns make the timing of return to driving after musculoskeletal injury or orthopaedic surgery an important decision that is made by orthopaedic surgeons on a daily basis. Neither the American Academy of Orthopaedic Surgeons nor any other orthopaedic specialty society has endorsed recommendations, policies, or practice guidelines that address when a patient is able to return to driving after a musculoskeletal injury. To our knowledge, there are no specific guidelines available on how the decision should be made, who should be involved, or to what extent retesting of driving abilities after an injury should be required. The only and most recent guidelines available were developed in 2003 by the National Highway Traffic Safety Administration (NHTSA) in cooperation with the American Medical Association specifically to assess the ability to return to driving in older patients1. While these guidelines address to a limited degree musculoskeletal disability in older individuals, they are not specific to musculoskeletal injury or orthopaedic surgery and they are not entirely applicable to younger age groups. They also fail to incorporate a substantial part of the already limited orthopaedic literature on the topic2-10. The American Occupational Therapy Association (AOTA) is the only organization that has addressed the issue and actually offers Driving and Community Mobility Specialty Certification for occupational therapists who seek the training (www.aota.org). Comprehensive evaluation of driving abilities, as recommended by the AOTA, involves both an office evaluation and a behind-the-wheel assessment administered in a properly equipped test vehicle. Unfortunately, such specialized programs are not standard in conventional occupational therapy practices and are not always geographically or financially accessible to all patients recovering from musculoskeletal injury or orthopaedic surgery.

To address the issue of return to driving in our practice, we formulated a return-to-driving policy that takes into account the needs and concerns of our patients as well as the concerns of orthopaedic surgeons. We developed our policy after anonymously surveying a sample of our patients as well as a group of orthopaedic surgeons practicing in the New England area.

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Medicolegal Concerns

A lack of accepted orthopaedic practice guidelines has the potential to expose practitioners to medicolegal claims should patients be involved in motor vehicle collisions in which the preexisting injury may have been a causal factor. Causality may not only be limited to physical impairment arising from a limb injury or orthopaedic surgical procedure but may also relate to other aspects of postinjury or postoperative care. These include concerns regarding the inappropriate use of medication, cognitive or neurological impairment, inappropriate use of splints or assistive devices while driving, or even the failure to diagnose and treat associated deficits, such as a new postinjury vision or hearing impairment or other nonorthopaedic condition that could limit driving ability. The brief and infrequent patient-physician interactions that characterize our health-care system do not often facilitate the proper comprehensive assessment of a patient's capabilities as required for safe driving. While a surgeon may be capable of determining when an injured limb may withstand the demands of driving, he or she may not be qualified to make a final determination of overall driving ability given the multisystem requirements that the task of driving demands.

State licensing authorities can be of some limited assistance with regard to the assessment or retesting of driving ability after injury. Readily available mechanisms to expedite recertification of a patient after recovery from an injury by means of a practical driving test that a patient could take after being advised to do so by a physician would address patient safety issues as well as physician medicolegal concerns. However, such expedited recertification pathways do not always exist. While thirty-eight states have established medical assessment boards that can address return-to-driving issues on a case-by-case basis, only nineteen have a readily available testing pathway that a patient can follow once he or she has recovered from an injury or surgical care1. In nineteen states, authorities or medical advisory boards base decisions on a patient's ability to drive on medical certification by a treating physician, thus not necessarily limiting the medicolegal exposure of the certifying physician1.

A recent medicolegal concern is also the situation in which an impaired patient may injure a third party. Medicolegal liability in this situation may be broader than previously realized. A third party may seek damages against the treating physician of the patient who was driving when the injury occurred. In this situation, it is unclear whether any malpractice insurance is applicable to address third-party claims since there is no patient-doctor relationship between the physician and the victim. In the state where we practice, the Massachusetts state Supreme Judicial Court recently reversed a lower court decision clearing a physician from responsibility for medication side effects that allegedly contributed to a motor vehicle collision in which a third party was fatally injured2. Allegations of inappropriate medication management have been the primary cause of litigation in driving-related incidents in our geographical area of practice. A review of the malpractice case database of the Controlled Risk Insurance Company of Vermont, a risk retention group, revealed that the two primary allegations have been that inaccurate dosage information was given to a patient or that the treating physician failed to properly inform a patient of the risks associated with medications prescribed. A total of six cases have thus far been filed, and all but one have been dropped or denied. To our knowledge, no case involving a motor vehicle incident allegedly resulting from improper advice given by an orthopaedic surgeon to a patient with regard to his or her ability to drive secondary to a musculoskeletal condition has been filed in our state.

A less discussed medicolegal concern involves potential liability exposure in not reporting an impaired driver. Six states have mandatory reporting laws requiring physicians to report impaired drivers, primarily for conditions that may cause “lapses in consciousness,” but also for other less specific findings that may compromise safe operation of a motor vehicle1. Another thirty-six states “encourage” reporting but do not require physicians to do so. However, only twenty-two states offer legal immunity or protection to the reporting physician from a patient who might seek damages secondary to being reported1.

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Elderly Patients

The risk of a patient driving and being involved in a motor vehicle collision because of a prior injury must be minimized, while at the same time practitioners should not unreasonably prevent a patient from driving. While the focus of this article is on the return to driving of the injured patient irrespective of age, orthopaedic surgeons are also increasingly involved in the decision-making process for elderly drivers who may have experienced a musculoskeletal injury in addition to perhaps having preexisting limitations. Only forty-two states require vision testing for a driver's license renewal, ten states have a practical testing requirement after a certain age, and seven have a written test requirement1. Other than a requirement for a vision examination, twenty-two states do not have any age-based renewal procedures such as limited mail renewals or a more frequent renewal interval after a certain age1. As a result of this situation, and in the context of an increasing population of elderly individuals, a physician is often the only individual capable of limiting the driving ability of a potentially impaired older patient. Many practicing orthopaedic surgeons may not be aware of published NHTSA guidelines1 nor have access to the specialized occupational therapy services that are required to properly assess driving ability in older patients.

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Scientific Background

The scientific literature regarding the assessment of the timing of return to driving is limited and has been focused mostly on the assessment of reaction times after elective procedures. Spalding et al.3 and Pierson et al.4 examined the reaction times of drivers following total knee replacement, and MacDonald and Owen5 studied the reaction times of drivers following hip replacement. Hau et al.6 examined driving reaction times after right knee arthroscopy. Nguyen et al.7 and Gotlin et al.8 examined driving reaction times after anterior cruciate ligament reconstruction. Holt et al.9 reported braking times after metatarsal osteotomy. Few studies have examined reaction times or driving ability following musculoskeletal trauma. Egol et al.10 tested braking times for patients who had undergone operative fixation of a right ankle fracture and found that, by nine weeks, total braking time had returned to a normal baseline value. A survey by Rees and Sharp11 polled orthopaedic consultants in the United Kingdom regarding when they believed patients with treated, pain-free limb fractures could resume driving. No consensus was reported for many common fractures, particularly of the upper extremity. In another survey in the United Kingdom, with regard to the ability to drive while wearing a cast, Von Arx et al.12 concluded that while the majority of surgeons offered advice to their patients as to when they could drive, there was overall an unsatisfactory degree of consensus or advice from insurance agencies and authorities. To our knowledge, no survey of orthopaedic surgeons in the United States has been published.

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Assessment of the Needs and Concerns of Patients and Orthopaedic Surgeons in Our Community

Our practice provides level-I and community trauma care to a diverse urban population of patients. Two fellowship-trained orthopaedic traumatologists supported by six additional surgeons with nontrauma subspecialty training treat on the order of 1200 patients a year. Of these patients, approximately 30% are geriatric patients with a low-energy traumatic injury; 40% are younger patients with high-energy, blunt multiple trauma; and the remaining 30% are mixed-age patients who have an isolated low-energy limb injury or are having an arthroplasty or other elective procedure. Return-to-driving decisions are made on a daily basis and, not infrequently, with some degree of patient-physician conflict when physician recommendations do not meet patient expectations.

In order to facilitate the decision-making process, we decided to formulate a fair return-to-driving policy that would serve the needs of the patients in our practice and would address the physicians' concerns. To understand physicians' concerns in our region of practice, forty-one of forty-four participating orthopaedic surgeons were surveyed during the 2007 AO New England Trauma Summit held in Stowe, Vermont. Participants were anonymously polled on their recommendations on return to driving following specific injury patterns. Decision-making on clearing a patient to drive was also surveyed, as well as attitudes toward liability. Questions were of an open-ended format to allow physicians to add commentary (see Appendix). A second survey of seventy patients returning for follow-up in our practice was also performed. The patients were anonymously polled by means of an institutional review board-approved questionnaire about their experiences and attitudes regarding return to driving following a musculoskeletal injury or orthopaedic surgery. It was not our intention to obtain a statistically rigorous sample of our patients but rather to obtain some basic working data to understand our patients' needs and concerns. Our focus was on obtaining anonymous data so that sensitive questions could be asked. No incentive was provided for participation, and no attempts were made to correct for any bias in responses related to clinical outcome. The patient questionnaire is also illustrated in the Appendix and was designed by the senior author (E.K.R.) solely for this application.

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Surgeon Survey Results

The forty-one orthopaedic surgeons who completed our questionnaire varied substantially with regard to how long they waited before telling patients they could return to driving (Table I). Various criteria for assessing a patient's ability to return to driving were reported, and some surgeons reported more than one criterion for assessment. A majority (68%) indicated that they instruct patients to practice driving in a parking lot until they feel comfortable; 13% instruct patients to seek clearance from their physical therapist; 20% ask patients to be off narcotic medication before driving; and 12% allow patients to drive when they resume full weight-bearing and when they no longer need assistive devices. Additional single responses included one practitioner who recommended that patients should take a new driving test through their state licensing authority and another who referred patients to a driving simulator laboratory available at his institution's occupational therapy department. The majority of respondents used the commentary section of the questionnaire to express their opinion that patients should exercise personal responsibility in deciding when to drive.

Regarding surgeons' concerns about the decision process, 68% of the surgeons reported generally feeling uneasy about telling patients that they could drive again and 44% reported a concern about potential litigation if a patient were in a collision after being allowed to drive. Only 3% of the respondents were aware of some litigation in their geographical area of practice involving a return-to-driving case.

The majority of respondents (76%) did not have a return-to-driving policy that they followed consistently. When asked in a multiple choice format who they thought should be involved in the decision to allow a patient to return to driving, some physicians answered with more than one option. Twenty-eight percent of the respondents indicated that the physician alone should decide when a patient was ready to return to driving, 78% responded that the patient should decide, 13% preferred to defer to the physical therapist treating the patient, 6% thought that the Department of Motor Vehicles or the state licensing authority should decide, and another 6% thought that the family or employer should also have a role in the decision.

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Patient Survey Results

The anonymous questionnaire was returned by ninety-one (28%) of the 330 patients who were seen for follow-up in our trauma clinic and at random sessions of four additional subspecialty clinics (sports, hand, oncology, and arthroplasty) during an approximately one-week period (February 20 through 28, 2007). However, twenty-one questionnaires were unusable as they had been submitted with more than 50% of the questions unanswered or had written commentary rather than quantifiable answers to the multiple-choice questions. After these were excluded, a total of seventy questionnaires were analyzed. The questionnaire was offered to patients at the time of registration and was completed by the patients while they waited to be seen. While all patients seen for follow-up with the orthopaedic trauma service were offered the questionnaire by the registration staff, it may not have been offered to some patients at follow-up visits with the subspecialty services. No data are available on how many patients of the 330 patients seen during that time period were missed in this manner, so the reported response rate may be underestimated. All completed questionnaires were deposited by patients into a box at the registration desk.

Many patients reported having more than one injury. The injuries included twelve fractures of an upper extremity, twenty fractures of a lower extremity and/or the pelvis, twenty-seven non-fracture-related disorders of an upper extremity, and twenty-two non-fracture-related injuries of a lower extremity. Forty-nine of the seventy respondents reported having had a surgical procedure. A large proportion of patients (42%) reported that the inability to drive presented a major difficulty (Fig. 1). Patients to varying degrees relied on friends, family, and public transportation for rides, with 26% feeling that the inability to drive presented a major financial hardship beyond the hardships presented by their injury (Fig. 2). Many patients did not consult with their doctors before driving, found initial opposition by their doctors regarding their return to driving, had begun driving while still on narcotic pain medications, or at times felt unsafe when driving because of their injuries (Fig. 3). While 82% of the patients who were not yet driving at the time of the survey reported that they would consult with their doctor for permission before they started driving again, only 64% of those who were already driving had actually done so. It is of interest, from the practice guideline or policy formulation standpoint, that 71% of the patients said they would approve of a strict policy that recommended a new state-administered driving test following a “serious” injury. However, only 10% said that they would approve of a strict policy recommending a new driving test following “any” type of musculoskeletal injury.

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Discussion and Our Return-to-Driving Policy

These patient responses suggest that the inability to drive following a musculoskeletal injury or orthopaedic surgery can present a substantial inconvenience as well as a financial difficulty. This may explain why patients, without consulting their physician, often return to driving while still taking narcotic pain medications, despite the advice of friends and family or despite feeling unsafe because of the injury. The practitioner survey data suggest that the return-to-driving decision is of concern to orthopaedic surgeons from both a safety and a medicolegal standpoint. Practitioners surveyed varied to a great degree in their practices when clearing patients for return to driving.

The results from both surveys were used by our orthopaedic trauma service to develop a return-to-driving policy that serves the needs of our patients as well as addresses our medicolegal concerns. We offer our present policy within the orthopaedic trauma service at our institution as an example of an option reached after careful deliberation and after surveying a sample of our patients to understand their needs and expectations. We recommend that any policy that is implemented by a physician or practice group should be well documented, printed, and clearly stated to patients early in the physician-patient relationship, preferably before a patient inquires about driving again. It should not be so inflexible that it precludes from driving the patients who may not be at risk, but it should be universally applied to all patients. In our practice, we no longer “clear” patients for driving in the way that it has traditionally been done in the past. We offer patients advice as to when they may be ready to retest with the Department of Motor Vehicles and then allow them to follow through with this recommendation at their own discretion. Once a patient has reached this point, medical record documentation is made by stating that the patient “has improved to the point that he/she may drive again but was requested to recertify before doing so.” As an alternative, we can also provide a referral to one of two return-to-driving programs managed by independent occupational therapy services in the Boston area, where our practice is based. These programs are not affiliated with our institution, and their services may not always be covered by insurance providers. Fees for such programs may exceed $400. Our present policy is in print as part of a patient introduction brochure that is given to all trauma patients and their families on first contact with the orthopaedic trauma service. The brochure incorporates the return-to-driving policy as well as other trauma service policies for obtaining medication refills, completing disability paperwork, and other administrative regulations that we have adopted. Patients have generally responded positively. While elderly patients have sometimes complained, their family members, in most instances, have strongly appreciated our recommendations.

Our policy was reviewed by our risk management division, which concurred that it is advisable to notify patients of any return-to-driving recommendations including retesting. Our risk management legal services were of the opinion that communicating the importance of a driving assessment or recertification recommendation not only promotes personal and public safety but documenting the notification to the patient also contributes to reducing the likelihood of liability in the event of a claim alleging physician negligence. A recommendation to retest with a licensing authority after an injury is also common practice in other countries such as the United Kingdom13.

To better understand the potential physician liability in the context of releasing a patient to drive, a brief review of the legal concept of negligence is useful. Generally speaking, liability attaches when a party is negligent. A party is negligent when a duty of care to prevent harm exists, that duty is breached, and the breach causes harm to another14. A duty of care to prevent harm can only exist if the harm caused can be deemed as having been foreseeable2,15. This duty of care is satisfied when a party exercises reasonable care to prevent harm14. A policy that is communicated to patients can be an instrument to document that reasonable care was exercised. Furthermore, policies that are approved and agreed on could eventually become the benchmark for whether a physician's decision to release a patient to drive was reasonable and, thus, satisfied a duty of care. Standardized policies or practice guidelines would serve the dual purposes of seeking to prevent harm and avoiding liability.

The findings in our physician survey are consistent with the literature11,12 in demonstrating that there is no definitive consensus on standard return-to-driving recommendations. The survey also points out that 76% of physicians practice without a consistent policy regarding return to driving. The eventual development of standardized policies or practice guidelines would ideally provide guidance to physicians on when it becomes reasonable to release a patient to drive. The ultimate goal of these policies should be to identify when an individual can safely drive following medical care. The criteria for releasing a thirty-year-old patient following a carpal tunnel release are likely to be vastly different from those for an eighty-four-year-old patient with a hip fracture and questionable cognitive symptoms. Our policy as described above does not attempt to establish such differences and instead offers a similar recommendation to all patients regardless of injury or surgery type. This is its major limitation; however, it does allow a physician to decide when a patient is ready to return to driving, on an individual basis and before issuing the policy recommendation to recertify. We believe that the large individual variations in injury and abilities make the formulation of specific policies based on parameters, such as time elapsed after injury, very unlikely and probably not very useful. Deciding when a patient can return to driving is a difficult decision that may require data for appropriate decision-making that is beyond what is commonly available to the treating physician. The risk of medicolegal liability in cases in which patients may injure themselves or others appears to be increasing, and there are no established orthopaedic practice guidelines to follow. Because surgeons vary substantially in their practices regarding when a patient is ready to return to driving, and because patients can at times be unsafe drivers, formulating a return-to-driving policy could help to address patient safety and liability concerns even if it is meant to be applied within a single practice group. Our policy has been well accepted by our patients, but it may not be applicable to all practices. When available, specialized occupational therapy services and return-to-driving programs are a valuable resource. Finally, we believe that guidelines recommended by an orthopaedic professional society to advise the orthopaedic community and our patients would be of great value.

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Appendix Cited Here...

The surveys used in this report are available on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD).

NOTE: The authors thank the participants of the 2007 AO New England Trauma Summit for contributing to the survey of orthopaedic surgeons.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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