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The Orthopaedic Forum   |    
Driving After Musculoskeletal InjuryAddressing Patient and Surgeon Concerns in an Urban Orthopaedic Practice
Vincent Chen, BS1; Aron T. Chacko, BS1; Frank V. Costello, JD2; Nicole Desrosiers, NP1; Paul Appleton, MD1; Edward K. Rodriguez, MD, PhD1
1 Department 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
2 McCarthy, Schuman, and Coombes Associates 61 Russ Street, Hartford, CT 06106
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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.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Dec 01;90(12):2791-2797. doi: 10.2106/JBJS.H.00431
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Extract

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.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Edward K. Rodriguez, MD, PhD
    Posted on January 14, 2009
    Dr. Rodriguez responds to Dr. Lowe
    Beth Israel Deaconess Medical Center

    I appreciate Dr Lowe’s comments and I am pleased to have the opportunity to clarify what I believe might be a misinterpretation of our recommendations.

    In fact, I strongly agree with Dr Lowe’s premise that as physicians we may not have the expertise or means needed to properly asses and advise when patients may start driving after injury. It was this concern that prompted our search for a solution that resulted in the recommendations presented in our article.

    Dr. Lowe points out that after expressing the above concern we then made the jump to stating that the ultimate goal of a return to driving policy is to identify when a patient can drive safely. This is correct, but we also promptly added that having rigid policies based on parameters such as time after injury may not be useful or even practical. We do recognize that any specific policy may never clearly determine who can drive and who cannot, and would never have sufficient flexibility to account for the many types of patients, injuries, and ages involved. Thus, the goal of having a policy that clearly determines safety when driving after injury is most likely unattainable.

    Furthermore, as Dr Lowe points out, it may not be our role as surgeons to establish when a patient can safely drive again. Our solution was therefore to allow a physician to address independently the status of any individual patient before suggesting that the patient may be capable of driving again and requesting that the patient retest before doing so. In this manner, the decision on whether “the rigors of driving can be met by an injured extremity” is made by the physician, but the “public safety” component of the decision is transferred to the licensing authority to be addressed with a new test, and not assumed by the physician. This “public safety’ component of the decision involves a more comprehensive assessment of additional issues, abilities, or limitations.

    From this perspective, Dr Lowe’s closing recommendation that “the physician’s policy should be to issue a Medical Release certifying a patient to be healthy enough to participate in whatever activity, without consideration of the patient’s ability” is not inconsistent with our practice as stated in the article. The individual decision to tell a patient that he or she may be capable of driving again constitutes the medical release acknowledging that the patient is now healthy enough for the activity of driving. The recommendation to retest acknowledges that we are unable to asses the patient’s ability to do so safely.

    I also disagree that the process of formulating a policy may create liability where there is none. Medico legal exposure when making any medical decision that may involve patient or third party safety is just a fact of current medical practice. Taking appropriate and well thought measures to limit exposure can only be of benefit.

    William D. Lowe, MD
    Posted on December 22, 2008
    Medical Decision Making, NOT Public Safety Officer
    Carolina Orthopedic Specialists

    To the Editor:

    While I agree with the conclusions in this article, I challenge the premise that we, as physcians, have the responsibility or expertise to advise a patient on when it is safe to drive.

    The article states “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.” Why then do the authors make the jump to “The ultimate goal of these policies should be to identify when a patient can safely drive following medical care”?

    My words “It is OK for you to drive” have never meant anything other than ‘It is safe for your injured body part to perform or withstand the activity of driving’. However, that statement can be easily misconstrued by the public (and will be misconstrued by the courts) to encompass more than intended. As a physician I make medical decisions for an individual patient. It is not my responsibility to assess all patients ability to handle an automobile. We as physicians are not competent to make this judgment. The certification of ability to drive should be left to public safety officers, whose thoughts are geared toward the public safety and not the individual.

    We as physicians are licensed to make medical decisions.The decision to drive is a personal decision with the license granted by a state’s Department of Motor Vehicles. Medical malpractice carriers would be within their rights to deny coverage for non-medical opinions leaving a physician uncovered for liability from 3rd parties sustaining damages from our patients’ driving. Likewise, the decision to be gainfully employed is an employment decision, agreed to by employer and employee. The decision to attend public school or participate in sports or organized athletics is a personal or parental decision. We are qualified to make none of these decisions for our patients and should clarify our statements appropriately to indicate we are making medical decisions restricted to our specialty.

    Pursuing the authors’ goals as stated in this article simply adds liability where there is none. The physician’s policy should be to issue a Medical Release certifying a patient to be healthy enough to participate in whatever activity, without consideration of the patient’s ability.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family 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 author, or a member of his immediate family, is affiliated or associated.

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