Stop whinging - it might be your life that's saved

I took my daughter for her first driving lesson this week - one hour down and one hundred and nineteen to go. Lots of learner drivers, and their parents, are having a whinge about the increased number of supervised hours mandated in several states, and for those like my friend with twins, teaching your kids to drive must indeed seem daunting.
Other rules in some states include a total ban on the use of mobile phones for newly licensed drivers, and a limit on the number of passengers aged under 21 late at night.
Yet despite their unpopularity, a quick perusal of the literature appears to generally support the new driving rules.
For a start, according to a paper on the topic from Monash University Accident Research Centre, although novice drivers represent only a minor proportion of the licensed driving population, eg 14% of drivers in Victoria in 2002, they are around four times as likely to be involved in fatal and injury crashes than older, more experienced drivers.
And it’s not only age, but inexperience, that relates to crash risk, the paper says, with “errors in attention, visual search, speed relative to conditions, hazard recognition and emergency manoeuvres” being contributing factors.
On a more positive note, the Monash centre reports Swedish research which found that about 120 hours of supervised driving results in around a 35% lower crash risk than 40 hours. In fact, in 1993 when Sweden made a single change to the licensing system - lowering the age a learner permit could be obtained from 17 years 6 months to 16 years and therefore prolonging the training period – the country experienced a 17% reduction in crashes for all novice drivers.
Other US research, published in JAMA found that in young drivers, fatal injuries increased with the number of passengers in the car at the time.
In any sphere, new rules are almost invariably unpopular.
But as with any public health initiative, the number of beneficiaries can be estimated but not identified by name. Just as we’ll never know who among our hypertensive patients may have had a stroke without our treatment, none of us will ever know who would have lived or who would have died without a change to the rules.
It might be someone we love.

How to decide who's fit to drive.

I’m a bit of a Nazi about people who aren’t fit to drive but continue to get behind the wheel. While aware what a bummer it would be to lose your license, surely running over innocent people is even more of a bummer for all concerned.
Of course I might be particularly sensitive about the Mr Magoo types who struggle to park in our surgery carpark because I live in the same street. The idea of my children sharing a road with these incompetents is positively scary.
But a review in last week’s BMJ is a reminder against stereotyping the ability of older drivers. According to the article, the association between age and crashes per mile has been shown to be more related to low mileage than age and surveys reveal drivers over 80 to be consistently prudent behind the wheel.
Even people with early dementia are acceptably safe for around three years after diagnosis, the authors claim, by which time most have stopped driving. Which is lucky, because cognitive testing can’t discriminate well between early dementia patients who are safe on the road and those that aren’t.
One way to detect unsafe drivers is to ask family and friends about specific behaviours, such as driving the wrong way around roundabouts, getting lost in familiar areas, miscalculating speed and distances and poor judgement, the authors suggest. Sounds good in theory, but in my experience loyalty to the patient is often a barrier to honest disclosure about their driving ability. Similarly it seems doctors sometimes turn a blind eye out of concern about a patient’s loss of independence.
In short, recommending a patient lose their license is a balancing act between patient independence and population safety, and it’s probably among the harder decisions we have to make as doctors.
At least in our area there’s now a subsidised cab system for the elderly, and it’s this type of system that should be expanded so that independence and mobility isn’t totally dependent on being able to drive.

BMJ 2007; 334: 1365-69.