MEETING WITH EXPERTS
Ranks 2 and 13: Mission of Medical Advisors
Meeting attendees, both those with and without MABs, agreed it was important to have a Medical Advisory Board to help DMV administrative staff make fitness-to-drive decisions. Members agreed a recommendation for each jurisdiction to have an MAB was a best-practice recommendation. A good medical review program needs to have both physicians and administrative medical review personnel. Some cases are cut-and-dried and can easily be disposed of by applying medical standards/guidelines, but there are many complicated cases where a physician’s knowledge and advice are valuable and necessary. This advice cannot be left up to the driver’s treating physician because treating physicians don’t always have expertise in how a medical condition affects driving performance, and treating physicians who have a personal relationship with their patients often want to protect individual driving privileges. MAB physicians are needed to review some of the more complicated medical reports returned by treating physicians. Non-medical people cannot be trained in all the complexities (e.g., myocardial infarction, what type of arrhythmia, what type of seizure, what medication, is it a sedating medication?)
There was some confusion in the terminology relating to Medical Advisory Boards and Medical Review Boards and their missions. Since some States use their MABs only to hear appeals, or have a Medical Review Board to hear appeals in addition to having a Medical Advisory Board to review individual cases, it was agreed in this meeting that when we speak of a “Medical Advisory Board” we are referring to a group of physicians who review individuals’ cases and advise the DMV administrative licensing personnel regarding a person’s fitness to drive. Thus, the term “Medical Advisory Board” in this report will not mean a group of physicians whose sole function is to hear appeals of drivers who disagree with a licensing agency’s decision.
Regardless of whether a jurisdiction has an MAB, the use of Functional Ability Profiles (FAPs) was looked upon favorably by administrative medical unit supervisors in attendance to provide consistency in how physicians report the level of severity of a medical condition as well as in how DMVs make licensing determinations. In jurisdictions where there is no MAB or where the MAB is not used for case review, the use of FAPs was looked upon favorably by administrative staff and by several physicians in attendance to help medical review administrative staff make licensing determinations. Physicians in the meeting cautioned against using FAPs in place of case review by physicians for complex situations, and noted that FAPs, if used, need to be updated regularly with changes in state-of-the-knowledge. Also with regard to FAPs, one physician said it is difficult to subcategorize severity of medical conditions into more than two or three categories of risk (i.e., low-, medium-, and high-risk). It is difficult to draw the fine lines required to go beyond low, moderate and high, and have cutoffs in between for a five- or a six-level system of categorization.
It was decided the mission of the MAB should not be limited to hearing appeals of licensing determinations, as this would diminish the usefulness of physicians to the non-medical administrative staff when making the first licensing determination. It was agreed MAB physicians should review individual cases, and in the performance of this function it was agreed an individual MAB physician (rather than a quorum of the board, or a panel of MAB physicians) could review a case and make a determination. The MAB physicians based their recommendations on multiple opinionson the opinion of the DMV examiner who conducted a road test; on the highway patrol person who stopped the driver for an infraction; on the driving record that shows crashes, violations, and convictions; and on medical records submitted by treating physician(s).
Compensation of MAB physicians received attention during the meeting, even though the components relating to composition and compensation of board members received ratings placing them in the bottom half of the RVA. Meeting attendees agreed DMV physician staff positions for physicians serving on the MAB would be preferable, but not likely, due to costs. Where paid-staff positions are not possible, paid consultants would be ideal. In a jurisdiction that employs both full-time physicians and contract physicians, it was explained that consultants (contractors) are very useful when there is a large influx of cases and another full-time DMV staff position is not needed. Based on the demands of the medical decisions and the need to stay abreast of what the state-of-the-art is regarding medicine and functional ability to drive, MABs should be comprised of paid consultants, as opposed to volunteers.
It was suggested by physicians in attendance and met with agreement that the appropriate level of compensation should be equivalent to what physicians could make in their private practices or through a hospital.
Regarding perceived conflicts of interest and physician liability, as long as the licensing decision is the responsibility of the DMV, it will not appear as though the paid-physician advisors are siding with the DMV rather than with the patient. In addition, making the ultimate licensing decision the responsibility of the DMV removes the physicians from liability (malpractice suits) for their recommendations. Board physicians should not be held liable for their recommendations.
As far as what medical specialties should be represented on the board, it was recommended not to let the statutes determine how the board operates. For example, in jurisdictions where statutes require members to be physicians, an occupational therapist or registered nurse could not be part of the board.