SURVEY OF MEDICAL REVIEW PRACTICES IN THE UNITED STATES
The survey instrument developed by TransAnalytics project staff with the assistance of AAMVA and NHTSA is presented in Appendix B. Respondents completed the survey between January and March 2003. The survey contained three sections as follows:
- Section 1, containing 25 questions, was completed by all jurisdictions regardless of whether they had an MAB when this survey was completed.
- Section 2, containing 23 questions, was completed by the 35 States that had an active MAB when this survey was completed.
- Section 3, containing 7 questions, was completed by the 14 States that did not have an MAB, plus the 2 States that had an inactive/on-paper-only MAB when this survey was completed.
A cover letter for the survey was drafted by AAMVA and project staff that explained how the survey was structured, and provided a due date for survey completion and return to TransAnalytics. The cover letter also included a checklist of additional information to be returned with the completed survey (e.g., license application forms; medical and visual forms; and agency guidelines, procedures, and statutes).
The survey was mailed by AAMVA, under cover signed by the AAMVA senior vice president of the Programs Division. As surveys were received by the project principal investigator, quantitative data were entered into summary tables and qualitative data were reviewed for thoroughness. Survey respondents were then telephoned by the principal investigator, and asked to provide more detail for identified survey questions. Information from the telephone conversations was recorded manually, and was used with the written survey responses to produce a narrative detailing the procedures used in each jurisdiction for dealing with drivers who have functional impairments and medical conditions. Survey respondents were asked to mail forms, guidelines, and statutes used in their medical program operations. These materials were reviewed and incorporated into each State summary. The draft summaries were then e-mailed back to the survey respondents, who reviewed the information for errors or omissions. Respondents’ comments were incorporated into the final summaries, which comprise the project deliverable titled Summary of Medical Advisory Board Practices in the United States. This research product is posted on AAMVA’s Web site at the following address:
The document summarizes the activities of the Medical Advisory Boards (or other administrative units performing medical review functions) in the 50 United States plus the District of Columbia that determine fitness to drive for operators of personal or private vehicles not for hire. For each jurisdiction, a 5- to 10-page summary describes the organization of the medical program; mechanisms used to identify drivers with medical conditions and functional impairments; procedures and medical guidelines used to evaluate drivers for fitness to drive; evaluation outcomes, appeal of licensing action, availability of counseling and public information and educational materials; and administrative issues such as training of employees, driver-tracking systems, and barriers to implementing more extensive screening, counseling, and referral activities. Appendices that accompany the report present summary tables showing responses by State for each question on the survey, for ease of comparison across jurisdictions.
Similarities and differences in practices across the United States are highlighted in the following discussion.
Depth of Questioning Regarding Medical Conditions on Renewal Application Form
Self-reporting of medical conditions during license renewal procedures is a common mechanism for bringing drivers with medical conditions and functional impairments to the attention of the licensing agency. All but two States (Arkansas and New Hampshire) require drivers to answer questions about medical conditions as they complete their license application, and four jurisdictions said only first-time applicants were required to answer such questions.
There are large differences across jurisdictions in the depth of this questioning. The depth of questioning ranges from one simple question such as, “Do you have any medical conditions that may affect your ability to drive safely?” to very detailed, specific questions as are presented in Utah and Maryland, that list conditions. One State (Washington) revised its (single) question in response to American Civil Liberties Union criticism for requiring too much information from applicants.
Tests Conducted At Renewal
Another mechanism for identifying drivers with functional impairments is screening/testing at license renewal. Departments of Motor Vehicles (DMV) often perform vision screening upon license renewal, and some DMVs also require renewal applicants to pass a knowledge test. Two jurisdictions currently require renewing drivers 75 and older to pass a road test.
Administration of the knowledge test varies across the States when used as a tool for identifying drivers with possible impairments. In some States, all renewing drivers are required to take a knowledge test. In other States, a knowledge test is given to all reexamination drivers (drivers referred into the medical program by some mechanism). In other States, a knowledge test is used as a surrogate mental status test, and is given only to drivers who are suspected of having cognitive impairment (e.g., Connecticut and Virginia). One respondent said the practice of giving the knowledge test only to drivers suspected of cognitive impairment would not be acceptable in his State because it treats handicapped drivers differently and would run afoul of the Americans with Disabilities Act (ADA).
Level of In-Person Contact (Hearing, Interview) of DMV with Referred Driver Prior to Initiation of Reexamination Process
In most cases when the licensing agency receives a complaint or letter of concern regarding a driver’s ability to operate a motor vehicle safely, the agency begins the reexamination process by sending the driver a medical form that must be completed by the driver’s treating physician and returned to the licensing agency. Based on the information obtained in the physician’s report, the driver’s operating privilege may be continued without restriction; continued with restriction; continued based on the results of a DMV vision, knowledge, and/or road test; or withdrawn. But in any case, the reexamination procedure always requires receipt of a medical report from the driver’s treating physician.
However, in several jurisdictions, the driver is first called into a motor vehicle office for an interview or hearing to gather more information about the driver’s condition. The information gathered during the interview is used to determine whether the driver needs to undergo medical reexamination (a physical examination by the treating physician), or DMV reexamination (vision testing, knowledge testing, and/or road testing).
Breadth of Medical Criteria for Licensing Determinations
There is great variability in the medical criteria used to make licensing determinations. Some jurisdictions rely solely on the treating physician’s opinion regarding fitness to drive, while others employ very specific medical and functional criteria for several medical conditions (i.e., oxygen saturation levels for pulmonary disease; American Heart Association classifications for heart disease, etc.). Other jurisdictions have guidelines only for loss of consciousness/seizure disorders.
Three States use Functional Ability Profiles (Maine, North Carolina, Utah), where physicians classify their patients with medical conditions into specific levels of severity. The DMV uses a matrix and the input of the MAB to determine license restrictions, periodic retesting or medical review requirements, or loss of driving privileges.
With regard to seizure-free periods for loss-of-consciousness disorders, a few States have no set requirements, while other States have a 3-month, 6-month, or 12-month seizure-free period. There is also variability in whether States will waive a seizure-free requirement, such as when seizures result from physician-initiated changes in prescription seizure medications, or for seizures that occur only at night, or when there is sufficient warning of the onset of an episode.
Medical review of passenger vehicle drivers in the United States is currently conducted under 51 separate sets of criteria for fitness to drive. One survey respondent remarked that some older drivers could use the differences in policies as a basis of where to relocate for retirement, and live in a State with more permissive medical/functional requirements.
All jurisdictions have, at the very least, criteria for visual acuity. However, there is also wide variability in the absolute minimum visual acuity level allowed for driving (e.g., 20/50 to 20/200), although all States require 20/40 or better for unrestricted licenses. Some States allow drivers to meet the acuity standard through the use of binocular telescopic lenses (although most do not), and not all States allow driving with binocular telescopic lenses. In addition, not all States have a peripheral-visual-fields standard. Not all States test the vision of renewing drivers.
Physician Reporting Laws
Physicians who treat drivers with medical conditions and functional impairments are a mechanism outside of the DMV that may serve to bring potentially unsafe drivers to the attention of a licensing agency. Although all 51 jurisdictions accept reports of potentially unsafe drivers from physicians, only 6 jurisdictions require physicians to report drivers to the motor vehicle agency who have medical conditions or functional impairments that may affect safe driving ability. In four of these jurisdictions (California, Delaware, New Jersey, Nevada), loss of consciousness/epilepsy is presently the only condition that is required to be reported, but, in one of these States (California), the definition of “loss of consciousness” is broad. In California, “disorders characterized by lapses of consciousness” are defined as medical conditions that involve the following:
- A loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli;
- The inability to perform one or more activities of daily living; and
- The impairment of the sensory motor functions used to operate a motor vehicle.
Examples of medical conditions that do not always, but may progress to the level of functional severity are provided in the Code of Regulations, and include Alzheimer’s disease and related disorders, seizure disorders, brain tumors, narcolepsy, sleep apnea, and abnormal metabolic states, including hypo- and hyperglycemia associated with diabetes.
In the remaining two mandatory-physician reporting States, Oregon has recently moved from the requirement to report loss of consciousness only to “cognitive and functional impairments that are severe and/or uncontrollable to a degree that may preclude safe operation of a motor vehicle and are not correctable by medication, therapy, surgery, driving device, or technique.” Pennsylvania requires physicians to report any person over the age of 15 diagnosed with any of the specified disorders or disabilities defined by the Medical Advisory Board that could impair the ability to drive safely, as well as any other condition which, in the opinion of the provider, is likely to impair the ability to control and safely operate a motor vehicle.
Although all States allow physicians to report potentially unsafe drivers, not all assure that the reports will be held as confidential, and only 30 provide immunity from civil liability. Physicians may choose not to report patients if they fear retribution in the form of lawsuits or the possibility of losing a patient’s business. One or two States said increasing voluntary physician reporting by providing immunity may swamp already understaffed medical units.
Crashes and Points as Triggers for Retesting
A survey question asked whether a crash with a fatality, an accumulation of points, and/or an accumulation of crashes would prompt the licensing agency to require a driver to undergo evaluation. Such adverse driving events are another mechanism that jurisdictions use to identify drivers who may have medical conditions or functional impairments. Twenty-five jurisdictions reported that a crash with a fatality could trigger reevaluation, 3 said an accumulation of points could trigger reevaluation, and 15 said an accumulation of crashes could trigger reevaluation.
Presence of MAB and Scope of Activities
While 37 jurisdictions have MABs, there is variability in the scope of their activities. In one of these States, the MAB exists on paper only, and in another, the MAB is currently inactive. MAB physicians most frequently conduct reviews of medical reports submitted by drivers’ treating physicians to make fitness to drive determinations (33 States). However, in some jurisdictions, MAB physicians interview referred drivers (in 5 States, either in person or indirectly through the use of video), and even fewer (only 3) conduct hands-on screening or assessment functions. Some MABs review all cases referred to the DMV, while other boards review only those cases that cannot be handled through the application of medical guidelines by personnel in the DMV (because the case falls outside of the guidelines or physician reports are conflicting, etc.). In some jurisdictions, MAB review is reserved for cases where the driver appeals the DMV’s decision. Across the jurisdictions with MABs the number of case reviews performed by the MABs ranges from less than 5 cases annually to 36,000 cases annually.
Other functions of MABs in some jurisdictions include:
- Advising on medical criteria and vision standards.
- Developing report forms.
- Developing educational material.
- Recommending training courses for driver license examiners in medical fitness to drive.
- Apprising the agency on new research on medical fitness to drive.
Employment and Compensation of MAB Members
Most States that have an MAB have voluntary board physician membership. Twenty-five jurisdictions have board physicians who are volunteer consultants; 11 have board physicians who are paid consultants, 1 has a board physician who is a part-time employee of the licensing agency, and 2 have board physicians who are full-time employees of the licensing agency. It was pointed out by one respondent that voluntary membership makes it difficult to maintain membership, and another respondent said it often results in a long turn-around time for fitness to drive recommendations.
DMV Employee Awareness of Medical Conditions and Functional Ability
DMV licensing personnel who interact with the public are in a position where, if adequately trained, they may be a “first line of defense” in identifying original and renewal applicants who may have physical impairments and medical conditions that could impair safe driving ability. They may serve as a reliable source of referrals of drivers to the agency’s medical program, based on their observations and questions during the licensing process. Jurisdictions were asked whether they provide training for their personnel in how to observe applicants for impairing conditions. Jurisdictions were also asked whether their licensing personnel received specialized training relating to older drivers. Twenty jurisdictions responded that their licensing personnel receive training in how to observe for impairing conditions, and five jurisdictions (4 from the set of 20) responded that they provide specialized training for licensing personnel relating to older drivers.
Availability of Extended/Tailored/Home-Area Drive Test versus Standard Drive Test for Novices
Another difference in practices across States is the drive test. While some States administer extended/tailored road tests to drivers to ensure they can compensate for a physical disability (e.g., Arizona, Florida, Kansas, Washington), or home area tests to drivers who may need to be restricted to driving in very familiar areas (e.g., California and Wisconsin), other States administer the same test as that given to original applicants. One respondent commented that the Americans with Disabilities Act required the State to administer the same test to all applicants, thus eliminating the possibility of administering extended or area tests in his jurisdiction.
Availability of Customized/Restricted Licenses
Licensing agencies can allow drivers with medical conditions and functional impairments to continue to drive safely longer by (1) restricting drivers to driving during daytime only or only on roads with lower speed limits; (2) restricting drivers to driving only with prosthetic devices or vehicles with special adaptive equipment; and/or (3) restricting drivers to driving in familiar areas near their homes, either by restricting them to driving to specific destinations (e.g., church, doctor, shopping), or within a certain radius of home. Some States have extensive lists of restrictions that may be placed on licenses, including time-of-day and area limitations. Others have very limited types of restrictions that they may apply. Hawaii, New Jersey, and Rhode Island do not issue time-of-day or restricted area licenses. Rhode Island does not issue restricted licenses, beyond the requirement to wear corrective lenses or use special equipment; these are considered license classifications as opposed to license restrictions. There are no provisions for time-of-day or geographic restrictions, as Rhode Island considers drivers either medically qualified to drive or not medically qualified to drive.
Currently, all but four States (Alaska, Colorado, Mississippi, New Hampshire) have the capability to monitor drivers with medical conditions through periodic medical reporting. In these four States, a driver who has a progressive medical condition and is considered by the physician as “OK to drive now” will not come to the attention of the licensing agency again until the next renewal cycle, unless involved in a crash or reported by a source outside of the DMV.
Fifteen jurisdictions said they have an automated medical record system, and 28 jurisdictions said they have automated workflow systems. Most jurisdictions that do not have automated workflow systems have a mechanism for tracking drivers with medical conditions and functional impairments.
Age-based testing is permitted in five jurisdictions. A written and road test may be given to renewing drivers 75 and older in Washington, DC The District of Columbia regulations specify these tests shall be administered for this population; however, in practice the tests are only given when examiners observe signs of impairment. In New Hampshire and Illinois a road test is required at renewal for drivers 75 and older. In Oregon a vision test is required at 50 and older. In Pennsylvania, each month, 1,650 drivers over 45 are chosen randomly 6 months prior to the time of license renewal and must undergo vision and physical exams by a physician of their choice. Driver selection is weighted heavily toward the oldest drivers, and results in (almost) every driver over 85 being selected.
Some jurisdictions shorten the renewal cycle for older drivers, and others eliminate the opportunity to renew by mail as drivers age.
Reporting Sources Other Than Physicians
All 51 jurisdictions accept reports from law enforcement, 49 jurisdictions accept reports from the courts, 48 jurisdictions accept reports from family members, and 39 jurisdictions accept reports from friends and other citizens. Regarding reports from family, friends, and other citizens, some jurisdictions said they would accept reports from all three, while others said reports are only accepted from specific family members (e.g., immediate family; blood relatives of operators within 3 degrees of consanguinity, or the operator’s spouse, who has reached the age of 18, etc.).
Agency Public Information and Educational (PI&E) Activities and Counseling of Functionally/Medically Impaired Drivers
Availability, depth/breadth, and method of delivery of PI&E vary greatly across jurisdictions. Programs that educate older drivers about the importance of fitness to drive and ways in which different impairing conditions increase crash risk may help to keep older drivers driving safely longer (through self-awareness of impairments, self-restriction where appropriate, and by seeking remediation of functional impairments). Similarly, the provision of counseling to drivers with functional impairments to help them adjust their driving habits appropriately and/or to help them deal with potential lifestyle changes that follow from limiting or ceasing driving, is viewed as an important component of a program that seeks to increase the safe mobility of older persons.
Thirteen jurisdictions reported they provide such PI&E materials to older drivers. Ten jurisdictions reported they provide counseling to drivers with functional impairments, and 7 more jurisdictions refer drivers to outside resources for counseling.
Recommendations/Referrals for Remediation
Twenty-seven jurisdictions either refer drivers for remediation of impairing conditions or recommend drivers for remedial treatments, while 24 jurisdictions said they neither refer nor recommend remediation.