“You’re no longer safe to drive ...” ========================================== * Iris Gorfinkel “Aging is a battlefield,” a stalwart 80-plus patient asserts as he leaves my general practice clinic. He is barely gone when a mother and daughter enter the room. I finish my progress note on the previous patient and look up to see another familiar face, a face that fills me with foreboding. I’ve been dreading this visit. Linda (not her real name) has come to review her neurologist’s report about whether she can safely drive. Up until a year ago, Linda worked as an actor whose livelihood had depended on remembering her lines. She seems to have aged substantially from our last visit and looks all of her 78 years, perhaps more. In spite of our 19-year relationship, this is the first time that I meet Linda’s daughter, who is about my own age. Her presence adds a degree of intensity to the visit. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/191/40/E1107/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/191/40/E1107/F1) Image courtesy of [iStock.com/robertiez](http://iStock.com/robertiez) We review the neurologist’s report, even though her daughter was present when the neurologist formally assessed Linda’s forgetfulness. The news isn’t good. Linda had missed every question involving short-term memory, except for what season it was. In medical parlance, her short-term memory loss is profound. Although I’ve been Linda’s general practitioner for many years, her test results showing poor short-term memory come as a surprise. I feel an uneasy mixture of guilt and sadness on reading just how poorly she had performed. The guilt comes from the unfortunate reality that we, family physicians, often fail to recognize serious short-term memory loss in our patients. A staggering 91% of early dementia is missed by family doctors.1 More often the diagnosis is made by a neurologist after patients or family members request a referral to diagnose memory loss they’ve witnessed. The sadness is for what the future now holds for Linda. As family doctors, we miss these cases in large part because of time constraints. It’s nearly impossible to diagnose dementia when appointments are, on average, 15 minutes in length.2 A further difficulty is that patients’ manners and outward appearance are often affected only late in the course of dementia. Each of these factors had played a role in my failure to recognize the extent of Linda’s memory loss. Looking back, her three prior visits focused on her bone density, blood pressure and vaccinations. Most provinces and territories in Canada have legislation for reporting patients who are unfit to drive. If the memory loss that accompanies dementia is severe, a doctor is often obliged by law to report the driver as unsafe to the motor vehicle branch. Linda’s neurologist had left the final determination to a driver’s test scheduled in two months’ time. Given how rapid her decline has been, waiting two months for her formal driving assessment seems excessive to me. Within just the past year, she has gone from being fully independent and working to being forgetful to the point of needing her daughter to accompany her during our office visit. My initial reaction to the neurologist’s consult is one of sheer annoyance. Why has the neurologist left this for me to do? Yet, at the same time, I wonder if the neurologist had experienced the same sense of trepidation that I now face in discussing Linda’s safety to drive. Both patients and doctors intensely dislike this conversation. Patients often feel very threatened at the prospect of losing their licence. Doctors don’t relish being the bad guy. Still, I don’t feel comfortable leaving the decision for several months, so the onus to inform her is now my own. This responsibility is compounded by a sense of helplessness given my inability to improve her memory and a sense of failure in being unable to provide her with effective treatments. The discussion begins. We talk about the implications of her memory loss and how it could affect her driving. Sensing Linda’s tension, I try to gather what she understood from her visit with the neurologist. “I learned that I’m just fine,” Linda responds. Her daughter looks away and says nothing. Do I see tears in her daughter’s eyes? I review the neurologist’s note with Linda as her daughter, who is now blinking rapidly, carefully listens. Did the extent of her mother’s memory loss come as a surprise to her? She must have had at least an inkling of this before they visited the neurologist. I realize that Linda is not the only patient in the room and that her daughter is struggling to come to terms with her mother’s rapidly fading memory. “How do you feel when your mother is driving?” I ask. She quietly answers that she has actively avoided being driven by her mother for the past six months. She shoots a glance at her mother and then admits to having serious doubts about her mother’s safety behind the wheel. She talks about the conflict in having to cope with her mother’s anger and the impact it will have on her life if her mother is no longer to drive. No outcome is ideal. If we should wait for Linda’s driving test, she and her daughter may be at greater risk of an accident. And even then, there is a slight but real possibility that Linda could pass her driving test. Driving is a long-term skill that involves a strongly established memory, much like riding a bike. Losing one’s short-term memory affects a different skill set: remembering the intended destination, coping with slowed reaction times and recalling that, for example, a cyclist is nearby. I face Linda and gently explain that she will need to stop driving. Having known her for so many years makes this difficult, and I feel sad for having to tell her. There are so many feel-good moments in family medicine. Preventing a motor vehicle accident could be one of those moments, at least in theory. But at this particular moment, this feels purely hypothetical when I face Linda’s vitriolic response. “I am pissed!” Linda retorts. “Pissed?” I think. Her word choice is a first for her in conversation with me, both in its anger and in its aggression. I brace for the worst. The prospective loss of her driver’s licence both infuriates and terrifies her. “I’ve been your doctor for 19 years. As angry as you now feel, things would be much worse if you had a car accident that hurt you or someone else,” I try to reason. Linda turns away and stares at the wall, so livid she can barely speak. “I care about you a great deal. I’m trying to avoid trouble for you.” “I’m not a dangerous driver.” Linda’s eyes flash. “What am I supposed to do for groceries?” she demands, glancing at her daughter. Having known Linda for so long makes this all the more difficult. I offer to arrange home services that may help. Perhaps Meals on Wheels or grocery delivery to her home could make a difference. These suggestions do little to assuage Linda’s indignation. She is glowering. I realize that protecting her from harm is an important part of primary care, yet in spite of this I am not exactly feeling grateful to be informing her that she’ll need to stop driving. But who is better suited to this task than a general practitioner who has gained the trust of a patient over so long a time? Yet our relationship feels threatened by my having to report Linda’s short-term memory loss to the motor vehicle branch. Perhaps our relationship would fare better had the neurologist wielded this axe instead of my having to do the deed. I turn away from Linda’s anger and now face her daughter, expecting to hear words of support to her mother. Instead, her daughter just stares as she considers just what it will mean when her mother is barred from driving. This visit marks another milestone in her evolving role as caregiver to her mother. I then realize that not only are Linda’s daughter and I similar ages, our mothers are similar ages as well. I can’t allow myself to go there. The visit ends. Linda’s daughter talks about taking the car keys away from her mother that afternoon. “I really wish things could be different,” I start to say. “Don’t worry,” Linda’s daughter responds, her eyes now brimming with tears. “Mom won’t even remember this conversation in a few minutes.” ## Footnotes * *CMAJ* Podcasts: audio reading at [https://soundcloud.com/cmajpodcasts/190705-enc](https://soundcloud.com/cmajpodcasts/190705-enc) * This article has been peer reviewed. * This is a true story, though the patient’s name has been changed. “Linda’s” daughter has given her consent for this story to be told. ## References 1. Parmar J, Dobbs B, McKay R, et al. Diagnosis and management of dementia in primary care: exploratory study. Can Fam Physician 2014; 60:457–65. [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjg6IjYwLzUvNDU3IjtzOjQ6ImF0b20iO3M6MjM6Ii9jbWFqLzE5MS80MC9FMTEwNy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 2. Irving G, Neves AL, Dambha-Miller H, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017;7:e017902. [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiYm1qb3BlbiI7czo1OiJyZXNpZCI7czoxMjoiNy8xMC9lMDE3OTAyIjtzOjQ6ImF0b20iO3M6MjM6Ii9jbWFqLzE5MS80MC9FMTEwNy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)