By Robert Cribb, Declan Keogh and Max Binks Collier
When Ontario doctors see high-risk medical conditions that could impact a patient’s ability to drive, the protocol is clear: report them to the government.
Even when physicians believe patients pose no risk on the road, the province’s strict legislation compels formal reports to the Ministry of Transportation that trigger licence suspensions.
Meanwhile, in Quebec, Nova Scotia and Alberta, reporting is discretionary to varying degrees — meaning the decision is left to the practitioner’s own judgment.
The patchwork of models across Canada reflects a lack of consensus across the Western world over the role of health professionals in reporting patients whose conditions might make them unsafe drivers.
It’s not clear whether mandatory-reporting models like Ontario’s are the best way to keep the roads safe — especially with the collateral damage they cause.
An ongoing investigation by the Toronto Star and the Investigative Journalism Bureau (IJB) has shown mandatory reporting needlessly strips many Ontarians of their ability to access employment and schooling, imperiling livelihoods and trust in the health-care system.
At stake are public safety, personal freedom and patient trust.
A 2019 review of the available science found “inconclusive evidence” about whether mandatory reporting laws actually increase the reporting of potentially unsafe drivers and reduce crash risk. Photo credit: Toronto Star
Ontario’s model is “the most severe in all of Canada,” said Dr. Alan Hoffman, a sleep specialist in British Columbia who advises British Columbia’s Transportation Ministry about fitness to drive in those with sleep disorders.
“This is like overkill in Ontario, and I just don’t think it’s appropriate or fair to the drivers … You’re guilty until proven innocent.”
Interviews with leading Canadian medical experts and a review of regulatory models around the world raise questions about how Ontario identifies and treats drivers with medical conditions.
“If you read the section of the Highway Traffic Act and do exactly what it says, as a neurologist, I would be reporting every single patient I see,” said Dr. Richard McLachlan, a recently retired neurologist and professor emeritus of neurology at Western University.
Ontario law requires doctors, nurse practitioners and optometrists to report patients to the Ministry of Transportation “who have certain medical or visual conditions that may make it dangerous to drive.”
Those conditions include uncontrolled substance use disorders where patients are non-compliant with treatment recommendations, some psychiatric afflictions, seizure-causing disorders, cognitive impairments, and other “high risk medical conditions.”
When the ministry receives a report indicating a patient has one of these conditions, “a licence suspension will be issued,” states a ministry guide on filing the reports, known as medical condition reports (MCRs). The patient then has to apply to the ministry to have it reinstated.
This forces doctors to report patients even in cases when they do not see a threat to road safety.
“Rather than the ministry using its powers to ensure that people are safe to drive, it puts a wedge between physicians and their patients,” said Dr. Ross Upshur, a professor at the Dalla Lana School of Public Health who specializes in bioethics and who has filed MCRs on occasion. (Upshur sits on the IJB’s academic and editorial advisory board.)
Ontario’s reporting system was updated in 2018. Previously, the rules gave medical professionals greater latitude to assess the danger posed by patients who might drive, critics argue.
Under the old system, once reports were filed to the ministry, government staff would assess the reports before deciding whether to suspend licences.
“We need to consider dangerousness more than just diagnosis, which is what we used to do,” said Dr. David Gratzer, co-chief of general adult psychiatry at the Centre for Addiction and Mental Health (CAMH). “I worry that we’ve taken away clinicians’ judgment and understanding of people and replaced it with rules that are, at points, a little bit black and white.”
“Now it’s a philosophy of report first and ask questions later,” he said.
“We need to consider dangerousness more than just diagnosis,” said Dr. David Gratzer, co-chief of general adult psychiatry at the Centre for Addiction and Mental Health. Photo credit: Toronto Star
It is also not clear to what degree mandatory reporting is effective.
A 2019 review of the available science found “inconclusive evidence” about whether mandatory reporting laws actually increase the reporting of potentially unsafe drivers and reduce crash risk.
Ontario’s Ministry of Transportation defends the system.
“[It’s] a big reason why our roads and highways remain among the safest in North America,” the ministry said. “Ontario’s fatality rate has ranked our province among the top five safest jurisdictions in North America for over 20 years consecutively.” Ontario’s road fatality rate was 5.8 per 100,000 licensed drivers in 2018, according to the ministry.
In 2020, researchers published the “first comprehensive evaluation” of Ontario’s medical fitness-to-drive policies on road safety, and estimated the policies prevented 1,211 collisions over a decade.
But McLachlan said that a 2007 study on epileptic patients he co-authored indicated that Ontario’s mandatory-reporting system did not affect accident rates when compared to Alberta, where reporting is discretionary. His study also found more patients in Ontario withheld information about seizures from their doctors.
“Patients are definitely not as truthful to their doctors if they know the doctor is mandated to report them to the Ministry of Transportation,” McLachlan said. “That particularly applies to people who lost their licence and got it back again.”
When Karysa Mackay went to the hospital a little over two years ago for a flare-up of her depression, the 24-year-old registered nurse in Moose Factory, Ont., held back on describing how she was feeling.
“Some of the things I said maybe weren’t as in-depth or I wasn’t as truthful,” she said.
Karysa Mackay’s experience having her licence suspended has tempered her candour when speaking to doctors. “You might not speak exactly how you’re feeling, or you might sugarcoat it a little bit,” she said. Photo credit: David Jackson
The reason why? When she went to the hospital during an intense bout of depression the year prior, she ended up losing her licence after a psychiatrist she does not recall ever meeting reported her to the government. Her suspension was later overturned by a tribunal that found no evidence she posed a risk on the road.
The episode tempered her candour when seeking help.
“You might not speak exactly how you’re feeling, or you might sugar-coat it a little bit,” she said. “If you’re not telling them the severity of what you’re going through, you’re not going to get enough care.”
Mandatory reporting can “shift some behaviour underground, … fracture doctor-patient relationships and potentially worsen a patient’s mood disorder,” said Dr. Donald Redelmeier, a scientist at Sunnybrook Health Sciences Centre who has researched the efficacy of mandatory reporting.
Redelmeier ultimately supports mandatory reporting. Caring for patients whose lives have been forever changed by catastrophic car accidents informs his perspective.
“There’s just all the pain, all the anguish,” he said. “It just tears at my soul a little bit how lives have been ruined because of small errors that could have been entirely avoidable.”
Dr. Donald Redelmeier, seen here in 2010, is a scientist at Sunnybrook Health Sciences Centre who has researched the efficacy of mandatory reporting. Photo credit: Toronto Star
Dr. Raju Hajela, a contributor to a Canadian Medical Association guide on assessing fitness to drive, has worked in Ontario and Alberta and prefers discretionary reporting.
“There is a considered decision made between the doctor and the patient,” he said. “In the provinces where there is mandatory reporting, doctors are sometimes acting out of fear … There’s a lot of overreporting.”
Many physicians and road safety experts say that ongoing confusion about filing MCRs is also rooted in a lack of training.
“Physicians are forced to report but are not taught how,” said Dr. Frank Molnar, a geriatrician and another contributor to the CMA guide. “There are thousands of instances of [doctors] not knowing they should report patients with all sorts of medical conditions.”
“Medical schools generally teach this topic but a one-hour lecture out of thousands of hours of learning will not carry over to practice years later,” Molnar said.
A 2018 survey of 242 B.C. doctors found that 94.6 per cent reported having either no or only a little training when it came to familiarity with guidelines for determining fitness to drive.
Molnar said that doctors such as himself and the Canadian Medical Association try to address this knowledge gap by teaching other doctors about reporting unsafe drivers, but this amounts to “voluntarily donating time to do what ministries of transportation … should do,” Molnar said.
“An issue like this that affects all Canadians, should not be left to volunteers such as myself to do [in] our spare time,” Molnar wrote. The “lack of support in Ontario is appalling.”
In the state of Victoria, Australia, the onus is on drivers to report themselves. And they do.
Victoria has been a world leader in road safety for decades, having repeatedly implemented groundbreaking measures to reduce accidents. In 1970, it became the first jurisdiction in the world to make wearing a seatbelt mandatory.
Its vigorous road safety efforts have paid off. It has consistently been a leader in road safety among Australian jurisdictions; in 2019, Victoria’s road fatality rate was 4.06 per 100,000, compared to Australia’s average of 4.68.
While Victoria does not shy from taking bold action to keep its roads safe, it decided against implementing mandatory reporting because of inconclusive evidence that it was effective and evidence that it damages the patient-doctor relationship and could drive patients away from seeking health care.
“The lack of mandatory reporting is really important,” said Dr. Morris Odell, a recently retired physician in Victoria with expertise in traffic safety. “There are conditions such as epilepsy, diabetes, where it’s vital that there’s a good working relationship between patient and doctor. You can’t treat these conditions unless the patient tells you the truth about what’s happening … Mandatory reporting interferes with that.”
Instead, in Victoria, anyone — from doctors to members of the public — can report drivers to the state transportation authority. In about 60 per cent of cases assessed by the state government, however, it is drivers themselves who come forward.
Under Victoria’s system, straightforward cases can prompt a request for additional reports or driving assessments. More complex cases can trigger a review by a team of experts who consider the facts and make a consensus recommendation.
Those obviously unfit to drive lose their licences quickly, said Odell, who participated in Victoria’s fitness-to-drive assessments. Unlike in Ontario, the authorities in Victoria rarely automatically suspend the licences of reported drivers.
Victoria’s Department of Transport has assessed between 80,000 and 90,000 drivers annually for the past five fiscal years, according to a department spokesperson.
The transportation authority only suspends or cancels licences in approximately 12 per cent of cases, according to a 2018 report. Most often, drivers are required to undergo periodic reviews or drive with conditions on their licence, such as a prohibition from driving at night.
“One of the overarching principles behind the whole system is keeping people mobile for as long as possible, especially in rural areas where your whole life can depend on being mobile,” said Odell.
Many say it is past time for the province to reassess its approach to suspending driver’s licences based on medical conditions.
“It’s caused all kinds of angst,” said sleep specialist Hoffman. “I think people are yearning [for a system] where you don’t report everybody, you only report those that you feel are a threat.”
With files from Danielle Orr and Anrike Visser (Investigative Journalism Bureau) and Abeer Khan, Heidi Lee and Kayla Zhu (Toronto Metropolitan University)
The Investigative Journalism Bureau is a non-profit newsroom based at the Dalla Lana School of Public Health.
This article is also available on the Toronto Star website.