Health certificates valid while drivers severely ill

Illustration: maanteeamet

As often noticed by rehabilitation doctor Maarika Nurm, peeking out her window: patients freshly recovered from a stroke or trauma, only initially recovered, hop behind the wheel – even when warned by her to wait with driving due to health risks.

Riigikogu member Rait Maruste, having suffered a stroke a year and a half ago, did not drive for six months thereafter. «My wife drove. For that, we even got a car with automatic gearshift,» relates Mr Maruste.

«The trauma makes itself felt in various ways, depending on the part of the brain affected. I had double vision in the right corner of the right eye, trouble with coordination. Little by little, things get restored. Now, a year and a half later, I have no problems driving,» said Mr Maruste.

«Strokes and other serious brain damage may cause paralysis, disruptions of feeling and sense in limbs, problems with sight – both double vision and defects in visual field,» said Maarika Nurm, chief doctor of Keila Rehabilitation Centre. According to her, cognitive problems, often accompanying brain damage, are the most dangerous.

«Loss of ability to concentrate, to multitask; sensing malfunctions, decrease in skills and speed to solve problems, problems with memory,» listed Ms Nurm. According to her, patients are often unable to assess their abilities and fail to admit the problem. «They say they have been driving the whole life,» said Ms Nurm.

Relatives and friends often find themselves concerned, trying to talk the patients out of driving. Even so, driving is often given up only after repeated accidents. With luck, it is only the vehicle that suffers.

«It may well be that one just doesn’t feel the difference, after brain damage. Failing, for instance, to judge distances,» admitted Mr Maruste. «I repeatedly asked the doctor what I could and couldn’t do; the doctor said it was mostly up to how one feels. Naturally, people must always behave responsibly. However, in case of a shock, they may not perceive the consequences, it may be hard to assess one’s abilities.» He thinks that, with strokes, a time needs to be set when a person is supposed to have a health check. Also, the checks ought to include mandatory testing of driving abilities.

Ms Nurm pointed to UK, where no one is allowed to drive after a stroke, for a month. «Over there, a patient is expected to report to regulators of his/her health. Thereupon, they are issued a questionnaire; on the basis of answers, people are directed to mobility centres where doctors do a flash test, a specially trained driving instructors then testing the people out in traffic, to see how they do,» explained Ms Nurm. The Keila Rehab Centre is planning a mobility centre, of the British sort.

In Estonia, no compulsory checks are required to maintain right to drive as health deteriorates; issuing the health certificates required for the right to drive is often a mere formality for family doctors.

«Right to drive a vehicle is suspended by Road Administration in case a driver’s health does not correspond to prescribed requirements; for that, family should supply Road Administration with a renewed certificate stating that the driver is not allowed to be at the wheel,» explained the agency’s test department head Toivo Kangur.

Alas, it is not that simple. Family doctors may not be aware of serious health issues with their patients, as the latter have attended other doctors and failed to notify them.

«Attending physicians are not under definite obligation to inform Road Administration or family doctor of altered health situation; therefore, in Estonia, we are having a situation where people unqualified to drive enter traffic, there being no obligation to inform agencies authorised to suspend right to drive of severe damages to central nervous system,» explained Ms Nurm.

Family doctors being the ones who issue health certificates, Ms Nurm has passed information on her patients directly to them.

Meanwhile, as explained by family doctors’ society head Diana Ingerainen, the options for declaring health certificates invalid are unclear. «In some cases, with patients having serious health problems, I have anonymously, so to speak, called the Road Administration’s motor vehicle register, so they can send these persons for extra health checks,» Ms Ingerainen confessed.

According to Mr Kangur, Road Administration may suspend right to drive upon written notifications by family doctors or medical committee. However, if people possess valid health certificates and do not consider it necessary to have their health checked, family doctors and Road Administration cannot force it upon them. «Then there is nothing doing. Should people prove dangerous in traffic, acting inconsistently, police has the right to take them out,» said Mr Kangur. In that case, people will have to have their health checked.

«With strokes, it is advisable to have an extra check; even so, having had a stroke will not necessarily mean suspension of right to drive,» said Ms Ingerainen.

«Then there are health conditions rendering people temporarily unable to drive; everybody is expected to judge for themselves, when it is safe to drive again. Such as migraine head-aches, accompanied by disturbed vision, or fits of anxiety,» added Ms Ingerainen.

At the family doctors’ society’s initiative, a new and more specific order of obtaining health certificates may enter into force, starting next June. While currently the entire responsibility lies with doctors themselves, who are having to decide, in the face of resistance by patients, which checks will have to be made, the new order will make mandatory matters much more definite. «For all to have the same understanding of the basics of issuing certificates, we will make it digital; health checks will be made transparent,» said the society head.

According to Ms Ingerainen, this ought to do away with a situation where any health certificate may basically be purchased of family doctors.

Pursuant to new order, health certificates would come at three levels of complexity. A-certificate would be for ordinary drivers, applicants for weapons permits, and assistant police officers. B-certificates would be for security guards and railway workers, level C is required for policemen, prison workers, train drivers, sailors etc.

With each group, details of checks are specified. What is even more important, all data entered unto the certificate shall be verifiable via a common health database.

Health certificates are based on people’s own answers regarding their health. According to Ms Ingerainen, family doctors often run into young men who, on paper, seen to have two different bodies. «One comes to get health checked due to conscription to Defence Forces: he is of very poor health... Then the same young man, as if, comes to get the health certificate for driver’s licence, fit as a fiddle,» chuckled the doctor. Such cases of double health would be immediately exposed by the new system.

Even now, starting 2009-2010, family doctors are able to verify treatments of patients in any Estonian institution, via e-Health system, up to 97 per cent of cases. Thus, family doctors may remind patients, should they leave anything out while filling the blanks.

If everything goes according to plan and Riigikogu ratifies the amendments, all applying for health certificates will be handed pre-filled health declarations. These will automatically include all surgeries and serious sicknesses; all people will have to do is answer general health questions.

Next, doctors fill in their own data, prescribe further medical examination (if needed) and enters into that very system the health decision regarding driving or working as a policeman.

According to Ms Ingerainen, the authors of the amendment dream of an automatic notification system so that information of changed health would immediately reach Road Administration. Due to private data protection this could not be the diagnosis; just a notice that the person needs to undergo a fresh health check to obtain a new certificate.

«I think such notification would be fair; not just in the interests of Road Administration, but in the interests of the people concerned,» said Mr Maruste, the parliament member.