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| To Report, or Not Report |
| Columns - On the Web | ||||||||
| Written by Dr. Gitlow | ||||||||
| Tuesday, 07 August 2007 | ||||||||
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Every week you have the opportunity to see Mr. Smith, a young man with
alcoholism. He isn’t quite ready to enter treatment but clearly is
starting to show the signs. His wife is working with you to present a
united front, and even his employer is on board. You suspect that
within the next few months, Mr. Smith will be able to start getting
better. In the meantime, each time you see him in the late afternoon,
the smell of alcohol is on his breath. He acknowledges having a few
beers with lunch; you are relatively certain that “a few” is at least
three or four. His tolerance is high, however, Mr. Smith walks into
your office without difficulty, meets with you, and then walks out to
his car in the parking lot.
So, there goes Mr. Smith, with a blood alcohol level of 0.15 or so, to his car. He is about to drive under the influence, an illegal act nationwide. He does this regularly, frequently and with your knowledge. With due consideration of the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR 2 privacy and confidentiality issues that we discussed last time, as well as consideration for the public safety and the law as to your responsibility for all of the above, what will you do now? What are the requirements? There are certain requirements as to how you should proceed. In Pennsylvania, if you are a licensed clinician authorized either to diagnose or treat a condition that may impact driving safety, you must report the patient to the Department of Transportation within 10 days of diagnosis.Your identity is protected and you are specifically relieved of liability, either criminal or civil, for having made such a report. In Florida, you are allowed to submit a report to the Department of Highway Safety and Motor Vehicles if you have knowledge of a driver’s mental or physical driving impairment. Again, anonymity and freedom from liability are part of the process, though these variables are not consistently applied among states. The major difference in law between these two states lies in whether such a report is required. The difference in how specific patients might understand the degree of confidentiality that they expect from their treating clinician, however, lies with you and the degree to which you educate them. Online informational sources provide a healthy supply of background information that you should both understand and share with patients at the time of your first meeting. A quick overview is available at: http://www.nhtsa.dot.gov/people/injury/olddrive/CommMobilityDementia/pages/CurrentScr-StatePolicy.htm You will note that each state has differing definitions of what needs to be reported; who may or must report; what degree of confidentiality (if any) will be afforded to the information you provide; and what the consequences will be for both the reporter and the specified individual. There are clearly difficulties where state lines are involved; if you see a New York licensed driver in your office in Pennsylvania, do you have an obligation to make a report? The American Association of Motor Vehicle Administrators (AAMVA), at http://www.aamva.org, has a Model Law for reporting of driver impairment. Within the model law, a state department of motor vehicles will establish a medical advisory board to make advisory opinions. The model law specifies that any health care provider may notify the Department of Motor Vehicles (DMV) if a disease or condition is present that may impair driving to a degree that precludes safe operation of a motor vehicle. A thorough description of each state’s program is available by downloading a .pdf file from AAMVA entitled “Summary of Medical Advisory Board Practices in the United States.” This 2003 report is 453 pages and indicates that in Pennsylvania, approximately 16,000 reports are received each year indicating the presence of medical impairments. Pennsylvania specifically includes, “Use of any drug or substance, including alcohol, known to impair skill or function, regardless of whether the drug or substance is medically prescribed.” That clearly establishes the requirement to report any patient taking sedative or opioid agents as prescribed, as well as patients who are not in recovery from a substance use disorder. In California, a mandatory physician reporting law exists. It does not apply to non-physician clinicians, but should such a clinician refer a patient to a physician for consultation, treatment, or evaluation, one consequence would be a mandatory report. A failure to report such a patient results in the physician potentially being held liable as a proximate cause of a resulting motor vehicle accident. While addictive disease is not specifically included within the California regulation, the law does define reportable conditions as including a medical condition that involves the impairment of sensory motor functions used to operate a motor vehicle. It would be difficult to argue that this definition does not include substance use disorders. What are the consequences? Every single patient with active substance use in certain states must be reported to their DMV, and will likely lose their driver’s license as a result. Imagine, if these laws were to be followed precisely, the degree to which patients would likely fail to seek treatment for addictive disease. Imagine the lack of trust that would arise as the typically protected clinician-patient bond is broken. One might argue that reporting serves as protection for the patient just as we would report suicidal intent, or protection for the public as in the case of reporting homicidal intent. A report of suicidal or homicidal intent sometimes leads to a loss of liberty, typically brief, for acute treatment. Sometimes, reports of alcoholism to a DMV, as in Alaska, result in a minimum of one year without a driver’s license. To what degree do you feel these laws are followed? Would you report Mr. Smith? To what degree do you feel these laws are in the best interest of your patient and the public? As always, I welcome your thoughts and comments at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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