You Don’t Fatten the Lambs by Weighing Them

As I struggled to understand who is responsible for safe senior mobility, the image that appeared in my mind was a Thomas Nast political cartoon I remembered from a middle school history book. Members of the notorious Tweed Ring, caricatured as potbellied politicians in suspenders and top hats, stood in a circle, each pointing to the person beside him, assigning responsibility to someone else.

I'm worried about their driving - I think you should talk to them

I phoned an artist friend and commissioned a cartoon to capture the image I pictured in my mind, describing the people I saw as key players-family, public safety, healthcare providers, and of course, the older people. When I saw the cartoon she drew, it was perfect.

There in the circle were caricatures of the people we recognize in the senior mobility drama-adult children and their children, a healthcare provider, and the department of motor vehicles. The artist, Toni Wolf, was much kinder than Thomas Nast and everybody looks friendly and nice. But they are all assigning to the next person responsibility for talking about safe driving, and no one is talking to the older people, who appear in the remote corner.

Last week on the Storybook Tour, as I talked to medical students at the University of Oklahoma Health Sciences Center, the cartoon came to life. I was visiting with my dear friend, Dr. Germaine Odenheimer, a geriatric neurologist and a pioneer in the field of medicine and older drivers. Germaine and I became friends more than 20 years ago when I met her at a national conference. She is fond of telling everyone that I shook my finger and yelled at her, claiming doctors were not doing their job helping to identify impaired older drivers. Germaine teaches medical students and offers one of the only classes in the country on how to have a conversation with an older person about letting go of the keys. She contacted several of her former students who are now practicing. Dr. Gabriel Vidal, an internist, and Dr. Audra Yadack, a geriatric psychiatrist, agreed to tell their stories for the Tour. Germaine also interviewed for the Storybook Tour. She broached the sensitive subject about which we long ago argued, and have since simply agreed to disagree-mandatory reporting of impaired older drivers.

I asked Germaine if I could also speak with her current students, and she not only let me lead the class discussion, she left the room so her students could feel free to speak their minds. The subject I chose was mandatory reporting, and I pushed them pretty hard. I asked them how they felt about reporting impaired drivers, as people soon to become doctors. The students recognized there is a safety problem with diminished capacity older drivers and are not opposed to speaking to their patients about it, but they felt it was not their job to report them to a state agency. At first, they said it was the state's responsibility to identify impaired drivers. I told them a story I had just heard in Dallas. I interviewed a man who had to stop driving many years ago because he lost his vision. At the end of the interview, I asked him if he had any advice he would like to share with others. He suggested people learn to use the 211 call system and relayed how he learned how to renew his driver’s license through 211.

I switched off the camera. "Let me clarify this," I said. "Did you call 211 years ago when you could still see well enough to drive?"

"Oh, no," he said. "I just renewed my license."

I asked permission to switch the camera on so he could tell his story, and he did. [link]

A few days later, in Oklahoma City, I told the Dallas story to a blind woman, who offered that she had also just renewed her license. Apparently it is easier to renew a license than it is to apply for a state ID card. 

After hearing this story, the medical students could see that we may not be able to rely on the states to screen out impaired drivers, but they still did not feel it should be their job. They were more than willing to refer questionable cases to another professional, such as an occupational therapist, but they just did not think it was a medical issue.

Mandatory reporting was even more objectionable to them. I pointed out that there is mandatory reporting for many public health issues, sometimes as difficult to call as diminished capacity to drive. Depending on state law, there is mandatory reporting for elder abuse, child abuse, tuberculosis, HIV, STD’s, spinal cord, brain injury, and numerous other epidemiological public health concerns. 

This is where Germaine and I differ. While we both think motor vehicle injury and death is a public health issue (hard to argue it is not) I think it falls into the public health category of mandatory reporting. According to the National Highway Traffic Safety Administration Fatality Analysis Reporting System (FARS) 65,034 people age 75 and older have died in automobile crashes between 1994 and 2012. Since 90% of vehicle crashes are attributable to driver error, reporting will save lives. No one wants to be told what to do. But I guess that is why we have laws, because sometimes we just have to do what is in the public interest, for the good of others, for the good of all.

That said, I do realize that we don't fatten the lambs by weighing them. That is why I have not spent the last 25 years working on testing and reporting impaired older drivers, but on improved transportation for older people, so we can all make better choices. Without better alternatives to driving, our choices are so much more difficult than they need to be and our lives are unnecessarily diminished.

So whose responsibility is it to speak with impaired older drivers? Everyone.

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