Driving Restrictions for People with Epilepsy: Autonomy vs. Public Safety

Transcript

• 00:00The program for biomedical ethics.
• 00:04And,
• 00:05we have a great program
• 00:07for you tonight, which you
• 00:07can see up here. Really,
• 00:09it's a specific case that
• 00:10illustrates,
• 00:11the fascinating
• 00:13potential conflict or at least
• 00:14contrast
• 00:15between public safety and autonomy,
• 00:17the needs of the many
• 00:18and the needs of the
• 00:18few or the one.
• 00:20And so I'm really looking
• 00:21forward to this conversation.
• 00:23Let me say before we
• 00:24begin, the usual stuff I
• 00:26say, Forgive me for saying
• 00:27it one more time. First,
• 00:28I'm sorry to introduce myself.
• 00:30I know mostly. My name
• 00:30is Mark Mercurio.
• 00:32And for a little bit
• 00:32longer, I'm the co director
• 00:34of the program for biomedical
• 00:35ethics.
• 00:38And we are gonna tonight,
• 00:40hear from two speakers. First,
• 00:41doctor Ben Tolchin and then
• 00:43doctor Rich Maratoli,
• 00:45to talk about this subject.
• 00:46Now,
• 00:47to remind you, the the
• 00:49the the talks will be
• 00:50about, you know, thirty five
• 00:52to forty minutes by Ben.
• 00:53Everything's a little plus or
• 00:54minus. Right? And then Rich
• 00:55will talk for ten or
• 00:56fifteen. And then we should
• 00:57have about a half an
• 00:57hour for comment and conversation.
• 01:00It's just an interesting subject,
• 01:01and I know next to
• 01:02nothing about it. But I
• 01:03bet I'm like many people
• 01:04in the audience where I've
• 01:05had to face it with
• 01:06members of the family,
• 01:07and and or and also
• 01:09with, with colleagues.
• 01:11So this will be very
• 01:12helpful to us. So we're
• 01:13gonna enjoy the conversation,
• 01:14and we will, however, at
• 01:16six thirty,
• 01:17call it a night. So,
• 01:18please be aware of that.
• 01:19So if it's six twenty
• 01:20five, you're itching to leave
• 01:22and Rich is just saying
• 01:23something really intelligent, don't work
• 01:24out on him. Let him
• 01:25finish this point. Knowing that
• 01:27at six thirty, I promise
• 01:28to spring in.
• 01:30So let me,
• 01:31just remind the students, you
• 01:33need to sign up. I
• 01:33think Karen's gonna move these
• 01:34to the back because there's
• 01:35a bunch of students who
• 01:36had another meeting and are
• 01:37gonna be coming in a
• 01:37little bit late. So please
• 01:39make sure you sign up
• 01:40the the concentration students so
• 01:41you get credit for this.
• 01:42Now I wanna introduce, Ben
• 01:44Tolchin now,
• 01:47and then,
• 01:48and then I'll introduce Rich
• 01:49when Ben is finished. So
• 01:51Ben Tolchin is and if
• 01:53I get this no. Don't
• 01:54get this exactly right. Forgive
• 01:55me. But Ben is the
• 01:56director of the of the
• 01:57Center for Clinical Ethics at
• 01:59the health system, which is
• 02:00at Yale New Haven Hospital
• 02:01as well as our affiliated
• 02:02hospitals.
• 02:04And so Ben oversees all
• 02:05the clinical ethics work, at
• 02:07the in the adult service,
• 02:08here at Yale.
• 02:10He,
• 02:11is a neurologist, an adult
• 02:12neurologist by trade.
• 02:14He went to school at
• 02:15Harvard.
• 02:16And then, wait. Let me
• 02:17make sure I make sure
• 02:18I get this right. So
• 02:19I'm gonna look down. I
• 02:20apologize. I should have memorized
• 02:21this stuff. Medical school
• 02:23at Harvard University, neurology residency
• 02:25at Columbia University Medical Center,
• 02:27fellowships in medical ethics, clinical
• 02:28neurophysiology,
• 02:29and epilepsy at Brigham and
• 02:31Women's and Harvard Medical School.
• 02:34He's been recognized with the
• 02:35young investor
• 02:36young investigator award from the
• 02:38American Clinical Neurophysiology
• 02:40Society and the American Epilepsy
• 02:42Society and many other recognitions.
• 02:44Ben is a leader specifically,
• 02:46in the field of epilepsy
• 02:48studies.
• 02:51He he completed medical school.
• 02:53And it says it here
• 02:53twice. I'm gonna just say
• 02:54it twice.
• 02:56Of note is Ben is
• 02:57also taking over my role
• 02:59as co director along with
• 03:00Chan Miller, co director of
• 03:02the program for biomedical ethics.
• 03:03Now it said, I think,
• 03:04on some of the stuff
• 03:05that got sent out, Karen.
• 03:06I think it said that
• 03:07he was the interim co
• 03:09director of the program for
• 03:10biomedical ethics, to which I
• 03:11say not so fast.
• 03:13We still got I think
• 03:14I've got, like, four days
• 03:15left in this role. So
• 03:17it's not so fast there,
• 03:18Ben.
• 03:19I'm delighted that Ben agreed
• 03:20to speak
• 03:21this year. This and we've
• 03:22made these plans, you know,
• 03:23several months ago. So I
• 03:25am particularly delighted that it
• 03:26works out that that, my
• 03:27last night here is actually,
• 03:29Ben is the speaker. So
• 03:30we can have the passing
• 03:31of the, of the water
• 03:32bottle of the baton or
• 03:33whatever we can find here.
• 03:35But, very much looking forward
• 03:36to hearing Ben's talk. And
• 03:37then when Ben is done,
• 03:38I'll introduce Rich, and then
• 03:39we'll have a conversation.
• 03:41So doctor Ben Tolchin, thank
• 03:42you very much.
• 03:52So thanks very much. I
• 03:54I just wanna start by
• 03:55saying thanks to to Mark,
• 03:57who's been an incredible mentor,
• 03:58teacher, and and friend for
• 04:00for years,
• 04:02and has been
• 04:04similarly,
• 04:05a a mentor and teacher
• 04:06for for so many people,
• 04:07within the health care system,
• 04:08within the university.
• 04:10And and also thanks to
• 04:12to you for for your
• 04:13attention. You know, the last
• 04:14time I spoke at at
• 04:15one of these seminars,
• 04:17we were still remote. And,
• 04:20so it's it's really nice
• 04:21to, to be back and
• 04:22and be able to to
• 04:23speak to you all in
• 04:24person and to have a
• 04:25conversation.
• 04:28Today, I I wanna talk
• 04:29about,
• 04:31driving restrictions for people with
• 04:32epilepsy and and the balance
• 04:34between patient autonomy
• 04:36and and concerns for public
• 04:38safety.
• 04:40Some disclosures about research funding.
• 04:44My hope is that by
• 04:45the end of this talk,
• 04:45you'll be able to summarize
• 04:47the history of driving restrictions
• 04:49relating to epilepsy, particularly in
• 04:50the United States, that you'll
• 04:52be able to explain the
• 04:53evidence that mandated reporting by
• 04:55physicians and some driving restrictions
• 04:57have failed to prevent motor
• 04:58vehicle accidents and have caused
• 05:00unintended negative consequences,
• 05:02and that you'll be able
• 05:03to describe key consensus positions
• 05:05on driving and seizures
• 05:07currently advanced by both professional
• 05:09organizations
• 05:10and patient advocacy organizations, including
• 05:12the American Academy of Neurology,
• 05:14the American Neurologic Association, the
• 05:15Child Neurology Society, the American
• 05:17Epilepsy Society, and the Epilepsy
• 05:19Foundation of America.
• 05:24So so going back to,
• 05:27the the
• 05:28beginning of, automotive history in
• 05:31the,
• 05:32late nineteenth century,
• 05:33the the first motor vehicle
• 05:35accidents,
• 05:37caused by seizures were reported
• 05:38in in nineteen o six,
• 05:40shortly after,
• 05:41cars became
• 05:43available to the general public.
• 05:46And so when early driving
• 05:48license laws started to be
• 05:50contemplated and passed,
• 05:52in England, in India, and
• 05:54in the United States,
• 05:57in the nineteen thirties,
• 06:00these laws
• 06:01generally treated epilepsy as a
• 06:03permanently disqualifying condition. So a
• 06:05person with a history of
• 06:06epilepsy
• 06:07simply could not get a
• 06:08driver's license,
• 06:10in in any of those,
• 06:11nations.
• 06:14That that started to change
• 06:16in the late nineteen thirties
• 06:17as
• 06:18effective anti seizure medications began
• 06:21to be developed and and
• 06:22used.
• 06:24And by
• 06:25nineteen forty nine, Wisconsin actually
• 06:27became the first US state
• 06:29to relax the complete prohibition
• 06:31and to say, alright. You
• 06:33can drive if you have
• 06:34epilepsy,
• 06:35and,
• 06:36the epilepsy
• 06:37is adequately controlled.
• 06:39And and by that, they
• 06:42they define that as as
• 06:43being seizure free
• 06:45for two years.
• 06:47And Wisconsin actually
• 06:48was very diligent about this.
• 06:50They monitored
• 06:51the the outcomes of the
• 06:53drivers who were licensed,
• 06:54with epilepsy and and compared
• 06:56that to the general population.
• 06:57And they found that the
• 06:58rates of motor vehicle accidents
• 07:00among individuals with epilepsy,
• 07:02with well controlled epilepsy,
• 07:04were low and comparable to
• 07:06the general population of drivers.
• 07:08And that actually inspired
• 07:11a number of other US
• 07:12states to follow Wisconsin's lead.
• 07:14And by nineteen fifty six,
• 07:16there were eighteen
• 07:17states that similarly
• 07:19were granting driving licenses to
• 07:21individuals with controlled seizures. And
• 07:23there was another seven states
• 07:25that would take into consideration,
• 07:28the the control of of
• 07:30the seizures
• 07:31in in making driving license
• 07:33determinations.
• 07:34And then by nineteen sixty
• 07:35six,
• 07:36the UK followed
• 07:39a similar
• 07:42precedent and began to
• 07:44look at seizure control rather
• 07:46than simply a history of
• 07:47epilepsy
• 07:48as the major determinant,
• 07:50for for driving licenses
• 07:52in individuals with epilepsy.
• 07:55And from from the nineteen
• 07:56seventies onward, there's been a
• 07:58gradual liberalization
• 08:00of driving restrictions
• 08:02in,
• 08:03US states
• 08:04and in the UK.
• 08:06And
• 08:07many, but not all countries,
• 08:09have have followed that precedent,
• 08:11particularly,
• 08:12former Commonwealth
• 08:13countries and and,
• 08:15English speaking countries
• 08:17that that tend to look
• 08:18to the US and the
• 08:19UK
• 08:19for legal precedent have have
• 08:21have followed,
• 08:23that lead. Although there are
• 08:24still countries where
• 08:25simply a history of epilepsy
• 08:27is enough to,
• 08:29prohibit one from driving permanently.
• 08:33Importantly,
• 08:35in the US and the
• 08:36UK,
• 08:38commercial drivers are treated differently
• 08:40and with a great deal
• 08:41more,
• 08:43restriction. I think appropriately so
• 08:45given that,
• 08:47commercial drivers are driving,
• 08:50much longer hours often under
• 08:52more more
• 08:54difficult conditions,
• 08:55and they're driving
• 08:57either
• 09:00public transportation
• 09:01or larger vehicles that,
• 09:03pose significantly greater risk if
• 09:05there is a motor vehicle
• 09:06accident. And so interstate commercial
• 09:09driving
• 09:10is regulated by in the
• 09:11US by federal law, which
• 09:13has very strict
• 09:15prohibitions. Basically, some an individual
• 09:17has to be
• 09:18seizure free off of anti
• 09:21seizure medications for for at
• 09:22least five years in order
• 09:23to drive,
• 09:24commercially interstate traffic in the
• 09:26United States.
• 09:29But this gradual trend towards
• 09:31liberalization,
• 09:33I I think really
• 09:35led in in nineteen ninety
• 09:37one to professional organizations
• 09:39and patient advocacy organizations
• 09:41to come together
• 09:42and
• 09:45try to develop
• 09:48a consensus conference leading to,
• 09:51national recommendations on on what
• 09:53driving licensure law relating to
• 09:55epilepsy should look like nationally.
• 09:58And in nineteen ninety four,
• 09:59they did in fact, publish
• 10:00their recommendations and also published,
• 10:03model regulations and sample statutory
• 10:05provisions that,
• 10:07policymakers could draw on.
• 10:09And I want to highlight
• 10:11some of the positions that
• 10:12were advanced in nineteen ninety
• 10:13four because I think many
• 10:14of them hold up quite
• 10:15well today.
• 10:17So,
• 10:18the the consensus position statement
• 10:20from nineteen ninety four recommended
• 10:22that medical advisory boards, and
• 10:24we're fortunate to have the
• 10:25chair of,
• 10:26our state's medical advisory board
• 10:28here as our next speaker,
• 10:29should be setting medical criteria
• 10:31for driver licensure.
• 10:34They recommended that licensing criteria
• 10:36should appear in regulations and
• 10:38guidelines rather than in statute.
• 10:40So it's so the criteria
• 10:42for when somebody is safe
• 10:43to drive should not be
• 10:44written into the law, Rather,
• 10:46the law should empower
• 10:48medical advisory boards and and
• 10:50DMVs
• 10:51to set those criteria,
• 10:53and and to modify those
• 10:54criteria as the evidence changes
• 10:56and develops.
• 10:59The licensing process should allow
• 11:00individual consideration of driving risks,
• 11:03and licensing criteria should be
• 11:05fair, nondiscriminatory,
• 11:06and based on comparable risks
• 11:08in other populations.
• 11:11They recommended in nineteen ninety
• 11:12four a minimum seizure free
• 11:14interval of three months. So
• 11:15that's significantly shorter than the
• 11:18two years that Wisconsin had,
• 11:21set back in nineteen forty
• 11:22nine
• 11:23as a mandatory seizure free
• 11:25interval before before a person
• 11:27who has had a seizure
• 11:28can resume driving.
• 11:30They recommended that that three
• 11:31month interval could be modified
• 11:33based on favorable and unfavorable
• 11:35factors.
• 11:36And then they recommended that,
• 11:38practitioners should be allowed but
• 11:39not mandated to report unsafe
• 11:42drivers, and that practitioners should
• 11:44have legal immunity whether or
• 11:45not they reported,
• 11:47an unsafe driver.
• 11:49In two thousand seven, the
• 11:51American Academy of Neurology reviewed
• 11:53and reaffirmed these these positions
• 11:55and gave a few additional
• 11:57recommendations. I think the most
• 11:58notable of which was the
• 12:00recommendation that national and state
• 12:01governments should support alternative transportation
• 12:04for those restricted from driving
• 12:06for medical reasons.
• 12:09And and that's really been
• 12:11sort of the professional guidance
• 12:13on, driving an epilepsy, and
• 12:15it's been
• 12:16very influential
• 12:17in, state legislation.
• 12:21Although, I I will say
• 12:22that there is a wide
• 12:24range of heterogeneous
• 12:26laws,
• 12:27with
• 12:28different seizure free intervals ranging
• 12:30from three months to eighteen
• 12:32months,
• 12:34some where it's not really
• 12:35clearly specified what the seizure
• 12:36free interval is.
• 12:38There are different positions in
• 12:39terms of
• 12:40mandatory reporting
• 12:42by clinicians versus voluntary reporting.
• 12:45But all all of the
• 12:47the
• 12:48laws are are are fairly
• 12:50clearly influenced by that nineteen
• 12:51ninety four position statement.
• 12:55In two thousand twenty two,
• 12:56the AAN
• 12:58reviewed the, the position statement
• 13:00and brought in the other
• 13:01organizations that had been involved,
• 13:02the American Epilepsy Society, the,
• 13:05Epilepsy Foundation of America, as
• 13:06well as the American Neurologic
• 13:07Association and the Child Neurology
• 13:09Society.
• 13:10And
• 13:11all of the the organizations
• 13:13agreed that
• 13:14while most of the positions
• 13:16were,
• 13:18held up well,
• 13:19twenty five years later, there
• 13:21there were certain gaps, and
• 13:23there was also really
• 13:25a lack of attention to
• 13:26the evidence that had had
• 13:27continued to develop over the
• 13:29the twenty five years between
• 13:31the,
• 13:33the nineteen ninety four publication
• 13:34and and and two thousand
• 13:35twenty two. And so at
• 13:37that time,
• 13:39a a task force was
• 13:40assembled,
• 13:41of
• 13:42drawn from all of these
• 13:43different professional and, advocacy organizations
• 13:47to do a targeted,
• 13:49literature review. And and I
• 13:50wanna highlight
• 13:51a a few of the
• 13:52findings for you because I
• 13:53think they they bear
• 13:56on the issue of driving,
• 13:58with epilepsy and the balance
• 13:59of public safety versus autonomy
• 14:00there, but may also inform
• 14:04that consideration of that balance
• 14:05in other,
• 14:07conditions as well.
• 14:09So
• 14:10the,
• 14:12the targeted review found, first
• 14:14of all, that there is
• 14:15a modestly increased risk of
• 14:17motor vehicle accidents associated with
• 14:19epileptic seizures, and that risk
• 14:21is higher with more frequent
• 14:24seizures. The the greater the
• 14:25frequency, the higher the risk
• 14:25of motor vehicle accident.
• 14:27At the same time, there
• 14:28is not a statistically significant
• 14:31increase in fatal motor vehicle
• 14:33accidents among in drivers with
• 14:35epilepsy when compared to the
• 14:36general population,
• 14:38and the risk of fatal
• 14:39motor vehicle accidents in drivers
• 14:41with epilepsy is significantly lower
• 14:44than among individuals
• 14:45with alcohol use disorder,
• 14:47young drivers, or older drivers.
• 14:52The risk
• 14:53of recurrent seizures and motor
• 14:55vehicle accidents for individuals
• 14:57with epilepsy
• 14:59declines
• 15:00as that individual has a
• 15:02longer seizure free interval.
• 15:04And that's borne out in
• 15:06multiple studies,
• 15:08for example, showing that as
• 15:09you get to six months
• 15:10of seizure freedom, twelve months
• 15:12of seizure freedom, eighteen months
• 15:13of seizure freedom, the individual
• 15:15risk of a recurrent seizure
• 15:16goes down. And similarly, the
• 15:18individual risk of a motor
• 15:19vehicle accident goes down.
• 15:22But interestingly,
• 15:23at the same time, at
• 15:25a population
• 15:26level,
• 15:27legal requirements for universal seizure
• 15:30free intervals longer than three
• 15:31months do not appear to
• 15:32reduce motor vehicle accidents or
• 15:34fatalities.
• 15:35And this is based on
• 15:36two important natural experiments.
• 15:38One in,
• 15:40Arizona in nineteen ninety three,
• 15:42the state shortened their seizure
• 15:44free interval
• 15:45from twelve months of seizure
• 15:47freedom prior to a person
• 15:48resuming driving
• 15:49down to three months and
• 15:51surprisingly found no increase in
• 15:53in motor vehicle accidents or
• 15:54motor vehicle accident fatalities
• 15:56on
• 15:57a per mile driven basis
• 16:00when looking at the three
• 16:01years before that change and
• 16:02the three years after that
• 16:03change.
• 16:04Similarly, in two thousand three,
• 16:07Maryland also implemented
• 16:09a minimum
• 16:10three month seizure free interval
• 16:12prior to an individual seizures
• 16:13driving.
• 16:15Maryland actually made the modification
• 16:17that they would allow
• 16:18individualized
• 16:20adjustment of that seizure free
• 16:22interval by their medical advisory
• 16:23board, which is a particularly
• 16:25active and robust medical advisory
• 16:27board. And they followed up
• 16:29over the ensuing seven years.
• 16:31And what they found is
• 16:32that in seven years after
• 16:33they implemented about three months
• 16:35seizure free interval,
• 16:36with the modifications by their
• 16:37medical advisory board, there were
• 16:39only two motor vehicle accidents
• 16:42caused by seizures reported in
• 16:43the entire state of of
• 16:44Maryland, which is
• 16:46a astronomically
• 16:47low,
• 16:48rate of motor vehicle accidents,
• 16:50like a really phenomenal finding.
• 16:52And so so these two
• 16:53states' experiences suggest that
• 16:57while
• 16:58individually
• 17:00longer seizure free intervals
• 17:02are,
• 17:04lead to to safer outcomes,
• 17:07when you get to a
• 17:07population level,
• 17:09that doesn't hold up. And
• 17:11so and and so why
• 17:12might that be? It seems
• 17:14paradoxical.
• 17:15So there's also there are
• 17:17also findings that many drivers
• 17:18with seizures disregard legal restrictions
• 17:21on driving, and regulatory
• 17:23compliance
• 17:25may improve
• 17:26with less onerous seizure free
• 17:28intervals and may worsen with
• 17:30with more onerous seizure free
• 17:31intervals and with more onerous
• 17:33restrictions.
• 17:36Similarly,
• 17:37mandatory reporting by clinicians
• 17:40has been shown in epilepsy,
• 17:42in
• 17:43cardiac conditions, and many other
• 17:45medical conditions
• 17:47not to decrease motor vehicle
• 17:49accidents. So in the United
• 17:50States,
• 17:51there have been comparisons
• 17:52of neighboring states where medical,
• 17:55reporting is mandatory compared to,
• 17:57states where medical reporting is
• 17:59not mandatory.
• 18:00And in Canada,
• 18:01provinces where medical reporting is
• 18:03mandatory compared to provinces where
• 18:05medical reporting is not mandatory.
• 18:06And there does not appear
• 18:07to be
• 18:08a a benefit,
• 18:10in the the states and
• 18:12provinces with mandatory reporting.
• 18:15But there does appear to
• 18:16be an increased likelihood of
• 18:18unlicensed
• 18:19driving
• 18:20and also increased risk of,
• 18:23patients withholding medical information from
• 18:25their clinicians
• 18:26in the states and provinces
• 18:28with mandatory,
• 18:30reporting.
• 18:35You know, I think the
• 18:36these findings may suggest that
• 18:38what's going on is that
• 18:39while for an individual
• 18:41waiting longer may be beneficial
• 18:43and may improve safety,
• 18:46having across the board,
• 18:49universal
• 18:49restrictions
• 18:52of very long seizure free
• 18:53intervals,
• 18:54mandated reporting
• 18:56can be
• 18:57counterproductive
• 18:58because they undermine adherence
• 19:01and patients'
• 19:02willingness to share medical information
• 19:04with their physicians and with
• 19:05the DMV.
• 19:08Other findings include
• 19:10the the importance of driving
• 19:12for supporting work and social
• 19:13activities and actually the finding
• 19:15that it it is one
• 19:16of the the two really
• 19:17key,
• 19:19factors in quality of life
• 19:21in epilepsy
• 19:21following
• 19:23complete seizure freedom. The ability
• 19:24to drive is is is
• 19:25really one of the most
• 19:26important factors in quality of
• 19:27life for individuals with epilepsy.
• 19:30There's also some early evidence
• 19:33that psychogenic or functional seizures,
• 19:35seizures caused by stress or
• 19:37other,
• 19:38strong emotions
• 19:39rather than by epileptic form
• 19:41discharges can also
• 19:43cause motor vehicle accidents, but
• 19:44these are much less likely
• 19:46to
• 19:47result in hospitalization,
• 19:49than
• 19:51motor vehicle accidents caused by
• 19:52epileptic seizures. I will say
• 19:54that evidence is very preliminary.
• 19:55I think those findings in
• 19:57particular really need to be
• 19:58replicated.
• 20:02But based on this this
• 20:03targeted
• 20:04evidence
• 20:06review,
• 20:07the
• 20:09task force
• 20:11made a number of
• 20:13consensus recommendations,
• 20:15and these were unanimously agreed
• 20:17on by the representatives of
• 20:19the different organizations I mentioned
• 20:21and then were reviewed and
• 20:23approved
• 20:23by the boards of directors
• 20:25and the relevant committees of
• 20:27those organizations.
• 20:28And when I highlight some
• 20:29of the more important,
• 20:31consensus positions
• 20:33from those organizations. So first
• 20:35was a recommendation that national
• 20:36driving standards
• 20:38promulgated through a system like
• 20:39the Uniform Law Commission,
• 20:41which you may be familiar
• 20:42as as the group that,
• 20:45created the, Uniform Declaration of
• 20:47Death Act and the unit
• 20:49Uniform Atomic Gifts Act.
• 20:54The the national driving standards
• 20:55promulgated by the Uniform Law
• 20:56Commission,
• 20:57would reduce confusion and improve
• 20:59adherence with state driving standards,
• 21:01both among clinicians and among
• 21:03patients.
• 21:05In the absence of,
• 21:07national standards,
• 21:09state licensing criteria for medical
• 21:10conditions should be promulgated by
• 21:12regulations and guidelines
• 21:14based on enabling legislation rather
• 21:15than in statutes and should
• 21:17be developed by medical advisory
• 21:18boards working in collaboration
• 21:20with departments of motor vehicles.
• 21:24There was a recommendation that
• 21:25licensing
• 21:26criteria should be equitable,
• 21:28nondiscriminatory,
• 21:30objective, and compatible
• 21:31with comparable risks in other
• 21:33populations, so younger drivers,
• 21:36drivers with substance use disorders
• 21:38and older drivers and distracted
• 21:40drivers
• 21:40who are often
• 21:42much less strictly regulated than
• 21:44drivers with epilepsy.
• 21:47There's a recommendation
• 21:49that
• 21:50a minimum seizure free interval
• 21:52of three months should be
• 21:53required prior to driving and
• 21:55should be extended,
• 21:57in individual cases based on
• 21:59review of favorable and unfavorable
• 22:00features by medical advisory boards.
• 22:03Examples of a favorable feature
• 22:04that might weigh
• 22:06against extending the seizure free
• 22:08interval would be seizures that
• 22:09occur during a clinician directed
• 22:12medication change or,
• 22:14an established pattern of seizures
• 22:16occurring exclusively during sleep.
• 22:19Whereas unfavorable
• 22:20factors that might,
• 22:22weigh in favor of of
• 22:23extending
• 22:24a seizure free interval
• 22:26might include unambiguous
• 22:27nonadherence
• 22:28with medications,
• 22:30or medical visits, or seizures
• 22:31that are related to a
• 22:32substance use disorder.
• 22:37The,
• 22:38task force recommended that individuals
• 22:40with exclusively provoked seizures attributable
• 22:42to provoking factors that are
• 22:44unlikely to recur in the
• 22:45future may not require a
• 22:46seizure free interval at all
• 22:47prior to resuming driving. And
• 22:49so this would be individuals,
• 22:51for example, who,
• 22:55are, having seizures in the
• 22:56setting of a of an
• 22:57infection and a very high
• 23:00fever where the infection has
• 23:01been treated
• 23:02and the
• 23:04fever has been treated and
• 23:05is not expected to recur,
• 23:07that individual may be able
• 23:08to simply resume driving once
• 23:10the infection is is cleared
• 23:12and controlled.
• 23:13Similarly, individuals with previously well
• 23:15controlled epilepsy who experience seizures
• 23:17due to short term interruptions
• 23:19of anti seizure medications
• 23:21during a hospitalization
• 23:23or during a clinician directed,
• 23:26medication titration may also not
• 23:28require a seizure free interval
• 23:30prior to resuming driving once
• 23:32they have been restarted on
• 23:34their anti seizure medications
• 23:35and once,
• 23:37therapeutic blood levels have been
• 23:39have been achieved.
• 23:40And and that's an important
• 23:42factor because it's not uncommon
• 23:43for individuals with epilepsy
• 23:45to be hospitalized for various
• 23:46reasons, either for a seizure
• 23:47or for an unrelated medical
• 23:49issue.
• 23:50And for physicians who are
• 23:52not familiar with the patient's
• 23:53history to fail to provide,
• 23:56antiseizure medications or to provide
• 23:57the wrong antiseizure medications and
• 23:59for patients to have seizures
• 24:01in that setting
• 24:02through through no fault of
• 24:03their own.
• 24:06The task force recommended that
• 24:08patients and practitioners should pause
• 24:09driving during the tapering and
• 24:11following discontinuation of an anti
• 24:13seizure medication if if another
• 24:14such medication is not introduced,
• 24:17and that similarly individuals whose
• 24:19cognition or coordination are impaired
• 24:21due to medications
• 24:23should refrain from driving,
• 24:25that individuals with psychogenic
• 24:27or functional seizures should also
• 24:29be subjected to a similar
• 24:30three month seizure free interval
• 24:32prior to resuming driving, and
• 24:34that that might also be
• 24:35modified based on individualized
• 24:37case review.
• 24:39The task force recommended that
• 24:41health care practitioners should be
• 24:42allowed
• 24:43but not mandated to report
• 24:45drivers who pose an elevated
• 24:46risk and that,
• 24:48they should
• 24:50enjoy legal protections whether they,
• 24:53report or not report. I
• 24:54wanna be clear that the
• 24:55recommendation here is not that
• 24:57providers should not report,
• 25:00drivers who pose a risk
• 25:01to public safety.
• 25:03Absolutely, they should, but there
• 25:05should not be a legal
• 25:06mandate because of the evidence
• 25:08that we we have about
• 25:09the counterproductive
• 25:10effects of those legal mandates.
• 25:13And finally, a recommendation that
• 25:15nations, states, and municipalities
• 25:17should provide alternative methods of
• 25:19transportation and accommodations
• 25:21for individuals whose driving privileges
• 25:23are restricted due to medical
• 25:24conditions. So things like,
• 25:26public transportation,
• 25:27ride share programs, and hopefully
• 25:29in the near future,
• 25:31self driving vehicles.
• 25:34I wanna talk very briefly
• 25:36about sort of the the
• 25:37state of the laws in
• 25:39the United States, in particular
• 25:41around,
• 25:42mandated reporting. So
• 25:45most states, including Connecticut,
• 25:47provide for voluntary physician reporting
• 25:49of unsafe drivers. There are
• 25:51six states,
• 25:53Pennsylvania,
• 25:54New Jersey, and Delaware in
• 25:55the east, and California,
• 25:58Nevada, and
• 26:01Oregon in the west that
• 26:03mandate
• 26:06clinicians to report unsafe driving.
• 26:08And we we talked a
• 26:09little bit about the the
• 26:11lack of improvement in motor
• 26:14vehicle accident rates and motor
• 26:16vehicle accident fatality rates that's
• 26:18seen with the those requirements
• 26:20and also the fact that
• 26:21patients in states where those
• 26:23mandates exist are more likely
• 26:25to withhold medical information
• 26:27from their clinicians and are
• 26:29more likely to drive without
• 26:30a license.
• 26:33So,
• 26:34based on those findings,
• 26:37the,
• 26:38California legislature actually passed
• 26:40in two thousand twenty four
• 26:42a bill to end mandated
• 26:43reporting in that state.
• 26:46That was actually vetoed by
• 26:47the governor in October of
• 26:49twenty twenty four. My understanding
• 26:50is that California
• 26:53passes
• 26:55the the legislature passes most
• 26:57legislation,
• 26:59a little bit indiscriminately,
• 27:01and and the way the
• 27:02the state sort of restricts
• 27:04their legislation is by the
• 27:06governor playing a very active
• 27:07role in vetoing.
• 27:09Nonetheless, proponents have pledged to
• 27:11propose a similar bill on
• 27:12an annual basis, and the
• 27:13Epilepsy Foundation of America in
• 27:16particular
• 27:17has
• 27:19looked to this position statement
• 27:21to use in advocacy with
• 27:23the
• 27:24California legislature and with the
• 27:26governor.
• 27:27Obviously, California
• 27:28is the largest state,
• 27:30where twelve percent of US
• 27:32drivers are licensed is a
• 27:34particularly important and influential
• 27:36state. And and where California
• 27:38legislation goes, likely other states
• 27:40will follow.
• 27:42Interestingly, at the same time,
• 27:44there is also a bill
• 27:45in Michigan,
• 27:46which does not have mandated
• 27:47driving
• 27:48that,
• 27:50has been advanced. It, it
• 27:52is being opposed by the
• 27:53Epilepsy Foundation of Michigan and
• 27:55by the professional
• 27:57advisory
• 27:58committee of the Epilepsy Foundation
• 28:00of Michigan.
• 28:01But it is
• 28:02a bill to
• 28:06mandate physician reporting in Michigan.
• 28:08And this bill was inspired
• 28:11by
• 28:12an incident, a a specific
• 28:13motor vehicle accident
• 28:14in,
• 28:16Michigan
• 28:16where a state trooper was
• 28:18struck and killed by a
• 28:20driver who may have had
• 28:21epilepsy
• 28:22and who may have had
• 28:23a seizure. It's not
• 28:25clearly established, but but that
• 28:26incident was enough to inspire
• 28:28the writing of this bill.
• 28:30And I think that that
• 28:31highlights the point that
• 28:34well intentioned
• 28:36but
• 28:37restrictive
• 28:38laws
• 28:39are often passed
• 28:40in the setting of
• 28:43individual
• 28:44tragedies
• 28:46without consideration
• 28:47of of the larger,
• 28:49broader evidence around the issue,
• 28:51and that can be very
• 28:52counterproductive. I think we saw
• 28:54that going back to the
• 28:55nineteen thirties when,
• 28:57patients across the the board
• 28:59with epilepsy were prohibited from
• 29:00driving, and we're seeing that
• 29:01even today.
• 29:05Our our hope is that
• 29:07the
• 29:08the California will end
• 29:10mandated reporting that Michigan will
• 29:13continue not to mandate, to
• 29:14allow, but not require
• 29:17physician
• 29:18reporting going forward.
• 29:21So I just wanna wrap
• 29:22up with a couple of
• 29:23takeaway points, and then I
• 29:24will,
• 29:25turn things over to my
• 29:26distinguished colleague.
• 29:28So first, that there's a
• 29:29long history of well intentioned,
• 29:32stringent, universal restrictions on drivers
• 29:34with epilepsy.
• 29:37But as we've liberalized and
• 29:39individualized
• 29:40these restrictions based on clinical
• 29:42assessments,
• 29:43historically, we've been able to
• 29:45maintain public safety
• 29:46and improve adherence with both
• 29:48regulations and medical care.
• 29:52Reducing
• 29:53the required seizure free interval
• 29:55to three months with or
• 29:56without individualized,
• 29:58extensions
• 29:59has not increased motor vehicle
• 30:01accidents or motor vehicle accident
• 30:02fatalities in at least two
• 30:03states that have already,
• 30:06made this change.
• 30:08Mandated reporting has repeatedly proven
• 30:10ineffective in reducing motor vehicle
• 30:12accident or fatalities and makes
• 30:13patients more likely to withhold
• 30:15medical information and drive without
• 30:17a license.
• 30:18And finally, I would I
• 30:19would suggest that there may
• 30:20be a more generalized lesson
• 30:22here that where
• 30:24restrictions on individuals with medical
• 30:26conditions are necessary for public
• 30:28safety, we may be able
• 30:29to achieve
• 30:30better outcomes through liberalization
• 30:33and individualization
• 30:34of those restrictions
• 30:35based on
• 30:36individual clinical assessments.
• 30:39And with that, I'll pause.
• 30:41I'll turn things over to
• 30:43Mark and
• 30:44Richard.
• 30:48Thanks.
• 30:51Thank you. Thank you, Ben.
• 30:53You know, and it occurs
• 30:53to me that that when
• 30:54I was introducing Ben, I
• 30:56got distracted because the,
• 30:58woman of my dreams came
• 30:59in right as I was
• 31:00introducing. She says, don't do
• 31:01that. So I did it
• 31:02anyway.
• 31:04And I and I wanted
• 31:05to tell you and I
• 31:06meant to tell you. So
• 31:06I'm gonna take this since
• 31:07I'm since I'm up here.
• 31:08I'll say I'll do what
• 31:09I want. So I'll take
• 31:10this moment to talk about
• 31:11Ben just a little bit,
• 31:14because I it's something I
• 31:15intended to say ahead of
• 31:16time, and I didn't get
• 31:17the chance.
• 31:18So I met Ben, through
• 31:20my friend, Ernie Moritz, who
• 31:22was the chairman of the
• 31:23of the ethics committee at
• 31:24the, at the hospital
• 31:25at the beginning of the
• 31:26pandemic.
• 31:28And when the questions were
• 31:29raised, exactly what are we
• 31:30gonna do? Do we have
• 31:31a plan? What are we
• 31:32gonna do in terms of,
• 31:33crisis standards of care, which
• 31:35at the time we just
• 31:35called triage protocols? How exactly
• 31:37we're gonna do this if
• 31:38we run out of ventilators,
• 31:40if we run out of
• 31:40equipment? How are we gonna
• 31:42manage this problem?
• 31:43And, so I called, some
• 31:45big cheese to hospital and
• 31:46said, listen. If we have
• 31:47a plan, I don't know
• 31:48about it. What's the deal?
• 31:49And he said, well, we're
• 31:49gonna put a plan together,
• 31:50and you're gonna be on
• 31:51this group. And then,
• 31:53I got, on on a
• 31:55meeting with with
• 31:57with Ernie Moritz, who was
• 31:58chairing the committee. And he
• 31:59said, so we got this
• 32:00young guy, Ben Tolchin, who's
• 32:02gonna lead the effort as
• 32:02we figure all this stuff
• 32:03out. And I said, that's
• 32:04great. I never heard of
• 32:05him, but okay. If you
• 32:06say he's the guy, he's
• 32:07the guy. And so Ben,
• 32:10took over this group. It
• 32:11was kind of very motley
• 32:12crew of bioethicists and others,
• 32:15from within the the medical
• 32:17campus and some from on
• 32:18the main campus as we
• 32:19tried to figure out what
• 32:20we were gonna do. And
• 32:20it was really remarkable to
• 32:22see as we work through.
• 32:23And and this made me
• 32:24think of it, not just
• 32:26the the theoretical considerations.
• 32:29Right? Because there's interesting theoretical
• 32:31considerations here, I think, in
• 32:32terms of the safety of
• 32:32the public and individuals' rights,
• 32:34etcetera, which we'll get into.
• 32:35But also, now in the
• 32:36meantime, what about practical plans?
• 32:38And what we had to
• 32:39do then under Ben's leadership
• 32:41was far more complex than
• 32:43what we're actually talking about
• 32:44here. I'm not saying it's
• 32:45more important. This is also
• 32:46important, but it was very
• 32:47complex. And Ben did a
• 32:48marvelous job. I grew to
• 32:50have a great deal of
• 32:50respect for, this young associate
• 32:53professor. Were you an associate
• 32:54professor then then? No. He
• 32:55was an assistant professor. He
• 32:57was put in charge of
• 32:57this whole thing. And so
• 32:58when it came time for
• 32:59us to finally,
• 33:01professionalize,
• 33:03the ethics, the clinical ethics
• 33:04work at the medical center,
• 33:07We did a national search,
• 33:08and we brought it we
• 33:09had some marvelous candidates who
• 33:11we interviewed, and, Jack, you
• 33:12were involved in this.
• 33:14And we we had
• 33:16this tremendous
• 33:17search process, but it was
• 33:18clear, and Ben was one
• 33:19of the candidates. And it
• 33:20was clear that that despite,
• 33:22on the seniority scale, Ben
• 33:24was not high. He was
• 33:25clearly the most qualified. And
• 33:26by the way, he had
• 33:27proven himself as a a
• 33:29not only an excellent thinker,
• 33:30but an excellent leader as
• 33:31we've worked our way through
• 33:32the pandemic, particularly the early
• 33:34months of the pandemic. But
• 33:35there were other issues to
• 33:35be dealt with throughout that
• 33:37time.
• 33:38So anyway, what became,
• 33:40for me, a measure of
• 33:41respect for Ben then has
• 33:43now grown from respect also
• 33:44to a great deal of
• 33:45affection,
• 33:46and friendship.
• 33:47And it
• 33:48it pleases me greatly that
• 33:50the next time you come
• 33:51to one of these, it'll
• 33:52be Ben up here doing
• 33:53this. I'm delighted to be
• 33:55passing the baton along to
• 33:57Ben, who has become a
• 33:58really important part of our
• 33:59community. And I know the
• 34:00leaders of this program who
• 34:02are where'd Sarah go? She
• 34:03came. She went. Who are
• 34:04Sarah and Jen and Jack?
• 34:07And, of course, Karen. We'll
• 34:08talk to you about Karen
• 34:09later. But, of course, they're
• 34:10they're all welcoming Ben to
• 34:12this group as well. So
• 34:13I didn't really do that
• 34:14as well as I wanted
• 34:15to when you started. So
• 34:17Ben's about to give a
• 34:18great no. Wait. He already
• 34:18did give a great talk,
• 34:19so never mind that.
• 34:21Alright. Let's talk for a
• 34:22minute about Rich Maratoli,
• 34:23please. So Rich, I don't
• 34:25know well,
• 34:26but I've heard about him
• 34:27for years. Rich is a
• 34:29professor
• 34:29of medicine here. He's a
• 34:31geriatrician.
• 34:32He got medical undergraduate and
• 34:34medical,
• 34:35and public health degrees from
• 34:37Yale, slipped away to Strong
• 34:38up in Rochester to do
• 34:39a residency, came back here
• 34:41to do his fellowship.
• 34:42He is very well known
• 34:43in geriatric circles. He is
• 34:44the director of the assessment
• 34:46center, the Adler Center, on
• 34:47our campus here. He also
• 34:49has specific expertise related to
• 34:51driving restrictions for the elderly
• 34:53and working with people with
• 34:54Alzheimer's.
• 34:55And, Rich, if I'm not
• 34:57mistaken, you're on the you're
• 34:58a chairman of the of
• 34:59the advisory board, right, the
• 35:00medical advisory boards of the
• 35:02DMV. Right? So Rich is
• 35:03very much into the practical
• 35:04aspects of this as well.
• 35:06And with a great deal,
• 35:07you know and both of
• 35:08these guys run various national
• 35:09committees, and I'll spare you
• 35:11having to hear all that
• 35:11except to say that as
• 35:13is our practice here, we
• 35:14bring you people with tremendous
• 35:16expertise. And doctor Maratoli
• 35:18is certainly an excellent example
• 35:19that I really appreciate you
• 35:21making time. You heard Ben's
• 35:22talk. I'm sure you have
• 35:23a lot of criticisms about
• 35:24it, and I want you
• 35:25to really get into it.
• 35:26Don't be shy. Show your
• 35:28ideas. And then I wanna
• 35:29hear what what you all
• 35:30have to say about this
• 35:30as well. So, doctor Rich
• 35:31Maratoli, thanks for coming.
• 35:37Thank you, I don't get
• 35:39to wear a tie very
• 35:39often, so I bought a
• 35:40tie and jacket. I put
• 35:41it on. So
• 35:43Looking good. That's right. So
• 35:45post COVID. Baby blue. Good
• 35:46show. There you go. Exactly.
• 35:48Alright. So let's,
• 35:51just go over.
• 35:54So,
• 35:57I wanted to focus just
• 35:58on one aspect of this,
• 36:00and we can touch on
• 36:01some of the others later,
• 36:02on different, specifically on the
• 36:04issue of medical reporting,
• 36:06in Connecticut,
• 36:07in part because I've always
• 36:08found this to be a
• 36:09bit of a black box.
• 36:11As a clinician,
• 36:13we don't quite know what
• 36:14goes on.
• 36:15And also it means different
• 36:16things in different states. For
• 36:18those of you who are
• 36:19in training,
• 36:20or even those of you
• 36:21who are on the faculty,
• 36:21you may end up practicing,
• 36:23in a different environment.
• 36:25It's important to know,
• 36:27what the obligations
• 36:29and or requirements of you
• 36:31are, in that given state
• 36:32when you move back and
• 36:33forth.
• 36:34And the issue of medical
• 36:35advisory boards and medical reporting
• 36:37is one of those things
• 36:38that tends to vary tremendously.
• 36:41And as Ben touched on,
• 36:42when particularly when we're talking
• 36:43about private vehicle operation,
• 36:46licensing is a state by
• 36:48state concern.
• 36:50So it's commercial, particularly inter
• 36:52interstate commercial operation. Those are
• 36:55federal requirements and tend to
• 36:56be uniform and more stringent.
• 36:59But for
• 37:00private vehicle operations, it's really
• 37:02state by state.
• 37:03And so it's important to
• 37:05know what that is,
• 37:06and what influences those factors
• 37:08and also particularly what your
• 37:09obligations are,
• 37:11within that spectrum.
• 37:13So let's talk a little
• 37:14bit, about medical reporting in
• 37:16Connecticut, and we'll start with
• 37:17a little history.
• 37:19So, actually,
• 37:21Ben touched on it and
• 37:22said that we had voluntary
• 37:23reporting. But in fact, until
• 37:24nineteen ninety,
• 37:26Connecticut had mandatory,
• 37:28reporting.
• 37:29And that was,
• 37:31for,
• 37:32the two most common,
• 37:33issues,
• 37:34that are required when there
• 37:35is mandatory reporting,
• 37:37which is, which are seizures
• 37:39uncontrolled by medications or recurrent
• 37:41loss of consciousness.
• 37:43And then in nineteen ninety,
• 37:44they changed the law to
• 37:45may report from, requiring to
• 37:48report.
• 37:49And this is actually the
• 37:50wording,
• 37:51and this is the actual
• 37:52wording from the original,
• 37:54and we'll get to some
• 37:55of the things that those
• 37:56of you may notice,
• 37:57particularly regarding how they're defining
• 37:59who is reporting.
• 38:01In in the time, it
• 38:02was only physicians who were
• 38:04specifically enumerated, and they've subsequently
• 38:05expanded that to include,
• 38:07other health care providers.
• 38:09But the original statute said
• 38:11that any physician may report
• 38:12any condition with any chronic
• 38:14health problem,
• 38:15which in the physician's judgment
• 38:16will significantly affect their ability
• 38:18to safely operate a motor
• 38:19vehicle or with recurrent periods
• 38:21of unconsciousness
• 38:22uncontrolled by medical treatment or
• 38:24for vision problems affecting the
• 38:25ability to safely operate a
• 38:27motor vehicle.
• 38:30So,
• 38:31among some of the things
• 38:32and you'll see those of
• 38:33you who have read Ben's
• 38:34paper will realize that there
• 38:35are a couple of important
• 38:36factors,
• 38:37that come up around this
• 38:39issue,
• 38:40of reporting. And particularly, some
• 38:41of the main ones are
• 38:42confidential
• 38:43confidentiality
• 38:44and immunity
• 38:45for providing this information. And
• 38:47Connecticut,
• 38:48does have both of those,
• 38:50albeit with a little bit
• 38:51of a caveat.
• 38:53So the reports are indeed
• 38:54confidential,
• 38:56and are used solely for,
• 38:57licensing decisions. So this is
• 38:59a clinician now providing information
• 39:01to the licensing,
• 39:03agency in this in Connecticut,
• 39:04it's the the Department of
• 39:05Motor Vehicles.
• 39:06Any person acting in good
• 39:08faith without negligence or malicious
• 39:09intent shall be immune from
• 39:11civil liability for reporting.
• 39:14And as I alluded to,
• 39:16and there's a reason why
• 39:17there are air quotes around
• 39:17the confidentials, communications
• 39:19between,
• 39:20the DMV medical review unit
• 39:22and the medical advisory board
• 39:24are confidential,
• 39:25but any documents,
• 39:27may be obtained on written
• 39:28request. So,
• 39:29an individual, a driver can,
• 39:32indeed,
• 39:33request or, get subpoenaed,
• 39:36the individual around that information
• 39:38around that report,
• 39:39to determine who it was
• 39:41that submitted that,
• 39:43that report.
• 39:44Although most people can figure
• 39:45it out. So if they
• 39:46come to your office and
• 39:47see you and then a
• 39:47week later, they get a
• 39:48notice from the DMV,
• 39:50saying we want you to
• 39:51come in, most people can
• 39:52put two and two together
• 39:53no matter how cognitively,
• 39:55or otherwise impaired they may
• 39:56be. So, it's a bit
• 39:58of a moot point, but
• 39:59that there is a caveat
• 40:00around the confidential part.
• 40:02So, just so some understanding
• 40:04of what the issues are.
• 40:05So if a license,
• 40:07is suspended, restricted, or revoked,
• 40:09the driver has the right
• 40:10to appeal that determination,
• 40:12but they may not,
• 40:14operate a vehicle while that,
• 40:16appeal is pending.
• 40:18So this and then and
• 40:19this we get into my
• 40:20kind of interpretation of it.
• 40:21You're not gonna find this,
• 40:22anywhere exactly. But,
• 40:24effectively,
• 40:25there is sort of two
• 40:26level reporting,
• 40:28in Connecticut. Meaning that at
• 40:30one level,
• 40:31if an emergency action is
• 40:33required, so there's an imminent
• 40:34threat to public health or
• 40:35safety.
• 40:36So if someone has a
• 40:37severe impairment or there's evidence
• 40:39that they've,
• 40:40committed a variety of infractions
• 40:42where they they you have
• 40:43counseled them, advised them, and
• 40:45they've continued to drive and
• 40:46put themselves at risk where
• 40:47you have evidence of crashes
• 40:49or other issues,
• 40:50then you feel or there's
• 40:51severe impairment,
• 40:53from whatever condition,
• 40:54then you feel that that
• 40:55person should not drive under
• 40:57any circumstance.
• 40:59The license is revoked immediately.
• 41:01They have the option to
• 41:03appeal that and have an
• 41:04administrative hearing, and it's possible
• 41:07that they may get that
• 41:08license reinstated.
• 41:09So for instance, if there's
• 41:11a medical condition,
• 41:12someone has recurrent,
• 41:14loss of conscious, recurrent syncope,
• 41:16there's no ideology identified initially,
• 41:19but it turns out over
• 41:20time, they have sick sinus
• 41:22syndrome at a low heart
• 41:23rate, and they get a
• 41:23pacemaker placed, and the condition
• 41:25is restored. They can then
• 41:26appeal and say, look, the
• 41:27the problem, whatever it is,
• 41:28has gone away. This is
• 41:29not a recurrent or progressive,
• 41:32problem over time.
• 41:33But more often than not,
• 41:34there is is a,
• 41:36a more progressive problem that's
• 41:38underlying it. But they do
• 41:40have the right to have
• 41:40that heard and to to
• 41:41state their case to the
• 41:43contrary.
• 41:44Far more common,
• 41:46in where I suspect if
• 41:47many if any of you
• 41:48have reported, it's more likely
• 41:49in this scenario,
• 41:50is the non emergent,
• 41:53situation. And it used to
• 41:54be,
• 41:55that we had condition specific
• 41:57forms. So you had a
• 41:58you know, if you're you
• 41:59could either, submit a letter
• 42:01to the DMV saying, I'm
• 42:02concerned about,
• 42:03this person because of this
• 42:05condition.
• 42:06Please assess their ability to
• 42:08continue driving or to drive
• 42:09safely.
• 42:10Now there is a single
• 42:12form,
• 42:13which is this form here,
• 42:15which has,
• 42:16essentially,
• 42:17several,
• 42:18conditions listed out on that.
• 42:20So instead of nine,
• 42:21individual forms, there's one form,
• 42:23that you can fill out
• 42:24the individual sections.
• 42:26The print has correspondingly gotten
• 42:28much smaller. So effectively, it's
• 42:30testing your near visual acuity.
• 42:32And if you could read
• 42:33the form, you can probably
• 42:34pass the vision test,
• 42:35if one were required,
• 42:37for driving.
• 42:38But the big difference is
• 42:39so either you can,
• 42:41you can send a note
• 42:42to the DMV and they
• 42:43can then they would then
• 42:44send the form to the
• 42:45driver.
• 42:47And then the driver has
• 42:48to then turn that over
• 42:49to a clinician.
• 42:51And that once they receive
• 42:53that form, they have thirty
• 42:54days, to get that form
• 42:55filled out and sent back
• 42:56in.
• 42:57Now on the advisory board,
• 42:58what we'll see is oftentimes,
• 43:00because people can figure out
• 43:01who did the initial reporting,
• 43:03you will get you you
• 43:04know who reported them, and
• 43:06you'll get the form filled
• 43:07out by a different clinician
• 43:08because the person says, I'm
• 43:09not going back to that
• 43:10person to get this filled
• 43:11out. I will go to
• 43:12doctor Jones instead of doctor
• 43:13Smith,
• 43:14to get this filled out.
• 43:16But, anyway, be that as
• 43:17it may. The big difference
• 43:18is that they are unlike
• 43:20the first case where their
• 43:21license is revoked immediately.
• 43:23In this case, they're allowed
• 43:24to continue driving while this
• 43:25process is adjudicated.
• 43:26So there's a thirty days.
• 43:28The forms go back and
• 43:29forth. Then there has to
• 43:30be a decision on the
• 43:31basis of the medical qualifications
• 43:32unit, the medical review unit,
• 43:34the DMP.
• 43:35Are they gonna send that
• 43:36out to the medical advisory
• 43:37board? Is the medical, advisory
• 43:39going to recommend
• 43:40a an on road assessment
• 43:42as part of that? Again,
• 43:43the person is allowed to
• 43:45continue driving,
• 43:46in that period. So there
• 43:47is a difference, a big
• 43:49difference between the two, and
• 43:50then ultimately, it's adjudicated.
• 43:52So the content of these
• 43:54forms and in the small
• 43:55print for each of these
• 43:56conditions, basically, it's asking about
• 43:58the diagnosis,
• 43:59the etiology, and ideally the
• 44:01prognosis to the extent that
• 44:02we can identify those factors.
• 44:05And any exam or test
• 44:07abnormalities,
• 44:08any relevant history,
• 44:10any periodic reassessment that may
• 44:12be required. This is actually
• 44:13an important part,
• 44:15of the form. So if
• 44:16you have a person who
• 44:17you may you know, you
• 44:18don't really know if it's
• 44:19having an effect their condition's
• 44:20having an effect on their
• 44:21driving ability. Now you just
• 44:23kinda wanna get them assessed,
• 44:24but you also recognize that
• 44:25this may be a progressive
• 44:26process over time. Someone has
• 44:28a dementia regardless of etiology,
• 44:30Parkinson's disease, other things like
• 44:31that that are likely to
• 44:32progress,
• 44:33over time. Then even if
• 44:35they're safe to drive now,
• 44:36you can put in a
• 44:37stipulation
• 44:38that there's reassessment
• 44:39at every whatever the interval
• 44:40is, six months, twelve months,
• 44:42so that they're now in
• 44:43the system. Because otherwise,
• 44:45in Connecticut, once you have
• 44:46your license, as long as
• 44:47you pay your fee every
• 44:49six years,
• 44:50or and you don't get
• 44:51into trouble with the law,
• 44:53then basically you have that
• 44:55license indefinitely.
• 44:57And so this is one
• 44:57way to get the person
• 44:58into the system so that
• 45:00they can be reevaluated.
• 45:01And if there's no issue,
• 45:02no change in their condition,
• 45:04then nothing really happens as
• 45:05a result of that. They
• 45:06continue driving. But if their
• 45:08condition has changed or deteriorated
• 45:10in that interval,
• 45:12then,
• 45:13they may,
• 45:14have to get reassessed and
• 45:15and actually, undergo an on
• 45:17road evaluation.
• 45:19Okay.
• 45:20And then there's a comment
• 45:21on clinician recommendation.
• 45:24And in the statement, they
• 45:25actually didn't,
• 45:27advocate for this, but, this
• 45:29is in there. So in
• 45:30the recommend you know, in
• 45:31the opinion of the clinician,
• 45:33can this person operate the
• 45:35vehicle safety?
• 45:36Does this condition affect their
• 45:37likelihood,
• 45:39to, of operating the vehicle,
• 45:41and is a driving reevaluation
• 45:43necessary?
• 45:44Now this is
• 45:45speculative on the part of
• 45:46a lot of people because
• 45:47a lot of clinicians don't
• 45:48really know the answer to
• 45:49that. We can comment
• 45:50on the medical condition, its
• 45:52severity, its manifestations,
• 45:53But what that necessarily means
• 45:55in terms of translating
• 45:57to driving capabilities is much
• 45:58less clear for many of
• 46:00us and and rightfully so.
• 46:02And in fact, some states
• 46:03of Maine, for many years
• 46:04had a very good system,
• 46:05which is that the driver,
• 46:07the clinician,
• 46:08and the state each had
• 46:09their own sort of their
• 46:11lane, if you will, their
• 46:12own responsibilities.
• 46:13And it was the responsibility
• 46:14of the driver to report
• 46:15any condition that developed.
• 46:17They would then bring the
• 46:18form to the clinician,
• 46:20who then had to fill
• 46:21out, you know, was congestive
• 46:22heart failure? What, you know,
• 46:23what stage? What level? What's
• 46:25the degree of impairment? And
• 46:26then the state, the DMV,
• 46:28the licensing agency, would crosswalk
• 46:29that over to whether or
• 46:30not there is any licensing
• 46:32restriction that was required or
• 46:33any further testing that needed
• 46:35to be done. So it
• 46:36kinda compartmentalize
• 46:37those very well, but that
• 46:38varies a lot from state
• 46:39to state, and it's often
• 46:41not that well demarcated.
• 46:43So who may report?
• 46:45So it turns out anybody
• 46:46can report.
• 46:47So health care providers and
• 46:48law enforcement are by far
• 46:50the leading sources of reports,
• 46:52to the DMV, but anybody
• 46:54can. So family, friends, general
• 46:56public,
• 46:57you park in front of
• 46:57your neighbor's house too often,
• 46:59you block their view, maybe
• 47:00you clip their rose bush
• 47:01as you're turning in the
• 47:02driveway,
• 47:03that may set off, a
• 47:05report, from there, which is
• 47:06one of the reasons why
• 47:08no anonymous reports are allowed,
• 47:10and you have to do
• 47:11an affidavit form. They will
• 47:12the DMV will contact the
• 47:14reporter just to make sure
• 47:15that indeed this is a
• 47:16valid,
• 47:17concern,
• 47:19and, then we'll act based
• 47:21on the basis of that.
• 47:23So delineation of responsibility. So
• 47:25the DMV
• 47:26is ultimately the one that
• 47:27makes the determination
• 47:29about licensing decisions,
• 47:31based on health standards that
• 47:33are in the regulation.
• 47:34And the clinician who's doing
• 47:36the reporting provides the medical,
• 47:37information to inform that decision.
• 47:41If there's clear evidence of
• 47:42substantial health problems or impairment,
• 47:45and impaired driving, then the
• 47:46DMV medical qualifications unit,
• 47:49will make that decision on
• 47:50their own. If it's less
• 47:52clear, then there is a
• 47:53medical advisory board,
• 47:55for review and recommendation.
• 47:58There is a great deal
• 47:59of, variability in medical advisory
• 48:01boards in the US,
• 48:03from some states at one
• 48:05extreme having no medical advisory
• 48:06board to those who have
• 48:08one in name only, but
• 48:09they never meet up until
• 48:10the extremes of very structured
• 48:12ones that have full time
• 48:14personnel. Maryland,
• 48:15California has a huge one,
• 48:16but they're also a large
• 48:17state,
• 48:18with a lot of resources.
• 48:18Maryland, relatively small state population
• 48:20wise,
• 48:21actually has a very advanced
• 48:23system in place with full
• 48:24time,
• 48:25physicians, nurse practitioners, nurses, lawyers,
• 48:28and who actually do the
• 48:30medical evaluation themselves, a hands
• 48:32on evaluation.
• 48:32That is by far an
• 48:34extreme on the other end.
• 48:35Connecticut
• 48:36is in between the two.
• 48:38So,
• 48:39our,
• 48:40composition is up to fifteen.
• 48:42So it's eight or more
• 48:44up to fifteen.
• 48:45There excuse me. There are
• 48:47various, sub specialties that are
• 48:49involved in that. Those are
• 48:50actually enumerated,
• 48:51but they can't be others.
• 48:53They are recommended by the
• 48:55state medical or now state
• 48:57professional society, so they've expanded
• 48:59it beyond that.
• 49:00But they don't have to
• 49:01be they they go through
• 49:02those state,
• 49:04societies, but, they they will
• 49:06look for other individuals if
• 49:07they can't find anyone recommended.
• 49:10So it is a volunteer
• 49:12board.
• 49:13So there's no payment,
• 49:15involved prior to COVID.
• 49:17We would meet in person,
• 49:19twice a year in, in
• 49:20the DMV mothership in in
• 49:22Weathersfield.
• 49:24And,
• 49:26but post COVID, it's it's
• 49:27been all virtual,
• 49:29pretty much more down to
• 49:30one meeting a year, for
• 49:31the last five years or
• 49:32so. There is a quorum,
• 49:34needed for those meetings, particularly
• 49:36if there's anything that requires
• 49:37a recommendation.
• 49:39The individual members of the
• 49:40MAB so,
• 49:41reports are sent to the
• 49:43individual members based on their
• 49:44specialty,
• 49:45level of expertise or interest,
• 49:48and then their recommendation
• 49:50the MAB person's recommendation is
• 49:52mailed or faxed back to
• 49:54review. They've been
• 49:55contemplating doing it electronically but
• 49:57haven't figured out,
• 49:58the mechanism for being able
• 50:00to do that yet.
• 50:02So the MAB's responsibilities, which
• 50:04are enumerated in the statutes,
• 50:06advising that the commissioner
• 50:07of, the DMV on on
• 50:09health standards for safety and
• 50:10cooperation,
• 50:11recommending
• 50:12excuse me, procedures and guidelines
• 50:14for licensing around health issues,
• 50:17assisting in medical reporting,
• 50:19form development. So this was
• 50:20a project that went on
• 50:22for several years with back
• 50:23and forth,
• 50:24from,
• 50:25medical advisory board members.
• 50:27State of Missouri actually did
• 50:28a lot of work on
• 50:29the research behind having single
• 50:31individual forms versus a combined
• 50:33form, pros and cons, and
• 50:34then other states
• 50:36did versions of it on
• 50:37their own,
• 50:39recommending specific training for individuals,
• 50:42and then making recommendations,
• 50:44on individual health problem cases.
• 50:46So what is the outcome
• 50:47of that in the end?
• 50:48So, effectively, the MAB recommendation
• 50:51is that there's no evidence
• 50:52of a problem.
• 50:54No driving is allowed. So
• 50:55those are kind of the
• 50:56two extremes.
• 50:57Driving evaluation, meaning an on
• 50:59road assessment,
• 51:00is necessary.
• 51:01It may be qualified with
• 51:02certain restrictions,
• 51:04and there may be periodic,
• 51:05as I mentioned before, periodic
• 51:07submission of medical information,
• 51:09or there's not sufficient information,
• 51:11on the basis of what's
• 51:12provided. So we only get
• 51:14what is we don't get
• 51:15the actual medical records. We
• 51:16get the if there's a
• 51:17police report, we'll get the
• 51:18police report,
• 51:19and then the medical report
• 51:21that comes in,
• 51:22this form,
• 51:23which can have relatively little,
• 51:26or more detail in it.
• 51:27And sometimes that you can
• 51:28understand what's going on, other
• 51:29times you can't, and you
• 51:30can ask for more detailed
• 51:31information.
• 51:34So if a driving reevaluation
• 51:36on road assessment,
• 51:38is,
• 51:39the recommendation,
• 51:40that is typically done by
• 51:42a a DMV inspector, and
• 51:43there are certain individuals who
• 51:44do that in civilian clothing.
• 51:46Usually, it is done out
• 51:47of the closest DMV office,
• 51:50to where you live. So
• 51:52around here, it would be
• 51:53Hamden.
• 51:54But,
• 51:55you can request,
• 51:57although it's dependent on the
• 51:58availability of personnel,
• 52:00and this is a big
• 52:01plus, potentially for an individual,
• 52:03that it can be done,
• 52:04from the driver's home on
• 52:06a familiar route. So if
• 52:07they only drive a certain
• 52:08locus,
• 52:09around their home and in
• 52:10their own vehicle,
• 52:12the evaluation can be done
• 52:13that way rather than,
• 52:15in,
• 52:16a dual brake equipped vehicle
• 52:17on a route that they
• 52:18may or may not be
• 52:19familiar with.
• 52:21And then there's a thirty
• 52:22seven item form,
• 52:23that they go through and
• 52:24check off in, different situations,
• 52:27and road types,
• 52:29how well they do.
• 52:30So based on that, then
• 52:32there are some licensing options.
• 52:33So one is that their
• 52:34license is revoked entirely, no
• 52:35license, more full license, or
• 52:37a limited one with limitations
• 52:39such as driving in daylight,
• 52:41non highway, geographic area.
• 52:44In again, depending on what's
• 52:45identified,
• 52:46it can be limited.
• 52:48Enforcement of that may be
• 52:49difficult unless they're actually pulled
• 52:50over eventually. You don't know
• 52:51if they're complying,
• 52:53with that restriction,
• 52:54but for the most part,
• 52:55it tends to work pretty
• 52:56well.
• 52:58As mentioned before, the drivers
• 52:59do have the right of
• 53:00appeal,
• 53:01so they can
• 53:02request an administrative hearing. If
• 53:04they disagree with the decision,
• 53:06they can also request a
• 53:08repeat,
• 53:09a reevaluation
• 53:10even if they fail a
• 53:10test. And sometimes people then
• 53:12on, the repeat evaluation get
• 53:14their license. So I've had
• 53:15I want patient to kinda
• 53:16ping pong back and forth,
• 53:18over the years,
• 53:20depending on,
• 53:21you know, the outcome of
• 53:22that evaluation.
• 53:25So, again, in my view,
• 53:26there are a couple issues
• 53:27facing the board. It's very
• 53:28difficult to recruit members, new
• 53:30members in particular.
• 53:32It is not that time
• 53:33consuming, but it is time
• 53:34consuming.
• 53:35It is purely voluntary activity.
• 53:38There is a variability in
• 53:40the quality of the medical
• 53:41information that's provided,
• 53:43in reports that comes in,
• 53:44so it can be difficult
• 53:45to make that determination.
• 53:46And then from a population
• 53:48basis, there's often limited clinician
• 53:50knowledge of licensing health standards
• 53:52and medical review processes.
• 53:55And this has been around
• 53:56the first study I did
• 53:57on this was right around
• 53:58the time, that they changed
• 53:59the laws and that those
• 54:00issues were present then,
• 54:02and they persist in many
• 54:03ways, now thirty five years
• 54:05later or so.
• 54:07So just for those of
• 54:08you in the audience who
• 54:08are in training, this is
• 54:09the sort of most recent
• 54:11of the,
• 54:13the guides, to doing that.
• 54:15Unfortunately, it stopped in, two
• 54:16thousand nineteen. It's the latest
• 54:18edition.
• 54:19So,
• 54:20very similar to the American
• 54:21Academy of Neurology.
• 54:23There was a this is
• 54:24a sort of the general
• 54:25document. So this was originally
• 54:27produced by the AMA,
• 54:28in conjunction,
• 54:29with the National Highway Traffic
• 54:31Safety Administration. It was a
• 54:32very small pamphlet from nineteen
• 54:34eighty three.
• 54:35And then eventually, in two
• 54:36thousand and three, with backing
• 54:37from the National Highway Traffic
• 54:38Safety Administration,
• 54:40the AMA then went through,
• 54:42individual conditions in much more
• 54:43detail,
• 54:45and also on how clinicians
• 54:47can approach this issue,
• 54:49reporting requirements in different states.
• 54:51That was, so the first
• 54:53revised edition was two thousand
• 54:54three, then it got repeated
• 54:56again in two thousand ten.
• 54:58And then, the AMA was
• 55:00no longer involved. It got
• 55:01turned over to the American
• 55:02Geriatric Society,
• 55:04two editions in two thousand
• 55:05fifteen, and then this most
• 55:06recent one in two thousand
• 55:07nineteen.
• 55:08But it is a good
• 55:09resource. It is available free
• 55:11online.
• 55:12It does go through approaches
• 55:13to,
• 55:14to,
• 55:15you know, raise the issue
• 55:16with families, with individuals,
• 55:18and,
• 55:20things to think about as
• 55:21well as a detailed,
• 55:24review of,
• 55:25the literature to the point,
• 55:27of two thousand nineteen in
• 55:28terms of individual conditions and
• 55:30what the recommendations are. There
• 55:32are also versions available from
• 55:33different,
• 55:34countries. So, Great Britain, Ireland,
• 55:37Canada, Australia,
• 55:39all have versions that they
• 55:40update periodically that, again,
• 55:42sort of summarizes the information.
• 55:44So most of those are
• 55:45available, again, online and free.
• 55:46So if you have an
• 55:47interest, you gotta see what
• 55:49some of the latest summary,
• 55:50of that is. You can
• 55:51find those, documents there.
• 55:54And this was,
• 55:55this was based in part,
• 55:57on,
• 55:58paper that Don Bradley, the
• 55:59former,
• 56:00legislative legal counsel for the
• 56:02DMV,
• 56:03put together for Connecticut Medicine
• 56:05in ninety seven. So with
• 56:06that, thank you all very
• 56:07much.
• 56:11Thank you very much,
• 56:15Rich.
• 56:15Alright. So we have,
• 56:18we're gonna set up for
• 56:19a few minutes for some
• 56:20conversation.
• 56:21We have
• 56:22did I see two microphones
• 56:23up here a minute ago?
• 56:24Yeah. No? One here. Okay.
• 56:26Alright. Good. So if you
• 56:27guys could share that one.
• 56:28Do you have one? Karen,
• 56:29do you need this?
• 56:31One here. Okay. Great. So
• 56:32we will,
• 56:33open this up for questions
• 56:35or comments.
• 56:37And,
• 56:38Alexis, how do you Alexis
• 56:39jumping right on this. I
• 56:40love it.
• 56:43This is a fascinating issue,
• 56:45to me about justice and
• 56:47all and and, other other
• 56:49medical ethics aspects as well
• 56:50as practical stuff. We can
• 56:51get into that a little
• 56:52bit. In the meantime,
• 56:53we'll just wait one second
• 56:54if you have a question
• 56:55for, for Karen or Isaac
• 56:58to bring you a, a
• 56:59microphone so that the folks
• 57:00on Zoom can hear it.
• 57:01So let's start,
• 57:04with, that's a small microphone.
• 57:07Where'd Karen go? Karen's gone.
• 57:08So this is going pretty
• 57:09well so far. Can I
• 57:10get you guys to come
• 57:10up here? You're right here.
• 57:12And,
• 57:13Ben.
• 57:16This is the one you're
• 57:17talking to here.
• 57:19We're answering the tough question.
• 57:21He's got to provide you
• 57:23with.
• 57:27Well, we've got,
• 57:28we're a microphone shot, so
• 57:30that's alright. We don't have
• 57:32much. Okay. We got more
• 57:33food coming. Outstanding.
• 57:35Alexis,
• 57:36what's on your mind?
• 57:38I was just wondering there
• 57:40I think there are parts
• 57:41Thanks, Chad. Thank you. Oh,
• 57:42thank you.
• 57:44I think there are parts
• 57:44of the country where due
• 57:46to combination of, like, local
• 57:48infrastructure
• 57:49and local culture,
• 57:51driving like, it's very, very
• 57:53hard to live without driving,
• 57:54and driving is maybe regarded
• 57:55more as
• 58:00and
• 58:00I think just maybe
• 58:02those also might
• 58:03correspond with areas where it's
• 58:04more rural and a driving
• 58:05accident
• 58:06might be less likely to
• 58:07involve other people compared to,
• 58:09like, a busy urban area.
• 58:12And so I'm wondering
• 58:13if, like, when considering
• 58:15individualized driving restrictions,
• 58:17if,
• 58:18like, local factors like that
• 58:20should be taken account into
• 58:21account or if it could
• 58:22be purely based on the
• 58:23individual's
• 58:24metfold.
• 58:29Yes. So so I I
• 58:31have I have a thought
• 58:31on that. So so that
• 58:32that actually came up. Is
• 58:33this is this on? Yeah.
• 58:35So that actually came up
• 58:36in so so there's, like,
• 58:37a public comment
• 58:39Just a little closer if
• 58:40you would then. Around the
• 58:41around that position statement. And
• 58:43and and that was an
• 58:44issue that a couple of
• 58:45folks raised.
• 58:48And, you know, I think
• 58:49it's it's an important point.
• 58:51And I think there are
• 58:52reasons why
• 58:54you you might not want
• 58:55the
• 58:57criteria for driving licensure to
• 58:58be the same in, like,
• 59:00Arizona
• 59:01as in,
• 59:04you know, New York or,
• 59:05Massachusetts.
• 59:09It
• 59:10what what I would ideally
• 59:12like to see is
• 59:15uniform
• 59:16laws
• 59:17that empower
• 59:18medical advisory boards and DMVs
• 59:21in individual
• 59:22states,
• 59:23to to set
• 59:25regulations that they feel are
• 59:26appropriate. But I I do
• 59:27think it would be valuable
• 59:28to have,
• 59:30the underpinning laws be uniform
• 59:32between states to to improve,
• 59:37adherence and to to lessen
• 59:39confusion. Because I I I
• 59:40think as you
• 59:41are
• 59:42are perhaps beginning to to
• 59:44experience, there's a great deal
• 59:45of confusion even among clinicians,
• 59:48about, like, you know, what
• 59:49are the laws in my
• 59:50state? What are the laws
• 59:51in the next state over?
• 59:53And so I think there
• 59:53there there is a certain
• 59:55value in,
• 59:57consistency of the law, but
• 59:59at the same time, I
• 60:00think you're right that there
• 01:00:01are,
• 01:00:03geographic
• 01:00:04considerations that need to be
• 01:00:05taken into account. I think
• 01:00:06the the best mechanism there
• 01:00:07would be for the medical
• 01:00:08advisory board and the DMV
• 01:00:10to to set criteria based
• 01:00:12on, you know, on their
• 01:00:13state's
• 01:00:14geographic and sociopolitical
• 01:00:16needs. But that would be
• 01:00:17my thought.
• 01:00:23Jordan?
• 01:00:24Anyway, that is one of
• 01:00:25the reasons why there are
• 01:00:26some there's so much variability,
• 01:00:28and one of the arguments
• 01:00:29for sort of state determined
• 01:00:31because the individual both the
• 01:00:33legislate the the legislature is
• 01:00:35responsible
• 01:00:35to those individuals as are
• 01:00:37the clinicians, know what the
• 01:00:38issues are, and can make
• 01:00:39that determination. And it's also
• 01:00:40potentially an argument for voluntary
• 01:00:42versus mandatory
• 01:00:43reporting.
• 01:00:45And although there has been
• 01:00:46some fluctuation in the number
• 01:00:47of states that have mandatory
• 01:00:49reporting over the years, it's
• 01:00:50really pretty much always hovered
• 01:00:51in that six to seven
• 01:00:53states out of fifty.
• 01:00:55And the the six or
• 01:00:57seven may change a little
• 01:00:58bit over time, but it's
• 01:00:59it's never become a plurality
• 01:01:01or,
• 01:01:02you know, other ones because
• 01:01:04it does give you more
• 01:01:05flexibility in terms of how
• 01:01:06to do that. And that's
• 01:01:07one of the rationale or
• 01:01:08reasons for that.
• 01:01:12I'm gonna ask for some
• 01:01:14moral as well as some
• 01:01:15technical guidance.
• 01:01:17Years ago,
• 01:01:19the daughter of one of
• 01:01:20my patients called and said,
• 01:01:22please talk to my father.
• 01:01:23He is
• 01:01:24he's losing it. He can't
• 01:01:26he just can't be permitted
• 01:01:27to drive anymore.
• 01:01:28I think this was after
• 01:01:30nineteen ninety, so I wasn't
• 01:01:32legally mandated to report the
• 01:01:34guy. But,
• 01:01:36so he came in.
• 01:01:38I did the what I
• 01:01:40considered the appropriate exam,
• 01:01:42and I began to talk
• 01:01:43to him about the fact
• 01:01:45that he shouldn't be driving.
• 01:01:47And the man
• 01:01:49started wailing.
• 01:01:50I mean, this was he
• 01:01:52talked about this how this
• 01:01:53was gonna destroy his life.
• 01:01:56And the and the daughter
• 01:01:58almost immediately said, okay. No.
• 01:01:59No. No. No. No. I
• 01:02:00don't want you to don't
• 01:02:02do this to my father.
• 01:02:03And so I didn't,
• 01:02:06but I
• 01:02:08I worried about it.
• 01:02:09And I and I did
• 01:02:11not did not report him.
• 01:02:15And
• 01:02:16so what should I have
• 01:02:18done what should I do
• 01:02:19if I'm confronted with a
• 01:02:20similar
• 01:02:22circumstance
• 01:02:23again?
• 01:02:26Yeah. I mean, that's one
• 01:02:27of the main reasons I
• 01:02:28got involved in this. Not
• 01:02:29clinically
• 01:02:30even a magician, but most
• 01:02:31of the people we see,
• 01:02:33in the outpatient setting have
• 01:02:34cognitive impairment to some degree
• 01:02:36or another. And this issue
• 01:02:37came up, although often not
• 01:02:39raised by individuals and often
• 01:02:40not even by their family,
• 01:02:42but in the course of
• 01:02:43that discussion, it would come
• 01:02:44up.
• 01:02:46But and you could, you
• 01:02:47know, you could talk about
• 01:02:48Alzheimer's disease or other differentials,
• 01:02:50and the talk was going
• 01:02:51over the head. But as
• 01:02:51soon as you got to,
• 01:02:52and what that means is
• 01:02:54regarding driving, boom, people locked
• 01:02:55in. No matter how cognitively
• 01:02:57impaired they were,
• 01:02:58they understood what the implication
• 01:03:00of that was. So one
• 01:03:01of the reasons I got
• 01:03:02involved was to really help
• 01:03:03convince myself,
• 01:03:05of the need for change
• 01:03:06so that I could then
• 01:03:06try and convince the family,
• 01:03:08and the patient the need
• 01:03:09for change. And a lot
• 01:03:11depends on the condition, and,
• 01:03:12you know, part of it
• 01:03:13is to try and identify
• 01:03:14things that you could do
• 01:03:15something about.
• 01:03:17But for many conditions, there
• 01:03:18isn't something, but there may
• 01:03:19be.
• 01:03:20And so one of the
• 01:03:21rationales is to think about
• 01:03:22interventions. And in the last
• 01:03:23twenty, twenty five years, there
• 01:03:25actually have been intervention studies
• 01:03:26for individual conditions or medications
• 01:03:29or other conditions where showing
• 01:03:31that you can actually improve
• 01:03:32things.
• 01:03:34But if not, you can
• 01:03:34at least explain what the
• 01:03:35rationale, why you're thinking, why
• 01:03:37you're making the recommendation you
• 01:03:38are. One advantage of,
• 01:03:41voluntary reporting is it does
• 01:03:42give you some flexibility to
• 01:03:43make a recommendation to them.
• 01:03:45On the basis of x,
• 01:03:46y, and z, I think
• 01:03:47you really need to stop
• 01:03:48driving or limit your driving.
• 01:03:50Or at the very least,
• 01:03:51if you have a family
• 01:03:52member who's able and willing,
• 01:03:53I want your son, daughter,
• 01:03:55spouse to monitor that, to
• 01:03:57ride with you regularly.
• 01:03:58And as soon as they
• 01:03:59notice anything different, then let
• 01:04:01me know,
• 01:04:02and then we'll we'll go
• 01:04:03from there.
• 01:04:04And then if in follow-up,
• 01:04:06it turns out that they've
• 01:04:07ignored that, they don't do
• 01:04:08it, or they can't do
• 01:04:08it, then you have the
• 01:04:10the option to then report
• 01:04:12that individual to DMV,
• 01:04:14and to do it. The
• 01:04:15other rationale is reporting to
• 01:04:16the DMV is not the
• 01:04:18end of this process.
• 01:04:20All it means is that
• 01:04:21their license gets revoked. That
• 01:04:23doesn't mean that they're stopped
• 01:04:24driving.
• 01:04:25And so individuals, if they
• 01:04:26have their keys and have
• 01:04:27access to a car, can
• 01:04:28continue to drive regardless of
• 01:04:30whether they have a license
• 01:04:31or not. So one of
• 01:04:32the other reasons for going
• 01:04:33through this process and involving
• 01:04:35family now, again, in geriatrics,
• 01:04:36we have the advantage of
• 01:04:38having typically a family member
• 01:04:39or caregiver accompanying the individual,
• 01:04:41which is not the case
• 01:04:42in many private practice settings
• 01:04:43or many practice settings for
• 01:04:45other specialties.
• 01:04:46But is to to
• 01:04:48to convince or to help
• 01:04:49convince that family member that,
• 01:04:52other individual friend, whatever it
• 01:04:54is,
• 01:04:55of the need for change.
• 01:04:56Because somebody else is gonna
• 01:04:57have to enforce that, particularly
• 01:04:59in individuals who have cognitive
• 01:05:00impairment and are not aware
• 01:05:01of what their deficits are.
• 01:05:03So, you're again, you're trying
• 01:05:04to get somebody else to
• 01:05:05enforce that and come up
• 01:05:06with creative ways, to limit
• 01:05:08their access or eliminate their
• 01:05:09access to a vehicle if
• 01:05:10indeed it's gotten to that
• 01:05:11point.
• 01:05:13I I completely agree. I
• 01:05:14just highlight two points
• 01:05:16there. Like, one is the
• 01:05:17importance of, like, a longitudinal
• 01:05:19relationship. Right? And and so,
• 01:05:22you know, having the flexibility
• 01:05:25that voluntary
• 01:05:27reporting
• 01:05:28allows, you you can
• 01:05:30make a plan with the
• 01:05:31patient, with the family. You
• 01:05:32can follow it up. You
• 01:05:34can you can
• 01:05:36threaten
• 01:05:36in a
• 01:05:38if if necessary, that that
• 01:05:39you you will report if
• 01:05:42accommodations aren't made.
• 01:05:45But you don't have to
• 01:05:46just, like, right off the
• 01:05:47bat,
• 01:05:50report everybody, which is, you
• 01:05:52know, what you would have
• 01:05:53to do in New Jersey.
• 01:05:54You you you legally could
• 01:05:56not do what you did.
• 01:05:57You couldn't make a plan
• 01:05:58with the daughter. You couldn't
• 01:06:00make a plan to follow-up
• 01:06:01in clinic in three months.
• 01:06:03You you know, you just
• 01:06:04you have to report. I
• 01:06:05think that that's a really
• 01:06:06important difference.
• 01:06:08So I I wanna ask
• 01:06:09and touch base. Something you
• 01:06:11mentioned, Ben, really struck me.
• 01:06:12So so putting a a
• 01:06:14particularly a bioethic spin on
• 01:06:16this and and the idea
• 01:06:18of justice,
• 01:06:19which is that if we're
• 01:06:20gonna treat two groups differently,
• 01:06:22we need to have a
• 01:06:22morally relevant difference. So it
• 01:06:23seems to me what's relevant
• 01:06:25is the data or the
• 01:06:25data
• 01:06:26that you presented,
• 01:06:28to gave us a little
• 01:06:29taste of it at least.
• 01:06:30And and so it seems
• 01:06:32like just a basic injustice
• 01:06:34that there's all this for
• 01:06:36example, people with epilepsy. We
• 01:06:37can talk about the elderly
• 01:06:38next. But for people with
• 01:06:40epilepsy, there's so much focus
• 01:06:41on that. And, I mean,
• 01:06:42you pointed out, whereas compared,
• 01:06:44for example, with teenagers,
• 01:06:46that, in fact, on the
• 01:06:48road, they pose much less
• 01:06:50risk. And by by the
• 01:06:50way, of course, what makes
• 01:06:51this interesting for the students
• 01:06:52I think most of us
• 01:06:53get it. Even the students
• 01:06:54figure this out. That that
• 01:06:55that what makes this interesting
• 01:06:56is not that you're gonna
• 01:06:57get hit a tree and
• 01:06:58kill yourself, because any of
• 01:06:59us should be able to
• 01:07:00say as long as we're
• 01:07:00of sound mind, book, my
• 01:07:02car hits a tree and
• 01:07:02I kill myself, then that
• 01:07:03I'll take that chance. Obviously,
• 01:07:05the risk is that you
• 01:07:05hit somebody else,
• 01:07:07not just that you hit
• 01:07:07a tree.
• 01:07:08So
• 01:07:10that risk that we may
• 01:07:11pose to others might limit
• 01:07:13our own personal freedoms, but
• 01:07:14then that has to be
• 01:07:15done fairly. But do you
• 01:07:16think do you think it's
• 01:07:17done fairly now? In other
• 01:07:19words, the attention that's focused
• 01:07:20on people with epilepsy, does
• 01:07:22anyone focus that same degree
• 01:07:23of attention on, for example,
• 01:07:25adolescents? Right. So so I
• 01:07:27I I I think that
• 01:07:29it's
• 01:07:30been getting
• 01:07:32fairer over
• 01:07:34the years. I think it
• 01:07:35it started out,
• 01:07:37influenced
• 01:07:39by rare but very,
• 01:07:42you know, photogenic
• 01:07:44tragedies. I think there there
• 01:07:45was very strict,
• 01:07:47prohibitions
• 01:07:49from the get go. And
• 01:07:50I think there there still
• 01:07:52are these rare tragedies
• 01:07:55where, you know,
• 01:07:56innocent people are are killed
• 01:07:58by an individual who is
• 01:08:00not well controlled on their
• 01:08:01anti seizure medications, who's not
• 01:08:03adherent.
• 01:08:04And and and as nephrologist,
• 01:08:05I very much, like, see
• 01:08:07those cases.
• 01:08:09But
• 01:08:13when
• 01:08:16when patients are are adherent
• 01:08:18and the their clinicians
• 01:08:19are
• 01:08:20careful,
• 01:08:22I think it is possible,
• 01:08:24and I think that the
• 01:08:24data supports this on a
• 01:08:26on a population level to
• 01:08:28have
• 01:08:29safe
• 01:08:30driving for most individuals with
• 01:08:33epilepsy.
• 01:08:33And I think that while
• 01:08:35the the rates of motor
• 01:08:36vehicle accident fatalities are demonstrably
• 01:08:38much lower than they are
• 01:08:40for
• 01:08:41young drivers, for old drivers,
• 01:08:44for drivers with substance use
• 01:08:46disorders, for distracted drivers.
• 01:08:49And, unfortunately,
• 01:08:50there the
• 01:08:51there are these,
• 01:08:53you know,
• 01:08:54very,
• 01:08:56gripping anecdotes.
• 01:08:57And I think, you know,
• 01:08:58I think this is the
• 01:08:59the problem of allowing
• 01:09:02anecdotes to drive health policy.
• 01:09:05Right? I think
• 01:09:06this illustrates the importance
• 01:09:08of
• 01:09:09stepping
• 01:09:10back, taking a breath,
• 01:09:13not rushing
• 01:09:15to make policy on the
• 01:09:17basis of the latest
• 01:09:19tragedy or the latest news
• 01:09:21sensation
• 01:09:22and and looking at what
• 01:09:23objective evidence is available. And
• 01:09:25I think there there's been
• 01:09:26a trend in that direction,
• 01:09:29but even now, even like
• 01:09:30in Michigan, there there are
• 01:09:32examples where,
• 01:09:33that urge to make restrictive
• 01:09:35policies on the basis of,
• 01:09:39individual cases is still present.
• 01:09:41I think it's well intentioned.
• 01:09:42I don't think that anybody
• 01:09:43in Michigan is like, you
• 01:09:45know, trying to
• 01:09:46get people with epilepsy, but
• 01:09:48I I think they are
• 01:09:49being unduly influenced by this
• 01:09:52sort of single traumatic event
• 01:09:54and paying insufficient attend attention
• 01:09:56to the,
• 01:09:59very widely validated evidence at
• 01:10:01this point.
• 01:10:03Karen.
• 01:10:05Oh, I'm sorry. I apologize.
• 01:10:06Were you, hit it that
• 01:10:07way? You're next, please. Yes.
• 01:10:09Yes.
• 01:10:11So, I work in the
• 01:10:12emergency department, and it's no
• 01:10:14secret that the most common,
• 01:10:17medical issue associated with motor
• 01:10:19vehicle crashes is not epilepsy.
• 01:10:20It's,
• 01:10:22alcohol use disorder.
• 01:10:24And there we used to
• 01:10:25have a champion in our
• 01:10:26emergency department when I was
• 01:10:27a trainee here
• 01:10:29where,
• 01:10:31you know, he would write
• 01:10:32we would have to fill
• 01:10:33out these forms literally on
• 01:10:34almost everybody
• 01:10:36who, you know, had a
• 01:10:37significant car accident while intoxicated
• 01:10:40if there was evidence of
• 01:10:41alcohol use disorder. But I
• 01:10:43always felt uncomfortable because I
• 01:10:44didn't really know if the
• 01:10:46person, you know, sometimes it
• 01:10:47was their birthday. I would
• 01:10:48look on their, you know,
• 01:10:49on the medical record, it
• 01:10:50was their birthday. They were
• 01:10:51drunk that night, but I
• 01:10:52didn't really know if they
• 01:10:53had alcohol use disorder. Now
• 01:10:54the people who were still
• 01:10:55having a conversation and their
• 01:10:56alcohol level was five hundred
• 01:10:58and they had complete denial.
• 01:10:59I had nothing to drink,
• 01:11:00etcetera. Those people, it was
• 01:11:02much easier for me to
• 01:11:03make the diagnosis of most
• 01:11:05likely alcohol use disorder. And
• 01:11:07I could fill out that
• 01:11:08form, but I always felt
• 01:11:09badly,
• 01:11:10you know, being told I
• 01:11:11had to fill out the
• 01:11:11form with somebody. And so
• 01:11:13I know that person's long
• 01:11:15gone,
• 01:11:16that champion,
• 01:11:18who had us filling out
• 01:11:19the forms. And I don't
• 01:11:20think the EDA at Yale
• 01:11:22has filled out a form
• 01:11:23for an alcohol
• 01:11:24patient
• 01:11:25in, you know, five or
• 01:11:26ten years. And and yet
• 01:11:27we were probably doing forty
• 01:11:29a week before. So I'm
• 01:11:31just I'm not sure where
• 01:11:32that, you know,
• 01:11:34where the training is in
• 01:11:35terms of, you know, educating
• 01:11:38people like ED physicians around
• 01:11:39the state. Should we be
• 01:11:40filling out these forms? What
• 01:11:41should be triggering us to
• 01:11:43fill out the forms and
• 01:11:44do get any forms for
• 01:11:45alcohol use disorder from ED
• 01:11:47people? And I think the
• 01:11:48addiction medicine people, people would
• 01:11:50be afraid to tell their
• 01:11:51addiction medicine physicians
• 01:11:53what's going on with their
• 01:11:54alcohol use disorder if they
• 01:11:55thought their addiction medicine person
• 01:11:57was gonna fill out one
• 01:11:58of these forms.
• 01:12:02Yeah. I mean, I I
• 01:12:03think it
• 01:12:06is it
• 01:12:07alcohol use is a tricky
• 01:12:08one, in that if someone
• 01:12:10is not impaired,
• 01:12:12at other times. So if
• 01:12:13you refer that person for
• 01:12:14an evaluation
• 01:12:15and they don't drink for
• 01:12:16a period of time, then
• 01:12:17there may not be any
• 01:12:18underlying issues. So if you
• 01:12:19test them, then they may
• 01:12:20test fine.
• 01:12:22There are fairly stringent requirements
• 01:12:24around that, at least in
• 01:12:25terms of licensing.
• 01:12:27And more often than not,
• 01:12:28those people come to attention
• 01:12:29through law enforcement rather than
• 01:12:31through the medical arena per
• 01:12:33se. And there you have
• 01:12:34the evidence not only that
• 01:12:35they were
• 01:12:36intoxicated,
• 01:12:38but also,
• 01:12:39that there was evidence of
• 01:12:40an adverse event that occurred
• 01:12:41as a result of that.
• 01:12:43And then, you know, if
• 01:12:43there's a point system, you
• 01:12:44can accumulate that. Now people
• 01:12:46can bundle those. But if
• 01:12:47it there are recurrent episodes
• 01:12:48like that, then you could
• 01:12:49say, yes. That is indeed
• 01:12:51a problematic
• 01:12:52and the person with a
• 01:12:53problematic condition. And there are
• 01:12:55things like interlock devices and
• 01:12:56other things that can be
• 01:12:57mandated,
• 01:12:58if people reach that threshold.
• 01:13:00In the individual setting, it's
• 01:13:01trickier. But almost like Ben
• 01:13:03was saying before, in an
• 01:13:04acute patient setting, also, I
• 01:13:05mean, people come in, they're
• 01:13:07acutely ill, their condition then,
• 01:13:09you know, may be very
• 01:13:10different than it would be
• 01:13:11in two or three weeks.
• 01:13:11So the advantage is that
• 01:13:13you can tell somebody not
• 01:13:14to drive until they see
• 01:13:15their related specialist or their
• 01:13:17primary care clinician So that
• 01:13:18a few weeks out, they
• 01:13:19may have recovered to the
• 01:13:20point, that it is. That's
• 01:13:21not talking specifically about alcohol
• 01:13:23use, but any medical condition
• 01:13:24where there is a delirium
• 01:13:25or a change of functional
• 01:13:27status. So it gives a
• 01:13:28chance to for that individual
• 01:13:30to get back without actually,
• 01:13:31you know, getting their license
• 01:13:32revoked in the interim.
• 01:13:34I'll just say, I I
• 01:13:35think that the
• 01:13:37physician should be more active
• 01:13:38than we are in in
• 01:13:39reporting unsafe driving. I just
• 01:13:41don't think they should be
• 01:13:42mandated.
• 01:13:43I I I think that
• 01:13:44it's important that there are
• 01:13:45legal protections in place. Unfortunately,
• 01:13:47in Connecticut, there are. It's
• 01:13:48not the case in every
• 01:13:49state,
• 01:13:50to to protect,
• 01:13:52physicians who are reporting,
• 01:13:54what they believe to be
• 01:13:55an unsafe driver in good
• 01:13:57faith. And I I think,
• 01:13:59you know, I I would
• 01:14:00agree with Rich that that
• 01:14:01the majority of patients that
• 01:14:03I see who who have
• 01:14:05had their license
• 01:14:06revoked is because a a
• 01:14:08police officer
• 01:14:10witnessed
• 01:14:11a seizure or witnessed a
• 01:14:13motor vehicle accident or,
• 01:14:15because a because a police
• 01:14:17officer got involved. It's it's
• 01:14:18very rarely,
• 01:14:20as a result of the
• 01:14:21action of a of a
• 01:14:22physician. And I think that's
• 01:14:23that's
• 01:14:24I think I think we
• 01:14:25are
• 01:14:25failing to, you know, live
• 01:14:27up to our responsibilities
• 01:14:28when when
• 01:14:30when we practice that way.
• 01:14:31I think I think the
• 01:14:33the history at at the
• 01:14:34LED is is something that,
• 01:14:36you know, you should be
• 01:14:37proud of and and that
• 01:14:38should be considered for future
• 01:14:40training.
• 01:14:41Thank you. Yes. I think
• 01:14:42we have another question here.
• 01:14:43Thank you for the interesting
• 01:14:45thought. I was just
• 01:14:47curious, if it's even known,
• 01:14:49like,
• 01:14:50whether
• 01:14:51people with epilepsy like, how
• 01:14:53often they actually drive, if
• 01:14:54they drive as frequently as
• 01:14:56other people,
• 01:14:57and if the low rates
• 01:14:59of accidents could be actually
• 01:15:00affected by the fact that
• 01:15:01maybe they don't drive as
• 01:15:03often because maybe they are
• 01:15:05not as comfortable driving.
• 01:15:07Yeah. So so
• 01:15:08anecdotally,
• 01:15:09I think that
• 01:15:12and this this is not
• 01:15:12evidence based. This is this
• 01:15:13is sort of my my
• 01:15:14personal
• 01:15:15clinical experience. I I I
• 01:15:16think that
• 01:15:18many the the the majority
• 01:15:21of individuals with epilepsy are
• 01:15:22more thoughtful and careful about,
• 01:15:24like, when and how they
• 01:15:25drive and under what conditions
• 01:15:27than sort of the average,
• 01:15:29driving population. Having said that,
• 01:15:31you know, as was pointed
• 01:15:32out, there are a lot
• 01:15:34of states and even within
• 01:15:35Connecticut, there are a lot
• 01:15:36of regions where you just
• 01:15:37have to drive. Right? And
• 01:15:39and,
• 01:15:42you know, I I think
• 01:15:43it's
• 01:15:44not crazy
• 01:15:45for somebody who is considering,
• 01:15:47like,
• 01:15:48I can work and feed
• 01:15:49my family
• 01:15:50or I can obey the
• 01:15:51law.
• 01:15:52I think it's not crazy
• 01:15:53that people, like, really question
• 01:15:55that. And and I think
• 01:15:57that
• 01:15:58it's incumbent on
• 01:16:00governments and health care systems
• 01:16:02to think about if we're
• 01:16:04going to prioritize
• 01:16:06public safety,
• 01:16:08you know, over autonomy, like,
• 01:16:10we we need to
• 01:16:13make that,
• 01:16:15that law something that is,
• 01:16:18tolerable, that is not
• 01:16:20completely destructive to the individual
• 01:16:22and their family, which frankly,
• 01:16:24in many states and in
• 01:16:25many regions, it is.
• 01:16:27Fortunately, I think, you know,
• 01:16:29with ride share technology,
• 01:16:31with, self driving cars, I
• 01:16:33I think we're we're close
• 01:16:34to a place where where
• 01:16:37real accommodations can be widely
• 01:16:38available, but we're not there
• 01:16:40yet.
• 01:16:42Thank you. Yeah. Please, Sagar.
• 01:16:45Yeah. I I think you
• 01:16:46really,
• 01:16:47made your case
• 01:16:48that,
• 01:16:49this has to be looked
• 01:16:50at,
• 01:16:51comparatively
• 01:16:52to others'
• 01:16:54problems that drivers could have.
• 01:16:56So it it opened up
• 01:16:57my mind quite a lot
• 01:16:58on this. But I couldn't
• 01:16:59help but wonder about,
• 01:17:02some of the data you
• 01:17:03relied on in making the
• 01:17:04case. It must be very
• 01:17:05challenging
• 01:17:06to collect such data. I
• 01:17:08mean, per in particular,
• 01:17:10if somebody has died
• 01:17:12in an a motor vehicle
• 01:17:14accident, how are you gonna
• 01:17:15tell if they had a
• 01:17:16seizure?
• 01:17:17The yeah. I think that
• 01:17:18that's a fair point. And
• 01:17:19and and a lot of
• 01:17:19the data that we're looking
• 01:17:21at is based on,
• 01:17:23you know, reported,
• 01:17:26causes of motor vehicle accidents.
• 01:17:27And and and you're right,
• 01:17:28but the the reporting
• 01:17:31raises
• 01:17:33a
• 01:17:34a a a a a
• 01:17:35challenge, right, that,
• 01:17:36that that seizures may be
• 01:17:38less likely to be reported.
• 01:17:41I I would suggest though
• 01:17:42that, like, you know, compared
• 01:17:43to
• 01:17:44distraction,
• 01:17:45there's actually generally, like, more
• 01:17:47documentation of a person's,
• 01:17:49history of epilepsy,
• 01:17:52and, you know, in their
• 01:17:53medical records
• 01:17:54compared to, like, distractibility,
• 01:17:56you know, whether they're distracted,
• 01:17:58whether they are,
• 01:18:02even have alcohol use disorder.
• 01:18:04I think you can generally
• 01:18:05find, like, more,
• 01:18:08accurate information about,
• 01:18:09epilepsy and seizures than around
• 01:18:11some of the other conditions
• 01:18:12that are that are
• 01:18:14actually more problematic
• 01:18:16for for driving safety.
• 01:18:19Okay. So
• 01:18:21Karen tells me
• 01:18:23the pen has already got
• 01:18:24a lot of the good
• 01:18:24stuff.
• 01:18:26That's why pen gets a
• 01:18:27smaller bag. It's not.
• 01:18:29Rich has a bigger bag.
• 01:18:30So so I thank please
• 01:18:31join me. Thank you.
• 01:18:38Because you're one of the
• 01:18:39family, you don't actually get
• 01:18:40down on earth. A
• 01:18:42bag of stuff.
• 01:18:43Instead, let me just real
• 01:18:45quickly just say something about
• 01:18:46these about these meetings before
• 01:18:48I, ride off into the
• 01:18:50sunrise.
• 01:18:51So I'm I'm headed off
• 01:18:52to to to work on
• 01:18:54another program or another place
• 01:18:55just as kind of a
• 01:18:56retirement gig. I can only
• 01:18:57hope that I can gather
• 01:18:58a bioethics community like the
• 01:19:00one we gathered here, that
• 01:19:01I can gather a leadership
• 01:19:02team like the one that
• 01:19:03I've got here, with Jen
• 01:19:04and Sarah and Jack and
• 01:19:06Ben,
• 01:19:07and and one other person
• 01:19:08who has to be mentioned
• 01:19:10in all this. There's a
• 01:19:11lot that goes into this.
• 01:19:12Just this evening seminar series,
• 01:19:14and and it comes down
• 01:19:16to everything from reserving the
• 01:19:18room to organizing the food
• 01:19:19to help me,
• 01:19:21organize the schedule to making
• 01:19:22contact with the speakers, all
• 01:19:24these visiting speakers that need
• 01:19:25travel,
• 01:19:26plans. And I'll tell you
• 01:19:27that we have established our
• 01:19:28a reputation for ourselves over
• 01:19:30the years as a place
• 01:19:31for visiting speakers to come.
• 01:19:32And so we've been able
• 01:19:33to bring in wonderful speakers
• 01:19:35from all over, including wonderful
• 01:19:37local speakers. And one reason
• 01:19:38is that people say to
• 01:19:39me not infrequently, you know,
• 01:19:41Karen is fantastic. Karen makes
• 01:19:43it so easy. She's really
• 01:19:44helped me get from here
• 01:19:45to there that Karen makes
• 01:19:46the whole thing work. Karen
• 01:19:48Cole, who is the manager
• 01:19:49of this program, who many
• 01:19:50of you have been in
• 01:19:50touch with at one point
• 01:19:52or another, she manages not
• 01:19:53just the evening seminar series,
• 01:19:55but she manages the entire
• 01:19:56program for biomedical ethics and
• 01:19:58does a beautiful job of
• 01:19:59it and has for many
• 01:20:00years. So please join me
• 01:20:01in thanking Karen right now.
• 01:20:11And with that