IMPLEMENTATION OF A TEACHING PROGRAMME TO IMPROVE DOCTORS’ AWARENESS OF DVLA

GUIDELINES: A MULTICENTRE STUDY

Dr Mahiben Maruthappu MA BM BCh1

Mark Sykes BSc (Hons)1

Dr Ben L Green BSc MBChB2

Dr Robert Watson BA (Hons) BM BCh1

Dr Nicholas Gollop BSc MB BCh3

Mr Joseph Shalhoub BSc MBBS MRCS FHEA PhD1

Dr Ka Ying Bonnie Ng BMedSci, MBChB1,4

1 Imperial College London, London SW7 2AZ, UK

2 Leeds Teaching Hospitals Trust, Great George Street, Leeds, LS1 3EX, UK

3 The Norfolk and Norwich University Hospital, NR4 7UY

4 Chelsea and Westminster Hospital, Fulham Road London SW10 9NH, UK

Corresponding author:

Dr Ka Ying Bonnie Ng

Chelsea and Westminster Hospital

Fulham Road, London UK, SW10 9NH

bonnie.ng@doctors.org.uk

Tel: +44 7557991838

Keywords

Medical education, DVLA, Postgraduate education, Driving accidents, Driving restrictions

Word count

2006

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ABSTRACT

Introduction

Over half of the UK population holds a driver’s licence. Driver and Vehicle Licensing Authority

(DVLA) guidelines are available for conditions from most specialties. Despite this, no focused

training occurs in the undergraduate or postgraduate setting. We evaluate the impact of a teaching

programme to improve guideline awareness.

Methods

A 25-point questionnaire was designed using the current DVLA guidelines. Five questions were

included for the following fields: neurology, cardiology, drug and alcohol abuse, visual disorders,

and respiratory. This was distributed to doctors in training at five hospitals. Four weeks later a

single session teaching programme was implemented. The questionnaire was redistributed. Pre-

and post-intervention scores were compared using the Wilcoxon rank sum test.

Results

139 pre-teaching and 144 post-teaching questionnaires were completed. Implementation of a

single session teaching programme significantly improved knowledge of DVLA guidelines in all five

areas explored. Median scores: neurology- pre-teaching 40%, post-teaching 100%, p<0.001;

cardiology- 0%, 100%, p<0.001; drug and alcohol misuse- 0%, 100%, p<0.001; visual disorders-

40%, 100%, p<0.001; respiratory disorders- 20%, 100%, p<0.001; and overall- 28%, 92%,

p<0.001.

Conclusions

Knowledge of DVLA guidelines amongst our cohort was poor. Implementation of a single session

teaching programme can significantly improve guideline knowledge and awareness, serving as a

cost-effective intervention.

Research questions

Would the incidence of road traffic accidents attributed to medical conditions decrease if

knowledge of the DVLA guidelines was improved?

Are the DVLA guidelines being considered prior to the discharge of patients with conditions

that may impose driving restrictions?

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Are medical students or doctors being taught the DVLA guidelines during undergraduate or

postgraduate education?

As part of an induction or internal teaching session, will further hospitals train their medical

professionals to be aware of the DVLA guidelines?

How many patients continue to drive despite being informed of a driving restriction by their

doctor?

Summary bullet points:

Consideration of the DVLA guidelines is important to ensure the safe discharge of patients

presenting with a number of medical complaints

Awareness of the DVLA guidelines was poor throughout the hospitals tested in this study

A single structured teaching session can effectively improve doctors’ knowledge of the

DVLA guidelines

We encourage hospitals to introduce similar teaching sessions to their incoming doctors to

ensure consideration of the DVLA guidelines occurs when assessing a patient

INTRODUCTION

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The Driver and Vehicle Licensing Authority (DVLA) have published guidelines regarding fitness to

drive for medical conditions from most specialities (DVLA guidelines). Many of these conditions will

impose temporary driving restrictions; however some will enforce long-term bans. Considering that

approximately half the UK population holds a driver’s license(1), knowledge of the DVLA guidelines

amongst doctors is essential. Studies have demonstrated however, that doctors’ understanding of

DVLA guidelines is limited(2, 3, 4, 5)

There is a growing body of evidence attributing medical conditions to driving accidents(6, 7, 8)

Road injury continues to be one of the world’s leading causes of death(9). It is therefore accepted

that recommendations concerning fitness to drive are appropriate and should be enforced without

complacency(10, 11, 12).

The DVLA guidelines are available to both clinicians and patients. Clinicians have a legal duty to

inform their patients of any driving restrictions imposed upon them; however, it is then the patient’s

responsibility to notify the DVLA and uphold their restriction(13). There is demonstrable evidence

of a reduction in traumatic road incidents following physician advice regarding fitness to drive(14).

Precedent for legal action against doctors’ providing inaccurate advice has been established(15). It

is additionally noteworthy that doctors may breach confidentiality to the DVLA if they have

reasonable belief that the patient intends to continue driving. Patients have also been

demonstrated to misinterpret their own imposed driving restrictions(3). Despite this, there is no

focused training on use of the guidelines. Building on previous work, where our group

demonstrated low awareness amongst doctors of DVLA guidelines(5), we devised and

implemented a teaching programme to address this issue, with the aim of evaluating whether such

a programme could improve knowledge of this guidance.

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METHODS

A 25-point questionnaire was designed taking into account current DVLA guidelines in order to

assess doctors’ baseline knowledge of medical restrictions to driving. Five questions were included

for each of the following specialty areas: neurology disorders, cardiology disorders, drug and

alcohol abuse, visual disorders, and respiratory disorders. Specific questions, with the correct

answers in bold, are detailed in Table 1.

The questionnaire was distributed to a random sample of doctors at five district general hospitals

and one teaching hospital in the UK; (i) Ealing Hospital, London, (ii) Northwick Park Hospital,

London, (iii) Watford General Hospital, London, (iv) Norfolk and Norwich University Hospital (v) St

James University Hospital, Leeds, and (vi) Leeds General Infirmary, Leeds. St James University

Hospital and Leeds General Infirmary took part in a shared teaching programme via video link.

Participation in the study was voluntary and there was no incentive to take part. Participants

included foundation year doctors, core trainees and specialty trainees. Participants could either

complete and submit a paper questionnaire, or complete an identical online questionnaire via

‘SurveyGizmo’(16).

Two to four weeks after the completion of the initial questionnaire, a single-session teaching

programme was implemented in each hospital. The teaching session was interactive and included

a PowerPoint presentation detailing DVLA guidance on the driving restrictions in the five

aforementioned specialty areas. Teaching sessions were delivered by junior medical staff that had

been familiarised with the relevant DVLA guidance. A medical registrar or consultant was

additionally present in order to facilitate discussion and oversee the teaching programme.

Two to four weeks after the teaching programme, the same questionnaire was redistributed and

completed by the participants. Two individuals marked the questionnaires independently. Pre- and

post-intervention scores were compared using the Wilcoxon rank sum test as the data were non-

normally distributed.

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Subject areas

Neurology Cardiovascular Drug and Alcohol Abuse Visual Disorders

Respiratory

After a first episode of unprovoked epileptic seizure how long must a person stop driving for?

6 months

Under what circumstances is a patient with angina advised not to drive?

Symptoms at rest, with emotion, or at the wheel

In a patient misusing alcohol, their license must be revoked/ refused until a period of abstinence or controlled drinking has been attained. How long is this minimum period?

6 months

What level of visual acuity is needed to drive?

6/12. Or can read a number plate from 20m

Should a patient with a single attack of cough syncope cease driving?

Yes

If a patient has a vasovagal episode with a definite provocational factor when standing, how long must they stop driving for?

No restrictions

After a coronary artery bypass graft, how long must driving cease for?

4 weeks

How long must an alcohol dependent patient be free from alcohol problems before they can drive again?

1 year

In monocular vision loss, should the DVLA be notified?

Yes

How long must a patient with multiple attacks of cough syncope cease driving for?

12 months

After a solitary loss of consciousness, likely due to a cardiovascular origin, with an identified and treated cause, how long after the event can the patient start driving?

4 weeks

In general, after acute coronary syndrome is successfully treated with elective angioplasty, when can a patient recommence driving?

After 1 week

In a patient with alcohol dependence, following a solitary seizure associated with alcohol misuse, how long is a license revoked or refused?

6 months

In a patient with night blindness, the DVLA will assess their ability to drive once 2 standards have been met. What are they?

Acuity and visual fields

In an asthmatic, the DVLA need not be notified unless attacks have associated features. What are these?

Disabling, giddiness, fainting, loss of consciousness

In a patient with Parkinson’s disease, under what circumstances is their license refused/revoked?

If disabling, or there is significant variability in motor function

Clinically, when is a patient with aortic stenosis disqualified from driving?

If they are symptomatic

Drivers who are on an oral methadone maintenance programme may be licensed subject to a favourable assessment and a medical review. How frequently does this review take place?

Annually

Do colour blind patients need to notify the DVLA of their impairment?

No

Under what circumstances does a patient with carcinoma of the lung need to notify the DVLA of their condition?

Cerebral secondary metastases

For what period of time after a transient ischaemic attack/Stroke can a patient not drive?

1 month

After a pacemaker implant box change, how long must a patient cease driving?

1 week

“Multiple substance misuse and/or dependence is incompatible with licensing fitness”. True or false?

True

In patients with diplopia, when should they cease driving?

On diagnosis

In obstructive sleep apnoea, when can the patient start driving?

Satisfactory control of symptoms

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Table 1 - Details of the questions asked for each subject area included in the questionnaire. Five

questions were included for each of the following areas: neurology disorders, cardiology disorders,

drug and alcohol abuse, visual disorders, and respiratory disorders.

RESULTS

139 pre- and 144 post-test questionnaires were recorded across the five centres. Pre-intervention

scores have been previously published(5). The median scores before the teaching programme

were: neurology (40%; IQR 20-40%), cardiology (0%; IQR 0-10%), drug and alcohol abuse (0%;

IQR 0-20%), visual disorders (40%; IQR 20-40%), respiratory disorders (20%; IQR 20-40%), and

overall score (28%; IQR 20-36%) (Figure 1). The range of overall scores from the pre-teaching test

was 0% to 100%, with only two doctors (1.4%) achieving the maximum. Ten doctors (7.2%) in total

scored over 50%, with 129 (92.8%) scoring less than half correct prior to teaching.

Implementation of a single session teaching programme significantly improved knowledge of DVLA

guidelines, when measured using our questionnaire. Post-intervention median scores were:

neurology (100%; IQR 80-100%; p<0:001), cardiology (100%; IQR 80-100%; p<0:001), drug and

alcohol abuse (100%; IQR 80-100%; p<0:001), visual disorders (100%; IQR 80-100%; p<0:001),

respiratory disorders (100%; IQR 80-100%; p<0:001), and overall score (92%; IQR 80-100%;

p<0:001); illustrated in Figure 1. The range for overall post-teaching scores was reduced (24%-

100%) with only five doctors (3.5%) scoring less than 50% and 87.5% of doctors scoring over 70%.

Figure 1

Median scores at individual hospitals were recorded and compared using the Wilcoxon rank sum

test (Figure 2). All sites saw a significant improvement in their median scores following the

teaching session (Table 2). Norfolk and Norwich University Hospital achieved the highest median

scores both pre- and post- teaching intervention (36% and 100%, respectively), whereas Northwick

Park and Watford General Hospitals returned the lowest pre-teaching score at 28%, and Northwick

Park also achieved the lowest post teaching median score at 72%. Watford General Hospital

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demonstrated the largest improvement (68%), whereas Northwick Park had the lowest

improvement (44%).

Figure 2

Table 2 – Hospital specific Questionnaire scores pre- and post-implementation of the teaching

programme.

Questionnaire Scores

Pre-teaching Post-teachingHospital Trust Median (%) IQR (%) Median (%) IQR (%) Improvement (%)Norfolk and Norwich 36 27-48 100 96-100 64 (p <0.001)Northwick Park 28 17-32 72 62-82 44 (p <0.001)Ealing 32 20-36 98 92-100 66 (p <0.001)Leeds 30 21-36 88 80-96 58 (p <0.001)Watford General 28 24-32 96 84-96 68 (p <0.001)

Pre- and post-teaching scores were compared for individual questions. Results demonstrate an

increase in correctly answered questions throughout all subject areas following the teaching

session (Figure 3). Prior to teaching, the most incorrect responses were seen for question 22: How

long must a patient with multiple attacks of cough syncope cease driving for? (11.5% correct). The

most correctly answered was question pre-teaching was question 17: In monocular vision loss,

should the DVLA be notified? (68.3% correct). Following teaching, question 5 was answered most

poorly: For what period of time after a TIA/Stroke can a patient not drive? (77.1% correct). The

highest percentage of correct responses post-teaching was seen for question 15: “Multiple

substance misuse and/or dependence is incompatible with licensing fitness”. True or false? (95.8%

correct).

Figure 3

DISCUSSION

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The results of this study demonstrate shortcomings in doctors’ knowledge of the DVLA guidelines

in the hospitals we assessed, with only 10 of 139 doctors tested scoring over 50% on the pre-

intervention questionnaire(5) Our study has served to confirm a requirement for education and

shown how a single teaching session can act as a successful intervention. Following a single

session teaching intervention, 5 out of 144 doctors scored under 50%, with 42 scoring a maximum

100%.

We propose that the most likely reason for doctors’ low scores regarding DVLA guidance is

twofold: firstly due to a lack of awareness of the range of medical conditions outlined in the DVLA

guidelines; and secondly, due to a paucity of knowledge primarily attributed to limited formal

education regarding driving restrictions in an undergraduate or postgraduate setting. A number of

studies have previously identified a lack of awareness of the DVLA guidelines(3, 2, 5, 17), with

others reporting the potential legal consequences of not informing patients (15, 18). Similarly,

Brooke and Southward(19) also found that patients were not being informed accurately, if at all,

about their fitness to drive after suffering medical illness. Their suggestions were to increase

education for doctors about the guidelines and provide more informative literature for patients.

Incorporating DVLA guidelines into medical education using a single teaching intervention has

been shown to improve doctors’ knowledge and may therefore help to ensure a heightened

awareness of DVLA guidance during the discharge process. Educational programmes in hospital

have previously been attempted using presentations and ward posters to improve doctors’

understanding of the DVLA guidelines, but yielding only small improvements(2). We propose that a

structured teaching programme, facilitated by an appropriately familiarised individual and delivered

to doctors as part of post-graduate education/hospital induction can significantly improve

knowledge of DVLA guidelines. Similar opinions were reported by Morgan(20) who demonstrated

that junior doctors have limited knowledge of the guidelines, and suggested driving regulations as

a topic for post-graduate examinations. Integration of the basic legal aspects of medicine including

driving restrictions into the General Medical Councils (GMC) curriculum has been previously

proposed as necessity(21). This may further encourage students to consider including driving

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history as part of routine medical clerking, with consequent heightened awareness of relevant

medical conditions.

Individual question analysis (Figure 3) further suggests that in the areas tested, there is little

teaching being received. There is no evidence to indicate that the cohort as a whole had prior

knowledge regarding any of the 25 questions. Few individuals scored highly on the pre-teaching

test; but no questions posed achieved over 50% correct responses. It can be insinuated therefore

that not only is guideline teaching being omitted from medical education, but also that guidelines

are not being mentioned with reference to specific medical conditions when relevant teaching e.g.

neurology, cardiology etc are being delivered.

A site comparison was completed to illustrate any disparities in hospital-specific teaching. It could

be expected that tertiary centres for certain specialties would score higher, the same being

observed in teaching hospitals. Our results illustrate however that knowledge of the guidelines was

poor across all sites prior to teaching. The success demonstrated across all sites serves to confirm

how a single teaching intervention provides a efficacious and practicable means of delivering

necessary information to doctors.

Questions regarding the respiratory components of the guidelines returned the lowest scores

overall. This may represent more educational exposure to other conditions, particularly restrictions

following seizures, acute coronary syndrome, alcohol abuse, and deteriorating vision. Here we

reiterate however that common conditions such as asthma and chronic obstructive pulmonary

disease can have disabling sequelae and, in certain circumstances, necessitate reporting to the

DVLA. Drug and Alcohol abuse questions were the most improved responses following the

teaching session. It is likely that doctors completing the questionnaire were able to fully appreciate

the importance of this category; particularly when considering alcohol is ‘a factor’ in 9.6% fatal road

traffic accidents, and accounts for approximately 35% of accident and emergency attendances

(rising to 70-80% at the weekend)(22).

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The GMC has set out clear guidance to doctors regarding the process of restricting patients who

are unfit to drive; the DVLA are legally responsible for the final decision about a person’s fitness to

drive(23). It is within the doctor’s duty of care however to inform the patient that their medical

condition may affect their ability to drive, and that they have a legal responsibility to inform the

DVLA themselves. This demands doctors to have a thorough understanding of the types of

conditions that impose driving restrictions.

It could be argued that learning the DVLA guidelines in their entirety is an impractical task;

however, an awareness of the scope of the guidelines would at least allow reference to be made to

the literature prior to discharge. We propose the possibility of using smartphone applications

containing key information regarding the DVLA guidelines, allowing ease of access prior to patient

discharge. Alternatively, electronic discharge coding may in the future enable automated

recognition of DVLA notifiable conditions and flag-up the relevant guideline for the person

completing the patients’ discharge.

Limitations to the study and methodology were identified. We observed differing numbers of

responders pre- and post-teaching. The questionnaire required mostly free-text responses, but

also questions with a true/false or yes/no answer. Our results demonstrated that the most

accurately answered questions were those where the candidate was offered options (true/false

etc). Whilst this may indicate better knowledge of the question asked, the nature of the type of

question makes guessed responses more likely to be correct. Furthermore, a longer period

between the initial teaching session and the post-intervention questionnaire, combined with unique

pre and post-intervention questions would provide a better indication of student understanding, as

opposed to simply remembering the questions.

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CONCLUSIONS

To our knowledge this is the first multicentre study assessing doctor’s knowledge of DVLA

guidance. Our study has highlighted poor awareness of the DVLA guidelines amongst doctors

across five general district hospitals and one teaching hospital. We have demonstrated how a

structured single teaching session can act as a simple, cost effective intervention in achieving

significantly improved knowledge, and would encourage hospitals to introduce similar programmes

for their incoming junior doctors and doctors working in acute specialties.

ACKNOWLEDGMENTS

We would like to thank Dr Taha Soomro, Dr Justin Wormald, Dr Mirae Park, Dr James Diviney and

Dr Amy Taylor for their help in local data collection.

CONFLICTS OF INTEREST

The authors declare no financial, personal or professional competing interests related to the work

detailed in this manuscript, nor do any of the authors maintain a financial stake in any product,

device or drug cited in this report.

FUNDING

We declare no funding or support from any organization for the submitted work.

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FIGURE LEGENDS

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Figure 1 - Subject specific pre- and post-teaching median scores. Note the pre-teaching median

score for ‘Cardiology’ and ‘Drugs and alcohol’ was 0%.

Figure 2 – Median pre- and post-teaching questionnaire scores for each hospital.

Figure 3 - Correct responses for individual questions pre- and post-teaching.

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