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Dr. Arthur Neumann, a retired physician, has lived with diabetes since 1951. He awoke at 4:00 a.m. one morning suffering from a severe hypoglycemic attack and within minutes blacked out. Luckily, his companion was there to inject him with a shot of glucagon-a solution which raises blood sugar by forcing the liver to release stored glucose. Naturally, Neumann reported the incident to his doctor.
Two weeks later the Department of Motor Vehicles (DMV) sent Neumann a letter telling him his driver's license had been suspended. Neumann's endocrinologist had reported him to the health department without his knowledge. The letter detailed a long list of official procedures Neumann would have to follow before the DMV would reinstate his license.
"My doctor never even told me himself. I had to find out from the DMV," Neumann says.
Neumann felt betrayed by his physician, as well as frustrated at the DMV's brusque execution of the law. He had always maintained excellent control over his glucose levels. Not only was his hypoglycemic reaction an isolated incident, it occurred in the middle of the night, a time when he would never be driving.
Neumann's story has become a common complaint. People who run the risk of a blackout, through a neurological disease or via diabetes, face the possibility of losing their driver's licenses, just as Neumann did. The law says that doctors should report any patient who suffers from what the doctor deems "uncontrolled diabetes." But patients such as Neumann feel betrayed and angry by their doctors' breach of trust.
Most states have laws which require doctors to report to the health department any patient who suffers a condition involving possible lapses of consciousness. The health department then must report that person to the DMV. In California for example, Section 103900 of the Health and Safety code states: Every physician and surgeon shall report immediately to the local health officer in writing...every patient at least 14 years of age or older...having a disorder characterized by lapses of consciousness. The code then states: The health officer shall report in writing to the Department of Motor Vehicles...every person reported to it as a case of a disorder characterized by lapses of consciousness. The DMV then determines if the person is fit to drive. "Conditions characterized by lapses of consciousness," are defined by Title 17 section 2572 of the California Code of Regulations and include "uncontrolled diabetes mellitus."
The official DMV stance is that safety hearing officers handle each individual on a case-by-case basis. An episode of hypoglycemic unconsciousness will not automatically cause the loss of a person's driving privilege if the incident is isolated and the driver has a doctor's support. But if a person with diabetes lacks medical supervision or caused an accident, the DMV says it is likely that it will suspend that individual's license. Under this regulation, the DMV may consider a person guilty until proven innocent.
Raising the Issue of Harassment
Bob Durstenfeld, presently an engineer for Hewlitt-Packard, discovered that innocence can be difficult to prove after the DMV yanked his license. Durstenfeld attempted to bring a lawyer to a hearing at the DMV, but was told he could not have one. The DMV is not a court, he was told, and because of the regulatory nature of the law he must prove he deserves to have his license reinstated on his own.
To get his license back, Durstenfeld had to take time off of work to take a long series of tests including an optical field test and an optical timed test. His company did not cover the time he took off, and his insurance did not cover all the expenses for the optical tests.
"If you're going to live under these regulatory laws, you have to be responsible, and you have to able to document that you are responsible," says Durstenfeld. "Why do I check my blood sugar before I drive home? In case I have to prove that I am responsible."
Though Durstenfeld successfully regained his license, he may still be susceptible to what many consider to be a second form of harassment-the DMV's classification of medical cases as "poor drivers."
Cathy Hansel tested her blood just before a conference broke for dinner. Although her blood sugar was in the low fifties, she didn't treat the low blood sugar because she knew that she would be eating in a matter of minutes. She didn't realize that every person from the conference would converge into one single McDonalds. After five minutes, Hansel went to the front of the line and demanded a soft drink with sugar. She passed out before the employee had the chance to help her. Luckily, an ambulance arrived quickly to give her a shot of glucagon.
Paramedics must report any calls which involve a lapse of consciousness to the Health Department. Sure enough, two months after the incident, the DMV suspended Hansel's license.
Hansel was luckier than some, and with a letter from her doctor she managed to regain a probationary license. The terms of her probation classified her as a person with excessive violations or accidents. One moving violation would cause another suspension of her license. Though Hansel had a perfect driving record and the blackout did not occur while she was driving, the DMV's driver safety officer treated her as a negligent driver.
"On a philosophical level I can understand why the laws exist, but my hearing officer did not treat my case on an individual basis. The whole experience had a very negative impact on my life," says Hansel.
Many people have become fearful of how easy it is for the DMV to pull a license, and when speaking with Diabetes Health asked to remain anonymous. One reader who chose to withhold her name recently told Diabetes Health how, like Neumann, she feels betrayed by her doctor.
After two car accidents unrelated to diabetes and a minor hypoglycemic blackout in her own home, the DMV mysteriously received her name from an unknown source.
"One of my doctors ratted on me," she says, "I've had diabetes long enough to be able to tell if a hypo is coming on within seconds. If I feel even a twinge while I'm driving, I immediately pull over to eat a couple of glucose tablets and wait until my blood sugar rises. I have never had to administer glucagon. I don't feel like what the DMV is doing is fair."
The woman has been lucky and, so far, has managed to keep her license, but she says the DMV makes the inconvenience of her visits worse then they should be. For example, she has to take a driving test every time her license expires. The correlation between employing a driving test and gauging the likelihood of another lapse of consciousness escapes her. In her opinion, a driving test is a test of a person's driving skills, not their blood sugar.
Cathy Hansel, Bob Durstenfeld and the woman withholding her name all experienced the same treatment by the DMV's Driver Safety Office.
"I was put in the same category as someone who committed a crime," says Durstenfeld.
Doctors have to Protect Themselves
Medical professionals must make a thoughtful determination as to whether their clients are fit for the road before turning the judgment over to the state.
In a recent Internet forum hosted by Diabetes Health, a woman reported that she and her three children were struck by an automobile and filed a lawsuit against the driver. During the investigation the woman discovered that the driver had adult-onset diabetes, so she filed a third-party claim against the physician, asserting that the diabetes caused a "temporary lapse of consciousness" with a subsequent loss of control. The court affirmed that the physician had no duty to report a patient's diabetes to the DMV as long as the patient had not had a hypoglycemic blackout. The woman, who has another case pending on the same matter, has chosen to withhold her name for legal reasons.
L.E. Dodson, MD, who also participated in the forum, wrote that he has debated the ethical and moral implications of reporting a patient to the health department.
"I had one patient who suffered from a loss of hypoglycemic awareness. He drove his car off the road during an insulin reaction and initially refused to quit driving on his own. This was the only patient who has tempted me to report to the Department of Public Safety on my own," says Dodson.
Nancy Bohannon, MD of the Monteagle Medical Center also believes that doctors are sometimes morally obligated to report a patient who runs the risk of passing out and causing an accident.
"You have to remember that the patient is not only endangering himself, but everyone else on the road."
In deciding if a patient should be turned in, Bohannon weighs the aspects of each particular case.
"As far as reporting a person to the Health Department, it depends on my relationship with the patient. If the patient went unconscious at night I'd probably tell him to decrease his insulin dosage before bedtime, but if it happened during the day, then something is wrong with the patient's program. In that case I have to decide whether he is trying to take care of himself, or if he's negligent. If he is negligent I have to turn him in."
Trust Between Doctor and Patient
Because managing diabetes depends heavily upon patient self-medication, any hesitation to communicate with a doctor can carry dangerous ramifications. The threat of being reported to the Health Department may discourage patients from finding out how to adjust their routines in order to avoid a blackout from occurring again.
"A doctor should be well acquainted with the patient's habits before he makes [the decision to report a patient]," Neumann says. "And the least he can do is tell the patient face-to-face before he does it."
Attorney Fritz Zimmer agrees that this law [section 103900] can deteriorate the doctor/patient relationship.
"I don't like the law because it penalizes doctors for doing their jobs. The sanctity of the doctor/patient relationship has always been respected by the legislature and by the California courts," Zimmer says.
According to Zimmer, this particular law could actually endanger the health of patients, in addition to forcing new responsibilities upon doctors. A doctor must now consider sacrificing the patient's trust to abide by the law.
"Do we really want to put the responsibility on doctors to police their patients?" Zimmer asked hypothetically. "The whole idea has a Big Brother ring to it. It should be the DMV's and the patient's responsibility to determine his or her capability to drive."
Many doctors would just as soon not make those kinds of decisions, and many simply avoid the issue altogether.
"The buzz I hear in the medical community is that many doctors are either not reporting their patients, or simply asking their patients not to tell them if they lose consciousness," Zimmer says. "This 'potential for under-reporting' of low blood sugar events serves no one's interest."
Arthur Neumann says he ended his relationship with his endocrinologist after he received the notice from the DMV. He even stopped referring patients to him. Neumann says that he wrote a letter to the endocrinologist, explaining how he felt. The doctor sent a letter back to apologize.
"He said he had been nervous and admitted that he was covering his ass," Neumann says.
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