EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to assess Michael’s fitness to drive?

• Prompt: Ask about any history of hypoglycaemia, dizziness, or vision disturbances.
• Prompt: Explore driving patterns, fatigue, and near-miss incidents.

Q2. What are the relevant medical standards and legal considerations when assessing Michael?

• Prompt: Explain Austroads fitness-to-drive guidelines.
• Prompt: Consider conditional licensing options if vision impairment is present.

Q3. What clinical assessments and investigations would you perform?

• Prompt: Discuss vision testing, neurological assessment, and cardiovascular risk factors.
• Prompt: Identify when specialist input (e.g., ophthalmologist, endocrinologist) is needed.

Q4. How would you complete and document the fitness-to-drive assessment form?

• Prompt: Discuss objective documentation of findings.
• Prompt: Clarify when to recommend further assessment vs issuing an unconditional licence.

Q5. How would you communicate the outcome of this assessment to Michael?

• Prompt: Explain whether he meets driving standards and any licensing restrictions.
• Prompt: Address his concerns about job security with empathetic discussion.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to assess Michael’s fitness to drive?

A comprehensive history is required to assess medical fitness to drive per Austroads guidelines. Key areas include:

1. Driving-Related Symptoms and Functional Impairment

• Hypoglycaemia: Ask about episodes of hypoglycaemia, awareness of symptoms, and recent severe events.
• Vision disturbances: Any blurry vision, difficulty driving at night, or visual field loss?
• Neurological symptoms: Assess for dizziness, fainting, paraesthesia, or weakness.
• Cardiovascular risks: Any chest pain, palpitations, syncope, or exertional dyspnoea?

2. Driving History and Workload

• Type of driving: Long-haul vs local.
• Hours per shift: Fatigue risk from extended driving hours.
• Near-miss incidents: Any recent near-miss crashes or concerns from his employer?
• Use of adaptive strategies: Does he compensate for visual limitations (e.g., relying more on mirrors, slowing at night)?

3. Diabetes Management and Risks

• Blood glucose control: Has he had recent HbA1c checks? Does he self-monitor?
• Medication adherence: Consistently taking metformin, amlodipine, and atorvastatin?
• Complications screening: Has he had regular diabetic eye and foot checks?

4. Comorbidities and Risk Factors

• Cardiovascular risk assessment: Hypertension, cholesterol control, family history of stroke at 60.
• Medication side effects: Any drowsiness or dizziness affecting alertness?
• Sleep quality: Screen for sleep apnoea (snoring, daytime fatigue, observed apnoeas).

A structured history ensures patient safety and compliance with legal obligations, while addressing Michael’s concerns about his employment.

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Q2: What are the relevant medical standards and legal considerations when assessing Michael?

1. Austroads Fitness-to-Drive Standards

• Assess if he meets commercial licence standards based on:
  • Diabetes: Commercial drivers with diabetes must demonstrate stable control, no recent severe hypoglycaemia, and no significant complications.
  • Vision: Must have visual acuity ≥6/9 in at least one eye and visual fields ≥110°.
  • Cardiovascular risk: Assess risk of sudden incapacitation (e.g., uncontrolled hypertension, recent cardiovascular events).

2. Legal and Ethical Considerations

• Mandatory reporting: Some states require mandatory reporting of unsafe drivers.
• Conditional licensing: If vision is below 6/9 but correctable, he may qualify for a conditional licence.
• Confidentiality: While a duty of care exists, patients should be encouraged to self-report if appropriate.

3. Balancing Patient Autonomy and Public Safety

• Risk stratification: If mild diabetic retinopathy does not impair driving, he may continue driving with regular follow-ups.
• Job security concerns: Provide supportive discussion and potential referral for alternative licensing pathways.

Understanding Austroads guidelines ensures a legally sound and ethically appropriate decision.

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Q3: What clinical assessments and investigations would you perform?

1. Vision Testing

• Visual acuity (Snellen chart): Must be ≥6/9 in one eye.
• Visual fields (Confrontation test, automated perimetry if indicated): Assess for hemianopia or scotomas.
• Colour vision: May impact night driving ability.

2. Neurological and Cardiovascular Examination

• Peripheral neuropathy: Test sensation, reflexes, and proprioception.
• Cardiovascular status: Assess blood pressure, heart sounds, and pulses.
• Neurological signs: Screen for stroke risk, weakness, or cognitive impairment.

3. Diabetes-Related Assessments

• HbA1c: Ensure stable glycaemic control.
• Diabetic foot exam: Identify neuropathy affecting pedal control.

4. Further Investigations If Indicated

• ECG: If cardiac symptoms or hypertension concerns arise.
• Ophthalmology referral: If visual acuity does not meet standards.

These assessments help determine fitness to drive and guide licensing recommendations.

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Q4: How would you complete and document the fitness-to-drive assessment form?

1. Accurate and Objective Documentation

• Clearly state BP (130/78), vision (6/9 R, 6/12 L), HbA1c control, and neurological findings.
• Confirm absence of high-risk conditions (e.g., severe neuropathy, unstable diabetes, uncontrolled hypertension).
• Document any recommendations for ongoing monitoring or restrictions.

2. Recommendations on Fitness to Drive

• If Michael meets commercial standards, he may be cleared unconditionally.
• If vision impairment is significant but correctable, suggest conditional licence with ophthalmology review.
• If concerns exist (e.g., frequent hypoglycaemia, major vision issues), recommend referral for specialist assessment.

3. Patient Communication and Next Steps

• Explain whether he meets standards and any restrictions.
• Provide a copy of the completed form for submission.

Proper documentation ensures compliance with medico-legal requirements and patient safety.

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Q5: How would you communicate the outcome of this assessment to Michael?

1. Clearly Explain Findings

• Reassure him that his diabetes and blood pressure are well controlled.
• Discuss his visual acuity and whether he meets Austroads standards.

2. Address Licensing Outcome

• If he qualifies for an unconditional licence, explain the renewal process.
• If he requires conditional licensing, discuss the need for ophthalmology review.
• If concerns exist, outline next steps (further testing, temporary suspension, or referral).

3. Supportive Discussion Around Employment

• Acknowledge his concern about job security.
• Explain options for conditional licensing or adaptive driving measures.
• Offer a follow-up appointment to reassess if needed.

Clear and empathetic communication ensures patient understanding and adherence.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, covering symptoms, driving history, and risk factors.
• Knowledge of Austroads guidelines, ensuring legally sound assessment.
• Comprehensive examination, including vision, neurological, and cardiovascular testing.
• Accurate and legally compliant documentation of findings and recommendations.
• Patient-centred communication, addressing job security and next steps.

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PITFALLS

• Failing to ask about key symptoms (hypoglycaemia, vision issues, near misses).
• Not following Austroads guidelines, leading to inappropriate licensing recommendations.
• Overlooking required clinical assessments, such as visual field testing or peripheral neuropathy screening.
• Poor documentation, leading to medico-legal risk.
• Not addressing patient concerns, especially around job security and conditional licensing options.

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REFERENCES

• RACGP – Sickness Certification
• AMA – Guidelines for Medical Practitioners on Certificates Certifying Illness
• AHPRA – Good medical practice: a code of conduct for doctors in Australia – 10.9 Medical reports, certificates and giving evidence

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD