Discussion
Based on discussions and reflections among GPs attending a seminar on alcohol habits and health in general practice, this study found the role of expert assessor – and thus a mandatory reporting body – to be challenging. The following scenario will be familiar to many: a patient presents to their GP with health complaints; the doctor suspects that alcohol may be part of the problem, but the complex and uncertain implications of raising the issue makes the doctor hesitant to address alcohol use.
Although the harmful effects of alcohol are well documented, a discussion about alcohol also requires the doctor to consider legal aspects, including whether the patient is fit to drive.
The provisions of the driving licence regulation concerning alcohol are extensive, but rather vague in relation to assessing medical fitness to drive. Even the GPs who contributed to a study on alcohol-related health problems, and who might therefore be assumed to have a strong interest in quality development in general practice, found the regulation difficult to apply (27). According to the regulation, alcohol dependence, high consumption or harmful use do not in themselves automatically disqualify a person from driving; alcohol use must also be such that it may 'lead to behavioural disturbances and cause health impairment with an increased risk to road safety' (28). The recommendations from the Norwegian Directorate of Health therefore rely on professional judgement. This may lead GPs, who often have to make such assessments in isolation rather than within a clinical community, to avoid discussing alcohol due to the complex and time-consuming nature of assessments.
The GPs' dual role as clinician and patient advocate on the one hand and expert assessor or reporting body on the other, can be challenging and lead to a breakdown of trust and complicate the patient-doctor cooperation (11). Other contexts in which the doctor's assessment can trigger intrusive measures in the patient's life include documentation for the Norwegian Labour and Welfare Administration (NAV) and notifications to child welfare services. It has been suggested that Driver and Vehicle Licensing Offices should have a doctor to perform medical fitness to drive assessments (29), allowing GPs to focus on maintaining the therapeutic alliance with the patient. However, GPs are probably in a better position to make a comprehensive assessment of a patient's health and whether they are medically fit to drive. It is therefore important to consider the extent to which GPs' dual role may discourage patients from seeking medical help or from discussing their alcohol use.
Our findings are consistent with previous studies showing that doctors sometimes choose not to request PEth testing even when the test is clinically indicated, for fear of having to assess medical fitness to drive (23, 30). PEth testing is a useful tool, however, both in clinical practice and in the follow-up after a patient has been deemed unfit to drive; however, the test does not provide a definitive answer to the question of fitness to drive (21, 31).
The findings also highlight how judicious use of the driving licence regulation may have therapeutic value. Where there is uncertainty about whether the legal requirements are met, the doctor can discuss this with the patient and facilitate constructive change processes. There is no duty to report cases where this is doubt, but the doctor should discuss openly with the patient how alcohol use may raise concerns about medical fitness to drive, and impose a temporary driving ban until this has been clarified. Furthermore, doubt indicates a level of alcohol use that may be harmful in the long term, and is a good starting point for further work on change, irrespective of whether the patient is ultimately deemed fit to drive. Our findings support the need for more standardised tools for assessing road safety risks associated with alcohol use.
Harmful use of alcohol and alcohol dependence are not uncommon (1), but few people seek help (32). A Swedish study found that treatment for mild to moderate alcohol dependence was equally effective when delivered by GPs as by specialists (33). We recently published an article on our seminar for GPs and how it helped normalise conversations about alcohol among participating doctors (34).
The data material in this study consisted of audio recordings of group discussions among GPs attending a seminar. The sample may therefore be biased, as participants may have had a particular interest in addiction medicine, been engaged in quality development in clinical practice, or found the topic especially challenging and wished to enhance their competence in this area (27). Moderated focus group interviews using an interview guide would have been an alternative approach. However, the participants' familiarity with one another likely contributed to a safe discussion environment and to open and candid exchanges on the topic.
It remains unclear whether the current driving licence regulation and associated guide on medical fitness to drive improve health care and contribute to road safety, or whether they instead act as a barrier to seeking help and may therefore have the opposite effect.