australians are reliant on driving as it allows people to maintain their independence and independence is a key component of positive ageing . public transport is often inaccessible or unavailable , particularly in rural areas . where and when public transport is available , older people and those with disabilities can experience problems getting on and off public transport or walking to and from stops [ 1 , 2 ] and can be at greater risk of being killed as pedestrians than are other age groups [ 25 ] . regardless of age , cognitive impairment has consistently been shown to increase the risk of crashing [ 6 , 7 ] . other factors which affect driving ability include visual defects such as constriction of binocular field , decreased grip , muscle strength and endurance , flexibility and motor speed , decreased neck rotation , arthritis , neurological impairment and falls [ 6 , 8 ] , insulin - dependent diabetes mellitus , and epilepsy . there are increasing numbers of drivers who continue to drive in later life [ 5 , 10 , 11 ] . given an ageing population and increased morbidity , there will be a greater proportion who have a diminished capacity for driving , with the number of fatalities involving older drivers being estimated to almost triple by 2025 . this prediction is based on a widespread perception that older people are at increased risk of car accidents [ 1113 ] . calculating the number of crashes per licensed driver and particularly for older drivers is not straightforward , for example , among the  old - old ( 80 years ) , many may not drive but keep their licences for identification purposes [ 911 , 14 ] . overall , older people are not at increased risk of crashing , but they are more susceptible to injury in road traffic accidents . older people tend to reduce their risk by self - limiting their driving to local trips in daylight hours [ 5 , 15 ] . indeed , it has been contended   that older people pose much less risk to other road users than do other age groups , yet incur a greater risk of death or serious injury to themselves and their passengers due to their physical vulnerability [ 1 , 1618 ] . regardless of age , relinquishing driving for medical reasons poses personal and professional challenges . with the exception of western australia , licensed drivers are legally required to declare any medical conditions or impairments that may affect their ability to drive safely to the relevant driver licensing authority . victoria is the only state or territory without mandatory medical or on - road tests for all older drivers . victorian drivers who have been reported to that state 's driver licensing authority ( vicroads ) must undertake clinical assessments or tests relevant to their impairment , as specified by vicroads after consideration of clinical advice or other relevant information , such as crash history . interestingly , older drivers in victoria perform similarly to drivers in other states in australia . evidence suggests that population - based screening is an inappropriate means of assessing the complex and multifactorial basis risk of driving unfitness . primary care providers ( known as general practitioners ( gps ) ) in canada and australia have reported concern about their role in assessing patients ' fitness to drive including the risk of socially isolating patients [ 2022 ] and privacy issues . beyond the national austroads guidelines   which apply to all states and territories and outline health professionals ' roles , there are no specific guidelines available for gps . the austroads guidelines include information to assist with clinical assessments such as cognitive and/or physical impairment . in addition , all state and territories have a medical report form for the gp or other health professionals to complete and forward to the driver licensing authority , which in victoria is vicroads . drivers can self - report to vicroads for testing and/or to relinquish their licenses ; a medical report can be completed by a gp and forwarded to vicroads , and vicroads can provide the driver with information , request that the driver undertakes tests relevant to their impairment , conduct a driving review and/or cancel a driver 's licence [ 9 , 19 , 24 , 25 ] . the aims of this study were to investigate how gps recognise and manage patients ' fitness to drive , with a particular focus on older patients , gps ' attitudes and beliefs about their role as assessors of a patient 's fitness to drive , gps ' experiences in assessing patients and providing reports to driving authorities , identify further educational needs of gps about driving competence in their patients . a mixed methods design includes semistructured interviews , a focus groups , and a literature search . three surveys were found during the literature search , providing information for the basis of this questionnaire [ 20 , 26 , 27 ] . additional questions were developed from qualitative data collected from individual interviews and a focus group . the questionnaire commenced with an introductory question about frequency of assessing a patient 's fitness to drive : if respondents answered  never ,  they were asked to complete section 1 ( demographics ) only and return the questionnaire in the reply - paid envelope provided . section 2 was about gps ' self - reported practices ( triggers for assessing a patient 's fitness to drive , frequency of conducting a driving assessment , uncertainty about patients ' ability to drive , dealing with the family , and recommending a conditional licence or restrictions ) ; section 3 was about gps ' attitudes to assessing fitness to drive and contacting the licensing authority , and section 4 was about educational needs . the questionnaire was mailed to gps in three rural and two metropolitan divisions of general practice . in australia , gps are members of divisions of general practice which are state- and federally funded organisations that provide administrative , technical , and professional development / education support to gps / practices in their local area . the five victorian divisions were purposively invited because of the existing positive relationship between the research team and the divisions , and the divisions positive relationship with the gps / practices in their area . at the time when the project was conducted , there were 29 divisions in victoria , of which 11 were rural . rural divisions were oversampled because public transport appears to be more limited in rural areas , raising greater challenges when assessing driving capacity . comparisons between gp subgroups were conducted using student 's t - tests and chi - square tests as appropriate . ethics approval was obtained from the monash university human research ethics committee ( muhrec ) ( cf09/2422 - 2009001415 ) . of the 1028 questionnaires mailed , 274 were returned , and of those , 14 were  returned to sender  and three were returned  blank .  of the 257 , 40 gps completed the introductory question about the frequency of assessing a patient 's fitness to drive and section 1 ( demographics ) only ; 217 completed the full survey ( response rate of 21% ) . most of these 217 respondents answered all questions ; the nonresponse rate to individual items ranged from 1% to 3% . results in the paper are reported with the percentage in brackets ( % ) . section  1the demographics presented in this section include the 40 gps who completed the introductory question and section 1 only , as well as the 217 who completed the full survey . this cohort 's characteristics are similar to the national median : the proportion of males ( national = 55% ) and females ( national = 44% ) , average age ( national = 55 years ) , and practice size ( national with > 5 = 41% )   ( table 1 ) . the demographics presented in this section include the 40 gps who completed the introductory question and section 1 only , as well as the 217 who completed the full survey . this cohort 's characteristics are similar to the national median : the proportion of males ( national = 55% ) and females ( national = 44% ) , average age ( national = 55 years ) , and practice size ( national with > 5 = 41% )   ( table 1 ) . section 2 ( gp self - reported practices)triggers for assessing fitness to drive were reported by respondents as being prompted by being asked to complete a vicroads medical report form ( 90% ) , when the patient was assessed as cognitively impaired ( 69% ) , or physically impaired ( 52% ) , or diagnosed with a psychiatric illness ( 25% ) , when the issue was raised by the patient ( 75% ) , by the family or other members of the community ( 80% ) , or during a health check ( 60% ) . visual acuity ( 93% ) , medication review ( 78% ) , cognitive tests ( 56% ) , taking a thorough history ( 56% ) , and hearing tests ( 52% ) were the most common forms of assessment . less frequently used were motor function tests ( 43% ) or taking a history from a spouse or other family member ( 37% ) . when uncertain about assessment , gps were most likely to refer to the austroads handbook ( 60% )   or refer the patient to an occupational therapist ( 59% ) . gps were less likely to reassess patients periodically to clarify fitness ( 35% ) , refer a patient to a medical specialist ( 26% ) , or refer to patient reeducation programs such as those available through the royal auto club of victoria senior drive school program ( 7% ) . half ( 50% ) the gps usually advised patients with early dementia to stop driving , similarly ( 46% ) usually advised patients with type 2 diabetes to notify the licensing authority of their condition . the gps were asked how they addressed family and friends ' concerns about a patient 's fitness to drive . respondents were most likely ( always / frequently ) to advise the family or friend to speak to the patient about their concerns ( 82% ) , or with the family members ' permission the gp would speak to the patient themselves ( 74% ) . gps were less likely to advise the family to contact the driving licence authority ( 47% ) , contact the patient and ask the patient to come in to discuss the matter ( 3% ) , or advise vicroads directly ( 8% ) . conditional licensing was viewed as a safe alternative to driving with an unrestricted licence ( 71% ) . however , respondents were less likely ( 25% ) to recommend issuing a conditional licence where there were residual concerns about a patient 's medical fitness . respondents were more likely to recommend patients to  not  drive at twilight / night ( 66% ) to drive within a defined kilometre radius from home ( 62% ) , avoid driving at busy times ( 54% ) , or to drive on minor roads ( 39% ) . few viewed driving with extra mirrors fitted to the car ( 9% ) as a safe alternative . triggers for assessing fitness to drive were reported by respondents as being prompted by being asked to complete a vicroads medical report form ( 90% ) , when the patient was assessed as cognitively impaired ( 69% ) , or physically impaired ( 52% ) , or diagnosed with a psychiatric illness ( 25% ) , when the issue was raised by the patient ( 75% ) , by the family or other members of the community ( 80% ) , or during a health check ( 60% ) . visual acuity ( 93% ) , medication review ( 78% ) , cognitive tests ( 56% ) , taking a thorough history ( 56% ) , and hearing tests ( 52% ) were the most common forms of assessment . less frequently used were motor function tests ( 43% ) or taking a history from a spouse or other family member ( 37% ) . when uncertain about assessment , gps were most likely to refer to the austroads handbook ( 60% )   or refer the patient to an occupational therapist ( 59% ) . gps were less likely to reassess patients periodically to clarify fitness ( 35% ) , refer a patient to a medical specialist ( 26% ) , or refer to patient reeducation programs such as those available through the royal auto club of victoria senior drive school program ( 7% ) . half ( 50% ) the gps usually advised patients with early dementia to stop driving , similarly ( 46% ) usually advised patients with type 2 diabetes to notify the licensing authority of their condition . the gps were asked how they addressed family and friends ' concerns about a patient 's fitness to drive . respondents were most likely ( always / frequently ) to advise the family or friend to speak to the patient about their concerns ( 82% ) , or with the family members ' permission the gp would speak to the patient themselves ( 74% ) . gps were less likely to advise the family to contact the driving licence authority ( 47% ) , contact the patient and ask the patient to come in to discuss the matter ( 3% ) , or advise vicroads directly ( 8% ) . conditional licensing was viewed as a safe alternative to driving with an unrestricted licence ( 71% ) . however , respondents were less likely ( 25% ) to recommend issuing a conditional licence where there were residual concerns about a patient 's medical fitness . respondents were more likely to recommend patients to  not  drive at twilight / night ( 66% ) to drive within a defined kilometre radius from home ( 62% ) , avoid driving at busy times ( 54% ) , or to drive on minor roads ( 39% ) . few viewed driving with extra mirrors fitted to the car ( 9% ) as a safe alternative . section 3 ( gps ' attitudes to assessing fitness to drive)gps were invited to respond to 14 questions about their attitudes towards assessing driving fitness . of importance to note is that the majority ( 85% ) felt it was the patient 's responsibility to report medical conditions to vicroads , that there were implications for vehicle insurance if a patient is unfit to drive ( 93% ) , that they ( the gps ) knew of alternative transport options in their local area ( 79% ) , and that reporting a patient to the driving licence authority impacted on the doctor - patient relationship ( 79% ) and led to negative consequences for the patient ( 79% ) ( table 2 ) . less than half ( 46% ) the gps reported having been unduly pressured by patients to reconsider a decision to report the patient to the licensing authority , and only a quarter ( 23% ) experienced patients leaving the practice over licence revocation . although there was agreement that a gp should be the initial person who assesses fitness to drive ( 62% ) , few felt that gps should be primarily responsible for making this decision ( 21% ) , otherwise , the responsibility rests with ots ( 54% ) . regarding contacting the drivers licence authority , around a third of the cohort ( 38% ) contacted vicroads for information about medical guidelines ; similarly , few ( 29% ) contacted vicroads about administrative procedures . gps were invited to respond to 14 questions about their attitudes towards assessing driving fitness . of importance to note is that the majority ( 85% ) felt it was the patient 's responsibility to report medical conditions to vicroads , that there were implications for vehicle insurance if a patient is unfit to drive ( 93% ) , that they ( the gps ) knew of alternative transport options in their local area ( 79% ) , and that reporting a patient to the driving licence authority impacted on the doctor - patient relationship ( 79% ) and led to negative consequences for the patient ( 79% ) ( table 2 ) . less than half ( 46% ) the gps reported having been unduly pressured by patients to reconsider a decision to report the patient to the licensing authority , and only a quarter ( 23% ) experienced patients leaving the practice over licence revocation . although there was agreement that a gp should be the initial person who assesses fitness to drive ( 62% ) , few felt that gps should be primarily responsible for making this decision ( 21% ) , otherwise , the responsibility rests with ots ( 54% ) . regarding contacting the drivers licence authority , around a third of the cohort ( 38% ) contacted vicroads for information about medical guidelines ; similarly , few ( 29% ) contacted vicroads about administrative procedures . section 4 ( gp education)the majority indicated that they wanted further education on how to assess fitness - to - drive ( 74% ) , functional assessments ( 70% ) and legal obligations ( 71% ) . there was mixed response to the format of the education , with more ( 62% ) preferring face - to - face learning ( 62% ) than an online activity ( 47% ) . alerts on medical software ( 60% ) , computerised templates ( 76% ) , and a one - page quick reference ( 76% ) in conjunction with  assessing fitness to drive guidelines   were tools that could assist gps to assess patients ' fitness to drive . the majority indicated that they wanted further education on how to assess fitness - to - drive ( 74% ) , functional assessments ( 70% ) and legal obligations ( 71% ) . there was mixed response to the format of the education , with more ( 62% ) preferring face - to - face learning ( 62% ) than an online activity ( 47% ) . alerts on medical software ( 60% ) , computerised templates ( 76% ) , and a one - page quick reference ( 76% ) in conjunction with  assessing fitness to drive  guidelines   were tools that could assist gps to assess patients ' fitness to drive . gps responses indicated concerns about their role in assessing patients ' fitness to drive . whilst the gps generally thought it was their responsibility to conduct initial driving assessments , many felt that the final decision should rest elsewhere and that  borderline  cases should be referred to specialist health professionals . while occupational therapists   and specially trained medical practitioners may also be involved in assessing driving capacity , patients tend to present to their gp in the first instance . in some regions of victoria , particularly rural regions , access to other health professionals can be limited . most respondents were concerned about their legal liability , and the consensus was that vicroads should take legal responsibility for the final ruling . this is in line with the legislative requirement , but the finding suggests that this cohort was fully aware of this . gps did not always recognise when a patient is not fit to drive or should have a driving assessment ; rather , the process tended to be reactive , in response to a variety of prompts . when asked what usually triggered the conduct of a driving assessment , most responded when they were asked to complete the vicroads medical report form . there is scope for gps to routinely assess patients ' cognitive capacity , psychiatric or physical conditions in the health check . some tests recommended in the literature , such as motor function tests , were virtually unknown to the participating gps , but tests required by the vicroads process such as visual acuity tests were mentioned by the gps . the gps were unlikely to refer patients to driver re - education program available through the royal automobile club of victoria   because the majority were unaware of the programs or what the program offered . most gps thought that this option was useful when patients were not really fit to drive without restrictions , but recommendations for conditional licences were not made very often . the gps recognised the gaps in their competency ; less than half were not confident in their abilities . most respondents were open to further education on the  when ,   what ,  and  hows ' of driving assessment . although recognised as an available resource , there had been only limited contact with vicroads for guidance or advice . most gps wanted further education or information about functional assessments and legal obligations . beyond the austroads guidelines   which refer to the health professionals ' role , there are no specific guidelines available for gps . on the provision of prompting alerts on medical software , a computerised assessment template and a one - page  quick reference relinquishing driving has psychological and physical impacts , including increased loneliness , social isolation and mortality risk , dependency on others for transport , and decreased health and participation in out - of - home activities [ 1 , 2 , 27 ] . although gps are used to difficult consultations , several felt compromised between being a patient advocate and the need to promote community safety . privacy was also a concern , for example , when approached by the family to deal with the patient , careful judgement is required by the gp . a major difficulty in advising people to stop driving is the major impact on patients ' lives , particularly since public transport is not always a realistic alternative in many areas of metropolitan and rural victoria and indeed in many parts of australia . of particular concern was the effect that driving assessments can have on the doctor - patient relationship ; many agreed that reporting a patient to the authority could have a negative impact on the relationship . almost half the gps felt that they had been unduly pressured by their patients to reconsider their decisions , although only a minority reported having patients leave the practice over revoking a patient 's licence . the response rate ( 21% ) in this study may limit the findings ' generalisability , although this response rate is consistent with other surveys in general practice . given the differing legislative requirements around mandatory medical or on - road tests for all older drivers in the states and territories of australia , these findings apply solely to victorian gps , although the concerns may be of interest and value to gps in other parts of australia and other countries such as canada , where medical practitioners grapple with similar challenges . gps tend to be  reactive  rather than regard driving assessments as a routine part of preventive medicine . only a quarter of gps frequently make recommendations for conditional licences , even though most believe that these are safe alternatives for those who are not fit to drive with unrestricted licences . while it is a patient 's responsibility to report to vicroads , it would seem that gps could be more proactive in this area , given that patients are less likely to know that this is what they should do . gps are uncertain about which assessment tools can or should be used within a consultation to help gauge fitness to drive . beyond the national austroads guidelines   which refer to the health professionals ' role , there are no specific guidelines , including guidelines about assessment tools , available for gps . not surprisingly , almost threequarters of the cohort indicated a strong interest in further education about driving assessments . further education may create greater recognition that assessing patients  at risk  of suboptimal driving skills for medical reasons should be a routine preventive measure in general practice . the national guidelines   could be clearer about what to do in  borderline  cases . this is particularly the case for patients with early dementia , but might also apply to people with medical conditions such as diabetes , where the risks of driving are not necessarily well understood by the medical profession . clarity about legal responsibility for reporting to the driving licensing authority , and publicising this , is required , as is the extent of medicolegal responsibility that rests with gps needs further clarification . the doctor - patient relationship can be compromised by having a gp as the final adjudicator on a patient 's fitness to drive gps needs further support in deciding on the driving fitness of borderline cases . this includes clear guidance on when referral is appropriate to ots and medical specialists . in doubtful cases , gps should have access to specialised health professionals who can take responsibility for deciding whether a patient is fit to drive . ( 1 ) education programs be developed by relevant organisations such as the royal australian college of general practitioners ( racgp ) ( which provides access to continuing professional development for gps ) , divisions of general practice , universities , and private organisations , on assessing fitness to drive and address ( a ) indications for conducting assessments , ( b ) how to conduct and complete an assessment , ( c ) how to manage the  at risk  group of patients , ( d ) medicolegal responsibilities , and ( e ) the availability of community resources . ( 2 ) vicroads publicise and help clarify the role of the general practitioner , other health professionals , and patients in undertaking driving assessments . ( 3 ) vicroads assist in clarifying the medicolegal responsibilities of the gp in their role as assessors of fitness to drive . ( 4 ) vicroads , the state government , insurance companies , and others help inform the public about their responsibilities of informing the appropriate authorities about medical conditions which could affect an individuals ' fitness to drive .
introduction . 
 most australians are dependent on their cars for mobility , thus relinquishing driving licences for medical reasons poses challenges . aims . to investigate how general practitioners ( gps ) recognise and manage patients ' fitness to drive , gps ' attitudes and beliefs about their role as assessors , and gps ' experiences in assessing and reporting to driving authorities and identify gps ' educational needs . methods . 
 mixed methods : questionnaire mailed to gps from three rural and two metropolitan divisons of general practice in victoria , australia . results . 
 217/1028 completed questionnaires were returned : 85% recognised a patients ' fitness to drive , 54% felt confident in their assessment ability , 21% felt the gp should have primary responsibility for declaring patients ' fitness to drive , 79% felt that reporting a patient would negatively impact on the doctor - patient relationship , 74% expressed concern about legal liability , and 74% favoured further education . discussion . 
 this study provides considerable information including recommendations about gp education , the assessment forms , and legal clarification .