What Should Doctors Do to Prevent Traffic Deaths?

When cars first became a common presence in American cities, doctors were shocked by the carnage. In 1925, editors of the New England Journal of Medicine called the bloodshed caused by motorists "appalling" and lamented children's loss of life as "a massacre of the innocent." The sense of urgency was still detectable a few decades later. In a 1957 report, Harvard researchers called the public health threat posed by automobiles a “mass disease of epidemic proportions.”

But as time went on, the medical establishment became much more muted in its response. Public health research gravitated to relatively minor risks -- like the connection between traffic collisions and diabetes or sleep apnea -- instead of more significant dangers like drunk or distracted driving. In 1987, some doctors took to the pages of the Journal to criticize their colleagues for being "relatively silent about the relation between alcohol and motor vehicle accidents."

These shifts are charted by David Jones, a doctor who studies the history of medicine at Harvard, in a recent review of how American physicians have addressed the public health threats posed by automobiles. Looking at the last century of articles about cars and public health published in the New England Journal of Medicine, Jones charted the fascinating historical trajectory of how physicians' views on driving-related health risks have shifted, in an article that was itself published in the Journal earlier this month.

Despite an article in the most recent edition of the Journal finding that distracted driving is associated with significantly increased crash rates among both novice and experienced drivers, Jones says doctors still don't seem to be comfortable taking decisive action to prevent these kinds of collisions.

I recently spoke to Jones about his research. Below is an edited transcript of our interview.

It sounds like doctors have been a little bit hesitant to intervene.

Because of their position on the front line of disease, doctors become aware very early on of what types of things in our society are causing threats to life and health. The question is: What’s the appropriate response?

When the first cars started showing up on the roads in the 1890s, within 10 years doctors at medical journals were astonished by the rising numbers of people who were killed in driving accidents.

Pretty early on, probably by the 1920s or 1930s, most doctors would say the biggest problem with driving is drunk driving. That’s totally clear now. If you look at the leading cause of car accidents, it’s alcohol. Society has responded by criminalizing drunk driving, which is probably appropriate -- although there are a lot of people who would say that the sanctions aren’t nearly strong enough.

What’s the role of doctors in all of this? One question that came up in the 1920s: Should everyone who wants a driver’s license undergo a medical examination? And many states considered those laws but none of them were seriously enacted. The doctors who responded to the New England Journal didn’t want to do that. That would have been a huge burden on physicians.

One of the things that struck me was, in the second half of the 20th century, in the Journal you have lots of articles about people who have weird heart problems, and is it dangerous to drive? And people who have epilepsy: Is it dangerous for driving? And people who have diabetes: Is it dangerous for driving?

And those are all true. But all of those are dwarfed by drunk driving. You can step back and say, “Why are doctors worried about the handful of people that have a heart attack and cause an accident, or the handful of people who have a seizure and cause an accident, when there are thousands or tens of thousands of people who get drunk and cause accidents?” And I think part of it is that doctors are ambivalent: Is alcohol a medical problem or not?

It sounds like doctors have become immersed in the wider cultural attitudes that are relatively permissive about driving.

Judging from the ideas you see in the New England Journal, they were reluctant to get involved in -- I don’t know, what do you call it -- the nanny state? Or the police state? They were reluctant to get involved in the fight between the public health powers and the society and the individual rights of the people.

Should you drive if you’re drunk? The answer is clearly no. Does government have a right to punish you for doing so? Yes. Should doctors prophylactically try to get your driver’s license removed to prevent that from happening? No one has been willing to say yes to that.

So if you’re a neurologist and you diagnose a patient with epilepsy that’s not controlled well with medication, do you have an obligation to call the motor vehicle agency and say, “Revoke that person’s license”? There are a small number of cases where doctors are expected to do what they can to pull someone’s license. It’s not true for alcohol.

So if a doctor happens to know that their patient is an alcoholic, they typically would not make any effort to get involved with licensing. Or there isn’t even a course of action for them to do that.

I believe both of those things are true. That doctor would not think that that is the doctor’s role and if the doctor were to call the Bureau of Motor Vehicles and say, “I just want to let you know that Mr. Smith is a habitual alcoholic,” I don’t think that are any legal or policy mechanisms to do that.

But in other cases there wouldn’t be a policy mechanism. I know with vision, there are very clear controls.

If an ophthalmologist sees a patient and that patient’s vision is 20 over 400, is that doctor required to call the registry? I don’t think so.

I’ve never, never heard of anyone reporting a patient as a result of alcoholism. And if doctors started doing that, it would cause a huge problem for the profession and society more broadly. People would either stop going to the doctor or they’d never admit to a doctor that they drank. People just don’t see that yet as the role of medicine.

The research article that was recently published in the Journal was about cell phone use. This is a less well-surveilled issue by doctors. One of my colleagues, Amy Ship, who works at the Beth Israel [Deaconess Medical Center] in Boston, she said she routinely asks her patients, “Do you text and use cell phones while you drive?” If they say yes, she reads them the riot act. And it’s her opinion that all doctors should do that. What percentage of doctors ask patients about this? I bet it’s close to zero.

Do you think that’s because car collisions aren’t considered a public health issue in the same way diseases or other public health threats might be?

Since the 1950s, and maybe even back as far as the 1930s, there have been public health researchers who have made the case that car accidents are a public health problem, because they’re usually in the 10 top causes of death each year. I think most doctors would admit car accidents are a public health problem.

Doctors won’t release a newborn from the hospital unless the family demonstrates that they have a car seat. Pediatricians will routinely screen parents about use of car seats, use of seat belts. So pediatrics has embraced this wholly. Do all doctors screen patients about seat belts? Back in Massachusetts they used to but as soon as Massachusetts passed a seat belt law, doctors stopped caring. They assumed that everyone was wearing seatbelts.

Why do you think driving is treated differently than other public health threats?

Say you’re seeing someone who is a bad or dangerous driver and you tell them to quit driving. We’ve structured our society in such a way, especially outside of the cities, you’re really car dependent. And so if you’re intervening against someone’s ability to drive, it’s a massive imposition: It can interfere with someone’s work; it can interfere with their ability to get groceries; it causes all sorts of problems.

If you’re a doctor with a patient with epilepsy and you call to report that patient to the registry, that’s not something you enjoy doing because what an awful impact this is going to have on the person’s life. So intervening in that way is a very different intervention than telling someone to quit smoking. So I think that drives part of the ambivalence.

And the other part is, is it really doctors’ role to tell people not to drink and drive? Do we live in a police or nanny state, or do individuals have to do the right thing?

The New England Journal published its first article about cell phone use in 1997, and it showed quite clearly that there’s no doubt that people who use cell phones have higher accident rates. Their recommendations, both in that article and the editorial that accompanied that article, were really modest. They were not going for a ban on cell phone use. They were saying that it’s the role of individual responsibility.

I’m not saying that response is wrong, I am just saying that is one response that puts the onus on the individual. And all you have to do is look around at other cars next time you’re driving and you will realize that individuals are not acting on that responsibility. People are constantly on their cell phones while they drive. So you know, appealing to individual responsibility is well and good, but the question is: What do you do when people have dropped the ball?