Bronze standard not gold standard
Pond and McNeil1 discuss methods of assessing the fitness to drive of older persons and state that on-road driving assessment remains the ‘gold standard’. But careful reading of the key reference cited to justify this conclusion,2 in fact, gives reasons why on-road assessment should be regarded as a bronze standard rather than a gold one.
Sawada et al conducted an extensive critical review of the literature regarding on-road driving assessments.2 They found that only four assessments (the Washington University Road Test/Rhode Island Road Test, the performance analysis of driving ability, the test ride for investigating practical fitness-to-drive, and the K-score), demonstrated high reliability and validity. Therefore, only a small number of on-road assessments should be considered. Moreover, Sawada et al caution ‘However, the ability to assess real-world driving depends on various environmental conditions’. This caveat is important because often, for the sake of protecting the assessor’s own safety, on-road assessment is conducted in a safe environment such as the grounds of a hospital, but rarely on freeways or at peak hour or in adverse weather conditions.
There are additional caveats regarding on-road assessments. Few studies have followed up participants long term to see if those who ‘passed’ the assessment remained relatively accident-free (false negative rate). Regrettably, it is difficult to determine if any of those who were determined unfit to continue driving would, in fact, have been safe (false positive rate). Nor is there information regarding for how long the result of an assessment remains valid before a repeat test is required.
The application of the term ‘gold standard’ to an assessment that, although having some face validity, has substantial shortcomings and is simply the best of a mediocre bunch, is a misnomer. It would be better termed a ‘bronze standard’; the accolade of ‘gold standard’ should be reserved for assessments of a very high standard.
The importance of authors and editors ensuring correct terminology use in published articles has become increasingly important with the advent of artificial intelligence (AI) and generative predictive text. All medical literature is being constantly searched and platforms updated so terms such as ‘gold standard’, used correctly or otherwise, will become enshrined in the AI literature as truth.
Author
Bruce Hocking MBBS, FAFOEM (RACP), FRACGP, Consultant in Occupational Medicine, Melbourne, Vic
Competing interests: BH was from 1994 to 2016 the Principal Medical Consultant to the National Transport Commission in the drafting of successive editions of Assessing Fitness to Drive (Austroads).
References
- Pond D, McNeil K. Clinical approach to driving and the older person. Aust J Gen Pract 2023;52(8):512–15. doi: 10.31128/AJGP-01-23-6693.
- Sawada T, Tomori K, Hamana H, et al. Reliability and validity of on-road driving tests in vulnerable adults: A systematic review. Int J Rehabil Res 2019;42(4):289–99. doi: 10.1097/MRR.0000000000000374.
Reply
It is critical to continue the discussion on this important issue, and we welcome the thoughtful comments presented by the author. In Australia, with vast distances and poorly available public transport, loss of ability to drive might result in devastating loss of autonomy, and so should be evidence‑based.
We acknowledge the significant limitations of on-road assessments to determine fitness to drive; however, any on-road assessment is superior to office-based cognitive or physical function tests. Further, we agree that an on-road test conducted under controlled conditions is inferior to one conducted in real conditions, but this is not feasible – both due to lack of resources and because of the very real risk to the driver and examiner should the driver be unfit to drive. Moreover, other authors have also noted that a comprehensive on-road evaluation is currently the most accurate gauge of fitness to drive, yet is limited by unstable medical conditions, which might not present during the test, high cost and lack of access in rural and remote regions.1,2 Given such limitations and the impact of artificial intelligence and generative predictive text, it might well be more exact to describe the on-road driving assessment as the ‘bronze standard’.
We need more office-based assessments developed to simulate an on-road test. The online assessment tool being developed as part of the ‘Navigating Fitness to Drive with Patients with Dementia’ research being undertaken by The University of Queensland, will enable the patient to use a computer or large tablet to identify potential hazards in on-road video footage from the driver’s perspective. It is hoped that this tool could be easily adapted to the general practice context and be available for use by 2025.3
The next step would be to test the power of this tool to predict crashes in the real world. It will be expensive to power such research adequately and autonomous cars might, after all, catch up and become a realistic option. In the meantime, it is important for the research community to continue to work on the development of feasible and reliable driving assessments.
Authors
Constance Dimity Pond BA, MBBS, FRACGP, PhD, Adjunct Professor, School of Rural Medicine, University of New England, Armidale, NSW; Adjunct Professor, School of Nursing and Midwifery, Western Sydney University, Sydney, NSW; Clinical Professor, Wicking Dementia Research Education Centre, University of Tasmania, Hobart, Tas
Karen McNeil BComm, MBA, PhD, Program Manager, HRMI Healthcare Transformation Research Program, University of Newcastle, Newcastle, NSW
Competing interests: CDP was Chief Investigator on a grant to the University of Wollongong, which published one of the references in the original paper, and funded the student project that resulted in another one of the references in which CDP co-authored. KM has no competing interests to declare.
References
- Lee L, Molnar F. Driving and dementia: Efficient approach to driving safety concerns in family practice. Can Fam Physician 2017;63(1):27–31.
- Wallis KA, Matthews J, Spurling GK. Assessing fitness to drive in older people: The need for an evidence-based toolkit in general practice. Med J Aust 2020;212(9):396–98.e1. doi: 10.5694/mja2.50588.
- Tsirtsakis A. New fitness-to-drive test could streamline process for GPs. RACGP, 2023. Available at www1.racgp.org.au/newsgp/clinical/new-fitness-to-drive-test-could-streamline-process [Accessed 26 January 2024].
Don’t make GP work unnecessarily complex
I was struck by the title of an AJGP article in the August 2023 issue, ‘Role of primary healthcare providers in supporting a gifted child’.1 After my initial double-take, I decided that the answer was, ‘the same role that we have for every child that we see!’. The authors admit that ‘research does not provide sufficient evidence to suggest that gifted children are at any greater risk than other children when it comes to social, emotional or other problems’. So why discuss this topic as yet another special role that general practitioners (GPs) should provide?
As GPs, we face an ongoing crisis of identity as the discipline struggles to attract trainees. The distinction between generalists and partialists is greater than ever. As many sub-specialists continue to narrow the number of conditions that they are prepared to manage, GPs will continue to manage ‘whoever walks in the door’. We do this by having a clinical approach that can meet the wonderful diversity of issues that we encounter. It is no wonder that so many young doctors prefer to ‘choose an organ’ and control their working lives accordingly. I see no sense in talking about special skills to deal with gifted children when there are so many more pressing issues requiring our skills and attention. GPs’ lives are already complicated enough.
Author
Malcolm Moore MBBS, FRACGP, MIH, General Practitioner
Competing interests: None.
Reference
- Ronksley-Pavia M, Ronksley-Pavia S. Role of primary healthcare providers in supporting a gifted child. Aust J Gen Pract 2023;52(8):522–27. doi: 10.31128/AJGP-12-22-6638.
Reply
Thank you for your correspondence, we appreciate that general practice is very busy; however, this informative article was written with the view that some GPs are seeking ways to assist these patients and their families.
Authors
Michelle Ronksley-Pavia PhD, FHEA, Med (G&T), GradDipEd (Sec), GradCertEd, BFA (Hons), Lecturer in Special Education and Inclusive Education, Acting Program Director Graduate Certificate in Special Education, School of Education and Professional Studies, Griffith University, Southport, Qld; Researcher, Griffith Institute for Educational Research, Arts, Education and Law Group, Griffith University, Southport, Qld
Steven Ronksley-Pavia Professional Firefighter, Freelance Writer, Brisbane, Qld
Competing interests: MR-P declares grants from the Academic Equity Development Program (AEDP), Arts, Education and Law Group, Griffith University and a Griffith University New Researcher Grant Scheme. MR-P is affiliated with Griffith Institute for Education Research (GIER), Griffith University, is an Australian delegate for the World Council for Gifted and Talented Children (WCGTC), is an Editorial Board member for the Journal of Gifted Education and Creativity, is Editor-in-Chief and Associate Online Editor for the ASSIST Journal and is a research committee member for SPELD Victoria. SR-P has no conflicts of interest to declare.