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Epilepsy & Behavior 10 (2007) 55–62

A comparison of physicians’ attitudes and beliefs regarding drivingfor persons with epilepsy q

Laura K. Vogtle a,*, Roy Martin b, H. Russell Foushee c, R. Edward Faught b

a Department of Occupational Therapy, University of Alabama at Birmingham, RMSB 338, 1530 3rd Avenue South, Birmingham, AL 356294-1212, USAb Civitan International Research Center 312, Department of Neurology, University of Alabama at Birmingham, 1719 6th Avenue South,

Birmingham, AL 35291-0021, USAc Survey Research Unit, Ryals Public Health Building, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL 35294-0022, USA

Received 14 April 2006; revised 30 August 2006; accepted 2 September 2006Available online 18 October 2006

Abstract

Objective. The purpose of this survey was to compare attitudes and opinions regarding driving restrictions for persons with epilepsy(PWE) between internal medicine and general practice physicians and neurologists.

Method. A questionnaire aimed at eliciting physicians’ perspectives related to driving with epilepsy was developed that focused onphysicians’ experiences and opinions with respect to driving issues for PWE. Three groups of physician subspecialties were targeted basedon the likelihood of persons with epilepsy in their practice: neurologists, family practice physicians, and internal medicine practitioners.Questions asked about driving with controlled and uncontrolled seizures, predictable auras, nocturnal seizures, seizures without loss ofconsciousness, patient reporting, seizure-related accidents, and patient justifications for driving.

Results. Error rates were high with respect to knowledge of state reporting practices, especially among family practitioners andinternal medicine physicians. Family practitioners and internists were less likely than neurologists to support driving for people withuncontrolled seizures under specific conditions and more likely to support a minimum seizure-free period before issuing a driver’s licenseand mandatory reporting of seizure information. Physicians who thought they were from states with mandatory reporting were moresupportive of mandatory reporting of seizure information and setting a minimum seizure-free period before a driver’s license is issued.Physicians having fewer patients with epilepsy were more likely to oppose driving in persons with intractable seizures.

Conclusion. Nonneurologists have more restrictive beliefs regarding driving for PWE, who are in fact allowed to drive in many states.Nonneurologists, in particular, demonstrated poor knowledge of state reporting requirements for PWE. The data from this study sup-port a significant effort to promote education of all physicians regarding state regulations and aspects of epilepsy related to driving.� 2006 Elsevier Inc. All rights reserved.

Keywords: Epilepsy; Driving; Physician and survey

1. Introduction

The ability to drive in the United States is important forpersonal autonomy, which is a basic premise of Americanlife. Persons who have recurrent seizures lose this autonomy,and as a result, their lives are significantly limited by, for

1525-5050/$ - see front matter � 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.yebeh.2006.09.003

q Portions of this article were presented at the Annual Meeting of theAmerican Epilepsy Society, Washington DC, December 2–6, 2005.

* Corresponding author. Fax: +1 205 975 7787.E-mail address: lvogtle@uab.edu (L.K. Vogtle).

example, difficulties with employment, social isolation, anddependence on others [1]. Legal requirements to relinquishdriving privileges or refuse to grant a driver’s license becauseof uncontrolled seizures exist in virtually every state in thiscountry, and indeed in most countries [2,3]. Such require-ments are based on concerns that persons who have epilepsyare likely to be involved in automobile accidents due to lossof consciousness and/or control during seizures, althoughdata supporting such concerns are not consistent [4]. Physi-cian participation is required in the process of implementingindividual state driving restriction requirements.

56 L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62

Six states currently require physicians to report to statelicensure boards when a diagnosis of epilepsy is confirmed.Another common requirement across states is the periodicsubmission of medical reports, in some states for a specifiedperiod and in others for as long as the person remainslicensed [5]. When such reports are filed and how vary bystate. Immunity from civil and/or criminal prosecution forfiling such reports varies, as does physician liability if a personwith epilepsy drives and causes an accident; statementsregarding liability are noted in individual state regulations [5].

Clearly, from this discussion, the involvement of physi-cians in the right to drive for persons with epilepsy is pivotal.Neurologists receive extensive training in the diagnosis andinterventions used in epilepsy, and some neurologists chooseto treat only persons with epilepsy. The number of neurolo-gists in the United States is small in comparison to physiciansin internal medicine and those in family medicine. Accordingto data from the American Medical Association, in 2003 thenumbers of physicians in several categories were as follows:family practice, 78,375; internal medicine, 109,317; and neu-rology, 11,763 [6]. It appears clear from these numbers thatthe availability of neurologists for care of persons with epi-lepsy is quite limited. As well, efforts to control health carecosts have limited referrals to specialists [7]. Montouris not-ed that only 17% of all persons with epilepsy ever saw a neu-rologist [8]. Subspecialists involved in the process of givingpatient care in compliance with state regulations may differin their advice to licensing agencies and patients. The pur-pose of this survey was to compare attitudes and opinionsregarding driving restrictions for persons with epilepsy(PWE) between internal medicine and general practicephysicians and neurologists.

2. Review of the literature

Surveys have been used both to study the involvement ofgeneral practitioners and neurologists in the care of PWEand to assess physicians’ knowledge of existing epilepsyregulations. Averis studied the awareness of general prac-tice physicians in South Australia with respect to the avail-ability of specialty services for PWE [9]. Respondents tothis survey indicated limited knowledge of the services,and only 33.7% rated their knowledge of epilepsy as goodor excellent. Despite this, the majority of general practitio-ners in this survey (91%) believed they should manage thecare of PWE. Those physicians with less knowledge of epi-lepsy were more likely to support joint management ofPWE with the specialized epilepsy services available.

Lambert and Bird surveyed general practitioners in Bris-tol, England, in part to understand existing practicesregarding epilepsy and specialty services in their localities[10]. Although all responding general practitioners referredtheir patients to specialty services, almost half treatedpatients prior to such referrals, and one-third rarely or nev-er consulted with the neurologists regarding choice ofappropriate anticonvulsants. Sixty-four percent of respon-dents were interested in ongoing epilepsy education.

Swartztrauber and Vickrey surveyed family and internalmedicine physicians and neurologists, using three scenariosof patients with neurological conditions to generateresponses regarding patient management preferences andreferrals to specialists [7]. Their findings indicated thatthe more knowledge a physician had regarding the condi-tions used in the scenarios, the less likely he or she wasto refer to specialists, with internists more likely to prefermanaging patients without specialty referral. The authorsnoted that there appeared to be a fundamental disagree-ment among the different physician groups with respectto their perception of their role in patient care. Referralpatterns in this study were not affected by financial incen-tives or utilization management.

A few surveys reviewing physicians’ knowledge and prac-tices relating to driving and driving with seizures have beencarried out. McLachlan and Jones studied the frequencywith which neurologists reported persons with seizures tothe authorities as compared with persons with stroke,dementia, and other disorders [11]. They found that report-ing of seizure disorders was significantly higher than report-ing of the other conditions, whether or not the neurologistpracticed in a mandatory or nonmandatory reporting dis-trict. Those neurologists in mandatory reporting districtswere significantly more likely to report persons with seizuredisorders. There was considerable disagreement as to dura-tion of seizure-free intervals before driving again.

Selmo et al. used scenarios to study family practice phy-sicians’ and neurologists’ awareness of driving laws relatingto seizures in Minnesota [12]. Neurologists were correct sig-nificantly more often than family practice physiciansregarding their knowledge of driving laws; however, bothgroups exhibited limited awareness of laws regarding hypo-glycemia- and alcohol-related reporting. Marshall and Gil-bert demonstrated similar knowledge limitations of drivinglaws in their assessment of Saskatchewan physicians,although their survey did not include seizure disorders[13]. Significant differences between specialists and familypractice physicians were noted only in the case of aorticaneurysm and continuous oxygen supplementation.

It is clear from this review that there is disagreementbetween physician groups as to the necessity for specialtyreferral for persons with neurological conditions. Althoughphysicians are responsible for reporting persons whosehealth conditions are more likely to result in an accident,physicians in several different countries are not knowledge-able about driving laws and are more likely to report PWEthan persons with other conditions who may be equally ormore at risk of causing driving accidents.

3. Method

This study is one arm of a larger investigation designed to gauge theeffects of transportation restrictions, mainly automobile driving, on thequality of life for PWE, which consisted of separate surveys of personswith epilepsy and physicians who treat them. This article describes themethods and outcomes of the physician survey.

L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62 57

A questionnaire aimed at eliciting physicians’ perspectives and con-cerns about driving with epilepsy was developed from literature reviewsand with input from neurologists (see Appendix 1). The survey focusedon physicians’ experiences with driving issues for PWE and opinions aboutthis topic. Specifically, questions were asked about driving with controlledand uncontrolled seizures, predictable auras, nocturnal seizures, seizureswithout loss of consciousness, patient reporting, seizure-related accidents,and patient justifications for driving. Three groups of physician subspe-cialties were targeted based on the likelihood of PWE in their practice:neurologists, family practice physicians, and internal medicine practitio-ners. The survey was pilot tested at the 2002 Southern Epilepsy andEEG Society Meeting in Charleston, SC, USA. Minor changes were madewith question wording, and some questions were deleted to reduce thelength of the instrument. The final instrument contained a total of 28questions.

The survey originally was to have been administered by telephone usingcomputer-assisted telephone interviewing (CATI) methodology. A ran-domly selected national sample of 1400 family practitioners, internal med-icine physicians, and neurologists was purchased from a commercialprovider, who indicated the list was derived from the American MedicalAssociation’s physician master file, including both members and nonmem-bers. Details of the randomization procedure were not provided; however,all 50 states plus the District of Columbia were included, and the number ofphysicians from each state was weighted by population distribution. Theinitial response efficiency of telephone interviewing was very poor. As anumber of respondents asked to have study materials sent by fax, it wasdecided to fax all surveys. Faxing was carried out by a computerized pro-cess. Physicians were instructed to complete the survey and fax it back tothe survey office. The primary return fax number led back to the computer,which saved the information as an imaging file. Electronic files, along withthose returned from the fax machine, were printed for data entry.

Four waves of faxes were sent using similar procedures, with approx-imately 100–200 faxes sent each evening over several days until all 1400physicians received faxed materials. Evenings were selected to minimizethe overlap between sending and likely receiving times. All numbers wererefaxed after a month, with a cover page reminder, a new appeal for aresponse, and a ‘‘thank-you’’ for those who had already responded. Thirdand fourth waves were sent to nonresponders.

Across the four waves, physicians returned 188 surveys. Four hundredthree surveys were faxed to nonworking numbers, 15 physicians were nolonger at the fax number provided, and 787 were not returned, for a totalof 982 faxes to the correct number, giving a response rate for faxing of19.1% (188/982). From the Southern Epilepsy and EEG Society meeting,the response rate was 43.8% (21/48). The combined response rate was20.0% (209/1045) which was calculated using the American Associationfor Public Opinion Research response rate 1 (AAPOR Outcome RateCalculator, Version 2.1).

4. Data analysis and results

The total number of usable surveys resulted in a samplesize of 209 cases for analysis. The combined results are pre-sented below and significant differences noted. Frequencyreports for the total group of responders were weightedto better represent the relative population size of familypractitioners, internists, and neurologists. Weighted fre-quencies are noted when they differ from unweighted fre-quencies. There were no differences between familypractice and internal medicine physicians with respect toall questions, so responses of these two groups were com-bined. All responses were summarized, and then compari-sons were performed between the combined physicians’group and the neurologist group. Descriptive statisticsand v2 analysis were used to analyze the data.

4.1. Respondent characteristics

All surveyed physicians treated PWE. Most physiciansspecialized in family practice (44% unweighted; 59%weighted); the remaining respondents were split betweeninternal medicine (27% unweighted, 28% weighted) andneurology (24% unweighted, 9% weighted). About one-third had 5 or fewer patients with epilepsy in their currentpractice (32% weighted) with a similar-sized group fol-lowed between 6 and 10 patients (31% weighted), with anoverall median of 10 patients. Epilepsy patients made up1% or less of about two-thirds of the physician practices(65% weighted).

Physicians were in practice for a weighted mean of 18.3years, and had treated patients with epilepsy for a mean of17.7 years. Physicians from 40 states were represented, with33% from the Southeast, 28% from the Midwest, 23% fromthe Northeast, and 16% from the West. Sixty percent of thesample practiced in areas with populations of less than250,000, 30% practiced in major urban areas, and theremaining 10% were from areas with populations of lessthan 50,000. It should be noted that one-third of the neu-rologists in this sample attended the Southern Epilepsyand EEG Society Meeting. The mean age of respondentswas 51 (SD 10.92). Sixty-six percent of the respondentswere male and 34% female.

When asked if they practiced in a state with mandatoryor nonmandatory reporting, 11% (weighted) of the physi-cians did not know. Those physicians who did responddemonstrated considerable inaccuracy in their understand-ing of states’ reporting requirements. Percentages and v2

results for individual specialty groups incorrectly indicatingresidency in mandatory reporting states are as follows: 34%(weighted) of family practice physicians (v2 = 24.97,P < 0.000); 39.5% (weighted) of internal medicinephysicians (v2 = 9.25, P < 0.005); and 18.8% (weighted)of neurologists (v2 = 5.85, P < 0.07).

Of the physicians who believed they lived in states withmandatory reporting or did not know, 18% felt they werevery knowledgeable of their state’s reporting laws and48% were somewhat knowledgeable. More physicianswho thought they were from states with mandatory report-ing laws were supportive of mandatory reporting, 90%, ascompared with 64% of physicians who believed theywere not from mandatory reporting states (v2 = 15.4,P < 0.001).

4.2. Group comparisons

Comparisons among physicians were conducted for thefollowing groups: (1) specialty: family practice and internalmedicine versus neurology; (2) number of epilepsy patients:610 versus P11; (3) years in treating epilepsy patients: 615versus P16; and (4) mandatory reporting state: Yes versusNo (Self-Reported). Seizure control was defined by three-fourths of the physicians (75%) as no monthly seizures,with 18% indicating one and 7% of physicians responding

58 L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62

that two or more seizures per month constituted control. Aone-way ANOVA revealed no differences between physi-cian groups on definition of seizure control.

4.3. Specialty

Although almost all respondents were opposed, familypractitioners and internists were more likely than neurolo-gists to oppose generally allowing people with uncontrolledseizures to have a driver’s license, 99.2% versus 91.7%(v2 = 6.86, P < 0.01); to allow people with uncontrolled sei-zures that did not result in loss of consciousness to have adriver’s license, 84.6% versus 60.7% (v2 = 12.79,P < 0.001); and to allow people with uncontrolled seizuresthat occurred nocturnally to have a driver’s license, 72.3%versus 44.6% (v2 = 13.00, P < .001). Family practitionersand internists were more likely than neurologists to agreestates should set a minimum seizure-free period before issu-ing a driver’s license, 96.1% versus 80.4% (v2 = 12.02,P < 0.005); and to support mandatory reporting of patientseizure information to state motor vehicle departments,90.1% versus 35.9% (v2 = 50.83, P < 0.001). Neurologistswere more likely than family practitioners and interniststo have had patients report having an automobile accidentdue to a seizure, 72.7% versus 33.3% (v2 = 24.35,P < 0.001); to have suspected that patients had had anunreported automobile accident due to a seizure, 60.0%versus 39.4% (v2 = 6.65, P < .01); and to have had patientswith epilepsy give justifications for their having to drive,74.5% versus 57.9% (v2 = 4.62, P < 0.05).

In general, family practitioners and internists were lesslikely than neurologists to support driving among peoplewith uncontrolled seizures under specific conditions andmore likely to support a minimum seizure-free periodbefore issuing a driver’s license and mandatory reportingof seizure information, even though more neurologistshave had patients report being in an accident because ofa seizure or suspected their patients had been in an accidentwhen not told.

4.4. Experience with epilepsy by specialty

Physicians with 10 or fewer epilepsy patients were morelikely than those with more than 10 epilepsy patients tooppose driver’s licenses for people with uncontrolled seizuresthat did not result in the loss of consciousness, 82.0% versus69.0% (v2 = 4.21, P < 0.05); and for people with uncon-trolled seizures that occurred nocturnally, 71.0% versus57.1% (v2 = 3.84, P < 0.05). Physicians with 10 or fewer epi-lepsy patients were more likely than those with more than 10patients to support mandatory reporting of patient seizureinformation to state motor vehicle departments, 87.0% ver-sus 62.8% (v2 = 13.34, P < 0.001). Physicians with morethan 10 epilepsy patients were more likely than those with10 or fewer epilepsy patients to have had patients report hav-ing an automobile accident due to a seizure, 69.0% versus24.8% (v2 = 36.38, P < 0.001); to have suspected that

patients had an unreported automobile accident due to a sei-zure, 61.2% versus 34.0% (v2 = 13.64, P < .001); and to havehad epilepsy patients give justifications for having to drive,71.8% versus 55.4% (v2 = 5.27, P < 0.05).

In summary, physicians with 10 or fewer epilepsy patientswere less likely to support driver’s licenses for persons withuncontrolled seizures that did not result in loss of conscious-ness or occurred only nocturnally and were more supportiveof mandatory reporting of seizure information. Physicianswith more than 10 epilepsy patients were more likely to havehad a patient report having an automobile accident due to aseizure, to suspect that a patient had an unreported automo-bile accident due to a seizure, and to have had an epilepsypatient give justifications for having to drive.

4.5. Mandatory reporting state

A number of physicians responding to this survey incor-rectly thought they were living in states with mandatoryreporting requirements. In this analysis, those physicianswere coded as living in mandatory reporting states accord-ing to those beliefs.

Compared with those who believed they lived in stateswith mandatory reporting, physicians in states withoutmandatory reporting of seizure information were morelikely to rate the risk for an injury accident for people withepilepsy as substantially or somewhat increased relative tothe risk for people without epilepsy, 69.1% versus 53.6%(v2 = 4.59, P < .05). Compared with those in states withoutmandatory reporting, physicians who believed they lived instates with mandatory reporting of seizure informationwere more likely to agree that states should set a minimumseizure-free period before issuing driver’s licenses, 95.2%versus 86.3% (v2 = 4.13, P < 0.05); to support mandatoryreporting of patient seizure information to state motorvehicle departments, 89.9% versus 64.0% (v2 = 15.39,P < 0.001); and to have reported patient seizure informa-tion to state motor vehicle departments, 64.7% versus33.0% (v2 = 18.00, P < 0.001).

Odds ratios were calculated for support for mandatoryreporting (see Table 1) and risk of driving for PWE (seeTable 2). Physicians who perceived they lived in states withmandatory reporting of seizure information were fourtimes as likely as those in states without mandatory report-ing to rate the risk of a PWE having an injury accidentwhile driving as being substantially or somewhat greaterthan that of a person without epilepsy. Physicians who sup-port the mandatory reporting of seizure information tostate motor vehicle departments were more than threetimes as likely than those who oppose mandatory reportingto rate the risk of a PWE having an injury accident whiledriving as being substantially or somewhat greater thanthat of a person without epilepsy. Neurologists were sixtimes more likely than family practitioners and interniststo oppose the mandatory reporting of seizure informationto state motor vehicle departments. Physicians who hadlower ratings of the risk of PWE having an accident while

Table 1Support for mandatory reporting of patient seizure information

Percent (n) Oppose vs supporta OR (95% CI)

Medical specialtyNeurology 29.6 (56) 6.18 (1.37–28.00)Family practice and internal medicine 70.4 (133) 1.00

Mean number of years treating patients with epilepsy 17.2 (195) 1.01 (0.96–1.06)Mean number of current patients with epilepsy 73.8 (186) 1.01 (1.00–1.02)Mandatory reporting state (self-reported)

No/don’t know 57.7 (116) 0.38 (0.11–1.31)Yes 42.3 (85) 1.00

Mean comparative risk of auto accident for PWE 2.2 (205) 1.95 (1.15–3.32)Had patient report auto accident due to seizure

No 54.1 (111) 0.52 (0.14–1.95)Yes 45.9 (94) 1.00

Suspect patient’s auto accident is due to seizureNo 53.7 (110) 1.22 (0.39–3.84)Yes 46.3 (95) 1.00

a n = 190.

Table 2Comparison of risk of injury accident for a person with epilepsy driving and a person without epilepsy driving

Percent (n) Rating of increased riska OR (95% CI)

Medical specialtyNeurology 29.6 (56) 1.27 (0.33–4.84)Family practice and internal medicine 70.4 (133) 1.00

Mean number of years treating patients with epilepsy 17.2 (195) 0.99 (0.96–1.03)Mean number of current patients with epilepsy 73.8 (186) 1.00 (1.00–1.00)Mandatory reporting state (self-reported)

Yes 42.3 (85) 4.15 (1.78–9.78)No/don’t Know 57.7 (116) 1.00

Support for mandatory seizure reportingSupport 77.4 (147) 3.47 (1.15–10.48)Oppose 22.6 (43) 1.00

Had patient report auto accident due to seizureNo 54.1 (111) 0.45 (0.18–1.15)Yes 45.9 (94) 1.00

Suspect patient’s auto accident is due to seizureNo 53.7 (110) 1.29 (0.55–3.07)Yes 46.3 (95) 1.00

a Substantial and somewhat risk versus slight and same risk (n = 205).

L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62 59

driving were almost twice as likely to oppose the mandato-ry reporting of seizure information to state motor vehicledepartments than physicians with higher risk ratings.

In general, physicians in states they believed requiredmandatory reporting were more supportive of mandatoryreporting of seizure information and of setting a minimumseizure-free period before issuing a driver’s license, and weremore likely to have reported seizure information to the state.

4.6. Regression analysis

Although analysis using group comparisons offers someinsights into physicians’ beliefs regarding driving and epi-lepsy, individual analyses are affected by the complexityof variables such as years of experience and numbers ofPWE treated. To generate a clearer perspective of physi-cian beliefs, regression analysis was used. Variables enteredinto the equation were medical specialty, mandatoryreporting state, number of PWE treated, years treating

PWE, and age, with support or lack of support for manda-tory reporting as the dependent variable. Only medical spe-cialty demonstrated significance at the 0.000 level. The r2

value was .19, indicating 19% of the variance in supportor lack of support for mandatory reporting was accountedfor by physician specialty.

5. Discussion

Response bias must be considered in the light of the lowresponse rate to this survey. Did those who completed thesurvey have strong feelings one way or another regardingdriving and PWE? If so, this would indicate the outcomesof this survey do not include the range of perspectives thatlikely exist regarding the topic. The fact that many physi-cians, especially family practice and internal medicine pro-viders, thought they lived in mandatory reporting stateswhen they did not suggests that perhaps there may be biasin the sample. One-third of the neurologists in the study

60 L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62

attended the Southern Epilepsy and EEG Society Meetingand completed the survey there. This could have biased theneurologists in the sample; in fact, many neurologists maynot treat PWE, whereas those attending a meeting with epi-lepsy as the topic likely do. This suggests that the data col-lected from neurologists may also be biased towardphysicians who treat epilepsy and are more knowledgeableof the condition and its ramifications on driving.

There was some disagreement as to what constitutes con-trolled seizures. Seventy-five percent of respondents indicat-ed no monthly seizures meant seizure control, with 25% ofthe study sample indicating they defined one or more seizuresa month as seizure control. This leaves open to question thesephysicians’ definitions of uncontrolled seizure disorder,which, in turn, has ramifications regarding how theirpatients are educated about driving restrictions.

States are by no means consistent in their requirementsregarding driving restrictions. Krauss et al. surveyed motorvehicle administration bureaus in all 50 states and the Dis-trict of Columbia [5]. They found that 10 states do not havespecific seizure-free periods, but make driving decisions ona case-by-case basis, with three additional states using aspecific system of criteria to make individual judgments.Other states include exceptions to their seizure-free periods;21 states issue restricted licenses to persons with nocturnalseizures, 11 issue restricted licenses for persons with pre-dictable auras, 14 states permit driving with solitary sei-zures, and 17 allow driving when seizures result from amedication change. There were a large number of physi-cians in this survey who were unable to correctly identifyreporting requirements for their state. This suggests thattheir understanding of the complexities related to individu-al state driving rules for PWE may also be inaccurate. Con-sidering the data from this survey, many family practiceand internal medicine physicians may in fact disagree withsuch guidelines. This is concerning when reflecting onMontouris’ statements indicating that only 17% of newlydiagnosed cases of epilepsy are seen by neurologists, and40% of all epilepsy cases are managed by general practicephysicians [8]. Swarztrauber et al. highlight the fact thatmany persons with epilepsy may never see a neurologist[7]. When considering results from this physician survey,such practice parameters may have ramifications for per-sons with epilepsy in terms of basic care, but also in termsof the kinds of advice and education regarding drivingthese patients receive. Fifty-two percent of respondentsdid not indicate their level of familiarity with driving laws;of the 48% who answered this question, only 12% of familypractitioners and 14% of internal medicine physicians con-sidered themselves very knowledgeable of their state’s driv-ing laws as compared with 27% of neurologists.

6. Conclusions

Physicians’ failure to understand, support, or correctlyinterpret driving restrictions may lead to unnecessaryrestrictions that can significantly affect quality of life. The

data from this and other studies indicate that physiciansare not knowledgeable of state driving laws and supportthe need for a significant effort to promote education ofprimary care physicians and neurologists regarding specif-ics of state regulations and aspects of epilepsy as they relateto driving. This is particularly true in the case of familypractice and internal medicine physicians, who apparentlydo not support driving for persons with conditions whoare, in fact, allowed to drive in a number of states, specif-ically PWE with predictable auras and nocturnal seizures.

7. Limitations

This study has several limitations. First is the lowresponse rate, some aspects of which were addressed previ-ously under Discussion. There may be other reasons forthe low response rate. The original survey was shortened toimprove response rate, as evidence has demonstrated thatphysician survey response rate is inversely related to thelength of the instrument [14]. Thomson et al. demonstratedthat the promise of larger prizes over smaller prizes was sig-nificantly more likely to result in satisfactory response rates[15]. No incentives were used in this survey, which may haveaffected outcomes. Standard procedure for survey researchwas followed in that nonrespondents received multiple fol-low-up requests for survey completion. This was not success-ful as evidenced by the 20% response rate. It is also possiblethe low response rate is likely due to factors cited in a surveyby Kaner et al., who noted that questionnaires frequently getlost in other paperwork, physicians are too busy, or ques-tionnaires routinely get thrown in the trash [16].

A large percentage of responding physicians believedthey came from mandatory reporting states, which mayin fact have skewed the data. Similarly, the percentage ofneurologists responding was higher than the percentageof neurologists in the overall population of physicians.Finally, the data collected at the 2002 Southern Epilepsyand EEG Society Meeting came from neurologists whotreat primarily PWE in their practice rather than the pop-ulation of neurologists overall. This may have skewed theirresponses to the questionnaire.

Despite these limitations, the findings of this survey areprovocative and indicate the need for further study of physi-cian knowledge and practices regarding driving for PWE. Itmay be that physicians’ beliefs may alter their advice to theirpatients regarding driving despite state laws. Physicians maynot be knowledgeable of their states’ laws on driving restric-tions for PWE and interpret them to their patients incorrect-ly. The number of patients affected by such potentialconcerns is unknown, but the impact on employment andquality of life in those persons is potentially significant.

Acknowledgment

This project was supported by Centers for Disease Con-trol Special Interest Project-4-01 awarded through theUAB Center for Health Promotion.

L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62 61

Appendix 1. Physician survey on epilepsy and transportationa

Please mark the response that best reflects your opinion.

62 L.K. Vogtle et al. / Epilepsy & Behavior 10 (2007) 55–62

a Physician Survey on Epilepsy and Transportation, University of Alabama at Birmingham.

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