One reason I see drivers become frustrated during the physical examination is when they are told that their blood pressure is elevated or that they may have hypertension. The “knee jerk” response is often shock, followed by denial, then utter assertion that it was normal two days ago when their own personal physician checked it. They sometimes actually recall a number like 120/80, and may even offer to bring in a note from their personal doctor in support.
This kind of reaction is completely understandable, given the nature and importance of the medical certification process. To have an elevated blood pressure during the physical examination may mean a reduced certification period on their DOT medical card, or temporary disqualification, which translates to “failing”, no matter how nicely you may choose to word it. Nevertheless, what’s strikes me as interesting, is that I get a similar reaction from my non-commercial driver patients, who are there to see me for medical reasons, rather than to “pass” some kind of medical certification physical. Maybe it’s just human nature, that we want to believe that we are better than we really are (in this case with regards to our health), although we know for fact that we are less than perfect.
First I try to get assuage their angst, with the intention of taking their mind off the blood pressure issue, but more so that I can continue with the rest of the examination. I also reinforce the fact I will be repeating the blood pressure reading later on, usually half an hour or more after completing the other parts of the exam, and generally when they had time to settle down a bit and are more likely than not to be more at ease. (Even if they continue to “press on” or persevere on the adequacy of my sphygmomanometer, or God forbid my examination skills!). Sometimes, I share with them the fact that I myself take a pill to keep my blood pressure under control, and that hypertension is not rare, affecting more than 60 million adults in the U.S. (approximately 31% of the population); And that because we usually don’t know the cause, and the potential for increased morbidity and mortality, it should be addressed seriously. I don’t know if they grow more at ease by the sharing of my tiny bit of personal information with them, or by knowing that they are not alone. At the very least my hope is that they might become more aware of how common it is, and that my intention is not to divulge onto them some rare or obscure diagnostic impression unbeknownst to the annals of modern medicine, just to be a hard “ass”.
Whether or not they think that their hypertension is due to the so-called “white-coat hypertension”, I tell them that it needs to be investigated by their personal doctor due to well know association of hypertension with heart disease and stroke. White coat hypertension itself is believed by some to increase the risk for long-term hypertension, as presented in this Mayo clinic Report. The converse, known as “masked hypertension “, which implies that the blood pressure is normal at the doctor’s office and only elevated when outside, is also potentially with risks as it may lead to misdiagnosis, or under diagnosis of hypertension as presented in this 2013 Washington Post article. The Washington Post article is also interesting in its discussion of Ambulatory Blood Pressure Monitors (ABPM), as used in some specialty practices like those of hypertension specialist, cardiology and nephrology groups. Although the studies of ABPM were more of case studies and not randomized placebo controlled trials, some of the findings regarding over and under treatment in “white-coat hypertension”, “masked hypertension” and what is known as “resistant hypertension” (patients whose office blood pressure readings remain elevated and seemingly not responsive to poly pharmacy), are thought-provoking, and at minimum suggest the need for further studies and a reassessment of our own clinical management of hypertension in the office.
So, all this aside, whether or not a driver believes that he or she has “white coat hypertension” or actual long-term hypertension, the fact remains that there are guidelines to follow, and those guidelines were developed to help the medical examiner render “best practice” decisions regarding commercial driver fitness determination. Those guidelines are clearly listed in the DOT Medical Examination Form itself, otherwise known as Medical Examination For Commercial Driver Fitness Form. As we all well know, the hypertension stages (Stages 1-3) and guidelines are also listed on the second page titled Testing (Medical Examiner Completes Section 3 through 7), and in the ensuing pages titled Instructions To The Medical Examiner. ( F.Y.I, the FMCSA has proposed a new Medical Examination Report Form with changes and additions that can be found in a previous post entitled New Forms For 2014 DOT Physicals...
49 CFR 391.41(b)(6) “A person is physically qualified to drive a commercial motor vehicle if that person —Has no current clinical diagnosis of high blood pressure likely to interfere with his/her ability to operate a commercial motor vehicle safely.”
49 CFR 391.43(f) Blood Pressure (BP) “If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently. An individual diagnosed with Stage 1 hypertension (BP is 140/90–159/99) may be certified for one year. At re-certification, an individual with a BP equal to or less than 140/90 may be certified for one year; however, if his or her BP is greater than 140/90 but less than 160/100, a one-time certificate for 3 months can be issued. An individual diagnosed with Stage 2 (BP is 160/100-179/109) should be treated and a one-time certificate for 3-month certification can be issued. Once the driver has reduced his or her BP to equal to or less than 140/90, he or she may be recertified annually thereafter. An individual diagnosed with Stage 3 hypertension (BP equal to or greater than 180/110) should not be certified until his or her BP is reduced to 140/90 or less, and may be recertified every 6 months.”
For more information on high blood pressure please see the following:
1. High blood pressure fact sheet from the Center For Disease Control(CDC): http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm
2. FMCSA Guidelines and Advisory criteria on the evaluation of hypertension and it’s relevance to commercial driving: https://nrcme.fmcsa.dot.gov/mehandbook/hypertension4_ep.aspx
3. Center For Disease Control 2103 Article: Prevalence of Hypertension and Controlled hypertension – United States, 2007-2010
4. Other references: See shared links in text.