Introduction: 2014 was a turning point for commercial driver medical examinations, more commonly known as DOT physicals.  When the compliance date for the National Registry of Certified Medical Examiners (NRCME) came on May 21, 2014 drivers were now required to be examined by a medical examiner listed in the NRCME.  Apparently many either didn’t get the “memo” or read it, given the number of drivers coming in to be re-examined (after their medical examiner’s certificate was invalidated and returned to them by the DMV).  What exactly were those uncertified or unlisted medical examiners putting in the required field for “National Registry Number” on the Medical Examiner’s Certificate (MEC) you wonder?  Well if they bothered to fill it out at all, from what I’ve seen, anything from their medical license number, NPI (National Provider Identification) number, or office phone number.  Unfortunately, those drivers had to pay another fee for a new examination by a certified examiner in order to receive a valid certificate.   Bottom line, save yourself time and money and use an examiner listed in the National Registry.

Driver Rage: I don’t want to start the new year of on a bad note but here it is.  Another issue has come to light while reading the American College of Occupational and Environmental Medicine (ACOEM) ‘s journal Commercial Driver Medical Examiner (CDME), but I think it’s prime time to talk about it.  It’s what I’ll  call “driver rage” or “office rage”, which is basically like “road rage” but in the office.  Any kind of violence on anyone is of course wrong, whether intentional or not, regardless of the assailant’s motive or state of mind. Understandably, as examiners we are making certification decisions that affects people’s livelihood, and because of that every examiner ought to give all drivers a “fair shake” and provide the best evaluation they can.  Keep in mind the vast majority of drivers will have a quick and unencumbered experience while getting a DOT physical examination.  However, when medical issues do arise, I would hope that those drivers exercise a little more restraint, since it may require more time to perform their physical and to order the workup and follow ups.  It’s part of your evaluation – the medical examiner is not out to “get you”.  Knowing how important the trucking industry is to the GDP of our nation and given the shortage of qualified and experienced drivers in today’s market, the last thing any one really wants to do is to keep you off the road.   But a DOT physical is used to determine commercial driver fitness.  It’s a fitness for duty exam.  It says so right there on top of the Medical Examination Report form (MER) or “long form”.   So there is no automatic two year certification (as one driver with diabetes and hypertension suggested he should have, because that’s how his personal doctor has always certified him in the past).  There are many reasons why a driver’s certification period may be less than 2 years or why a driver may be temporarily disqualified when certain medical issues arise.  But even when a driver does fail to meet the established medical standards such as vision, insulin treated diabetes or epilepsy standards, there are provisions in place that allows them to possibly be granted an exemption by the FMCSA, if they are examined by a medical examiner and are found to meet the driver physical requirements otherwise.   So if you do get angry (I understand), but please channel your anger appropriately, and don’t take it out on the examiner.  Personally, I usually tell drivers on the phone or in the office before examining them or accepting payment whether or not there is a reason why I may not be able to issue them a certificate that same day after reviewing their medical history.  I give them a choice of still going through with the examination and to finalize their certification at a later date when the required medical clearance or documentation is received.  If they choose to walk away and go see another examiner down the street, at least it was a more agreeable encounter between us, as opposed to having some one yell or throw a slew of expletives at me that I couldn’t possibly repeat here in a thousand years.  (By the way this is not a new problem since the NRCME.  Those of us who have always been trying to do the “right thing” and followed the FMCSA guidelines and recommendations as we saw appropriate know this for a fact.  My worst experience with driver rage was 5 years ago before the NRCME was in effect.  Long story short I don’t want to talk about it, but would certainly have given you an earful back then).  Does my reaction now reflect some sort of PTSD?  Perhaps, but that’s a subject for another day.   Anyway, as a resource for traumatized medical examiners, ACOEM’s CDME journal provided FMCSA contact information for examiners threatened by drivers.  I guess after reading the article in ACOEM, it stirred up some memories in me after yet another unwarranted encounter with an angry driver who was given a limited certification for medical reasons.   I can go on and on with some of these “bad” experiences, but I won’t, and that’s because I have no problem whatsoever with the overwhelming 95% or more of drivers that I see.  Fortunately, when things have gone bad  it never escalated to the point where I had to call in local authorities ( But In a couple of situations I did tell the involved person that I would in order to defuse the situation).  Anyway here’s the information from the CDME journal Fall 2014 issue (and thank you ACOEM for putting this out there):

Doctor Shopping: On the subject of doctor shopping, I don’t have the numbers yet to support this but I have to believe that with the NRCME in place, doctor shopping will become less prevalent.  First of all we now have a finite (though evolving) pool of examiners to choose from, and those examiners should be more or less homogenous given their similar training.  Even harder to doctor shop will be the time when the state driver’s licensing authority (SDLA) begins to receive driver exam results directly from the NRCME.   Of course this doesn’t mean that a driver with a restrictive medical condition can not go elsewhere to get certified, but hopefully it does mean that the most worrisome scenario where there is an unsafe driver on the road going undetected will be avoided.  Do I think some of my patients have doctor shopped?  I believe it’s more probable than possible.  I sometimes wonder about the driver that seemed sincere about not knowing that he could only get a 3 month certificate once (because his previous examiner did not tell him) whom I gave a 1 month card to get his blood pressure under control who never came back; or the driver who told me that he had surgical treatment for sleep apnea and was “cured” and would get the documentation from his surgeon but never returned;  the driver on anti-depressant that conceded he wasn’t really using them for sleeping (although it wouldn’t have mattered either way) who said he would get a clearance letter from his psychiatrist and never returned; The young “Yuppie” drivers using medication for ADHD who didn’t return, and so on.  This is not to imply that these drivers were dishonest.  It could simply be that they went to see someone closer and more convenient; Or maybe just more lenient.  Fortunately, the majority of the follow ups I request, actually do follow through.   On the flip side of this I am sometimes the one on the receiving end, meaning drivers that were restricted or disqualified by some other examiner have now come to me instead; Like the young driver who was disqualified due to an arrhythmia at another clinic who came to me after he got his cardiac workup and clearance (but still had pending diagnostic tests), who ended up getting certified for 3 months but never returned; There was also the older driver who swore that the other clinic had a leaky blood pressure cuff after she was disqualified for severe hypertension, and later came to me not only to be found to have stage 3 hypertension, but also an arrhythmia and possible pneumonia and had to be disqualified again.  I gave her clear written instructions on how to follow-up with her primary care physician for these medical issues but she did not return.  This is all post NRCME.  Just imagine what the terrain resembled before that.  In time it can only get better from here on.

Other Medical Certification Issues: Before discussing the latest bulletin on sleep apnea, there are some shop keeping issues that must be attended to.  Examiners have received several bulletins from the FMCSA, and although the contents of these bulletins have been published elsewhere, it is apparent that it’s never too much to repeat things, especially if the message is not heard or is quickly forgotten.

• On July 8, 2014 ( less than two months after the NRCME went into effect) the FMCSA sent a bulletin to remind medical examiners that some of the certified medical examiners are completing the Medical Examiner’s Certificate incorrectly.  Basically all the required fields need to be filled out and done so correctly when issuing a certificate.  Drivers who are qualified otherwise but need an exemption from the FMCSA should still be issued a certificate but with the appropriate boxes checked  (i.e. accompanied by a “diabetes” waiver/exemption or “seizure” waiver/exemption for example).
• September 2, 2014 FMCSA reminded examiners that they must continue to issue a certificate. They are reminded that drivers need to submit the hard copy of their certificate to the SDLA to obtain or maintain their CDL.  Confusion may have been raised with the start of the NRCME itself which went into compliance May 21, 2014 or due to notice of proposed rule making Medical Examiner’s Certificate Integration (78 FR 27343) also known as National Registry II published on May 10 2013, which is not yet in effect.  The FMCSA also reminded examiners that there has been no changes in the Medical Examination Report form (MER) and the Medical Examiner’s Certificate (MEC).  Previous posts on this site have featured information of the notice of proposed rule for these new forms, but invariably this may have been misunderstood by some that there were actually new forms out there to be used instead.
• An excerpt from the FMCSA Q & A states as follows:

What Medical Examination Report and Medical Examiner’s Certificate must I use? Current: Since May 21, 2012, there has been no change in the Medical Examination Report (MER) and the Medical Examiner’s Certificate (MEC). The forms are found athttp://www.fmcsa.dot.gov/medical/driver-medical-requirements/medical-applications-and-forms.

• January 10, 2015  FMCSA reminded examiners that all medical examiners must continue to provide drivers with a paper copy of their Medical Examiner’s Certificate.  The CDL holder would submit it to their SDLA.  In the future this information will be submitted from the NRCME to the SDLA.  CDL and CLP holders will need to carry their MEC for 15 days to allow enough time for the SDLA to receive the certificate.  Non-CDL drivers, however, will need to continue to carry the MEC to present to law enforcement officials.
• Finally, as a reminder please check off the CDL box on the MEC even if the driver doesn’t have one yet but intends to obtain a CDL, or has a CLP or intends to get a CLP.  In New York state, drivers have reported that they now need to present a valid MEC to the DMV before they can receive their CLP (even if they have already passed the written CDL portion).

Sleep Apnea:  Given it’s contentious nature, this topic will probably not be be simple or brief anytime in the foreseeable future.  Nevertheless, might I suggest that we take a step back for a moment and deflate the conversation a bit by a few “psis” (and I do apologize for the football analogy, but how can one resist given recent events preceding this year’s Super Bowl ).  First let’s not forget that most DOT physical examinations as previously stated are uneventful – driver in and driver out.  However, after several years doing them (other examiners may have similar accounts) I’ve had drivers young and old, CDL and non-CDL holders, present for evaluation with various medical issues like arrhythmia, vertigo, pneumonia, severe hypertension, depression, anxiety, schizophrenia, monocular vision, seizure disorders, acute low back pain, fractured foot, and yes – either with an established diagnosis of sleep apnea or with enough symptoms and findings on examination to warrant clinical suspicion and trigger screening.  What hopefully is conveyed here is that although most DOT physicals are usually more or less straightforward, there are definitely those where drivers present with more subtle clinical presentations that may require pause and a more careful evaluation on the part of the examiner.  In any case, since only the examiner is actually in the room with the driver at that time of the examination (not the insurance company, not the lawyers, not the motor carrier, not the company supervisor and not even the FMCSA), it is up to the medical examiner to make the best clinical evaluation and render a decision on certification.   The FMCSA  does have staff available for questions on certification issues.  Of course there is the FMCSA Medical Examiner’s Handbook (which is constantly being updated) and serves as a valuable resource for medical examiners.

So what about screening for sleep apnea or as commonly abbreviated OSA, for obstructive sleep apnea, the most common type?  Well we know that currently  Congress has ruled that the FMCSA can not issue new requirements on OSA without going through the formal rule making process. In their latest bulletin regarding this issue the FMCSA stated that:

FMCSA’s physical qualification standards and advisory criteria do not provide OSA screening, diagnosis, or treatment guidelines for medical examiners to use in determining whether an individual should be issued a medical certificate..

However, this doesn’t mean examiners should look away from a driver who they suspect to be at risk for OSA and do nothing, nor does it mean that examiners should screen every individual that walks in their office because they fit some formula for BMI or neck circumference.  It does mean that examiners should do their best to recognize drivers at risk (it could be a combination of physical attributes, and or co-morbidities such as diabetes, high blood pressure etc).

• January 20, 2015 the FMCSA issued a bulletin to medical examiners and training organizations on OSA.  The bulletin was to remind healthcare professionals on FMCSA’s National Registry of the current physical qualification standards and advisory criteria concerning the respiratory system, specifically how the requirements apply to a driver with OSA which is a respiratory dysfunction as is the case with emphysema, chronic asthma and bronchitis, carcinoma, and tuberculosis.

49 CFR 391.41 (b) (5) states that individuals who operate in interstate commerce are prohibited from receiving a medical examiner’s certificate if they have an:

“established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with is or her ability to control and drive a commercial motor vehicle safely”

OSA, depending on its severity may meet the criteria in 49 CFR 391.41 above and alert the examiner that the driver may be at risk for sudden or gradual incapacitation, which should prompt the examiner to refer the driver to a specialist for further evaluation and therapy.  It is generally accepted that there are serious cognitive and neuropsychological sequelae from OSA that increases the risk of crash.  Finding out how bad someone’s OSA is, is the first step or the screening process and probably the most controversial.  Sometimes, however, just getting a good history from patients or drivers as the case is here, can be daunting, even if the person is being genuine and truthful with the examiner.   With sleep apnea, I’ve seen drivers deny symptoms verbally, then recant either verbally or on paper when presented with a formal screening questionnaire like the Epworth Sleepiness Scale.  Also let’s not forget those drivers with normal weight and neck sizes but with mandibular or other anatomical abnormalities as a cause of their OSA.

• The FMCSA goes on to state that they issued advisory criteria in 2000 which was meant to assist medical examiners to apply the minimum qualification standards as published on the MER in 49 CFR 391.43 and in the MEC as 65 FR 59363.

In evaluating a driver the FMCSA recommended to examiners the following in making medical certification decisions.

• Primary goal is to identify drivers with moderate to severe OSA  (defined as apnea-hypopnea index or AHI greater than or equal to 15).  These drivers are not automatically deemed unfit but that the examiner recognize the need to be evaluated or if warranted ensure that they are managing their condition to reduce the risk of drowsy driving.  Again the bulletin clearly states that their advisory criteria does not include screening guidelines.

Basically, examiners should use their training, experience and all available resources to the best of their abilities to safely certify drivers and shouldn’t rely on exact and specific instructions on how to connect the dots (no pun intended) when performing DOT physicals and assessing OSA.

The best screening test in my opinion is really the one you can  truthfully perform on yourself.  Honestly, If I developed a tremor I wouldn’t perform an injection or a procedure on any of my patients if that would put them at risk (even if I’ve done it a million times).  As important as anyone’s job is, their health is even more important ( that really goes for all of us whether we are airline pilots, doctors, drivers, lawyers, etc..).  What does this mean for drivers?  I think that most professional and rational drivers realize that too.  I’ve already seen this for myself in reading the many driver and trucking blogs out there, as well as in driver oriented publications like Overdrive Magazine.  If you suspect that you have a medical condition (whether it’s hypertension, diabetes or OSA) see your regular physician first for proper evaluation and treatment and then go for your DOT physical.  If you do that, then you better hold on to your seats because your DOT physical will be so much easier and faster.  It will be more like “rolling” through a stop sign ( faster or slower depending on how quickly your documentation and records can be reviewed), rather than being pulled over and sent to your doctor or specialist for further work up or documentation.  Basically If you have medical issues come prepared with proper supporting documentation and treatment records, and you will more than likely get your medical certificate the same day. Back to the FMCSA bulletin:

• Methods of diagosing OSA  is given latitude by the FMCSA, as long as devices used ensure chain of custody.  In laboratory and at home polysomnnography or limited channel ambulatory testing devices are all mentioned as acceptable methods in the bulletin.
• Treatment options mentioned for drivers with OSA include:  weight loss, dental appliances, and CPAP or combinations thereof.    However the FMCSA was clear to state that their regulation and advisory criteria regarding OSA is not tantamount to recommendation for treatment, and that treatment decisions is best left to the treating healthcare provider and driver.
• In summary, the FMCSA reiterated that:

Current regulations and advisory criteria do not include guidelines concerning OSA screening, diagnosis and treatment.  Medical Examiners should rely upon their medical training and expertise in determining whether a driver exhibits symptoms and risk factors for OSA, and they should explain to drivers the basis for their decision if the examiner decides to issue a medical certificate for a period less than two years to allow for further evaluation, or deny a driver the medical certificate.

Randolph Rosarion M.D.