There is a reason why the PDR (Physician Desk Reference) is so bulky, listing every possible side effect for every drug from aspirin to anti-cancer medications.  The rumor is, as I was told in medical school is that the PDR is written by lawyers or “legal” minds, and not by doctors.  Whether true or not the irony is clear, and if true, it seems quite reasonable (to me anyway) why it would be more valuable to have it authored by legal persons rather than medical.  Nonetheless, the PDR is no doubt a valuable reference tool, not unlike FMCSA’s Medical Examiner’s Handbook, which is currently in defunct mode but soon to re-emerge, as we are promised.   If the previous FMCSA memorandum to medical examiners and training organization with regards to the obstructive sleep apnea (OSA) recommendations, and this new proposed rule to amend the regulations regarding insulin treated diabetes are any indications, I can only surmise that the FMCSA like it’s own Handbook is not so much as re-inventing itself but changing it’s look, putting on a new outfit so to speak, but in the process drastically altering the way commercial drivers are evaluated and certified.  Is this FMCSA “new look” just a way to appease lawmakers and stake holders, who no doubt put tremendous pressure on the agency, or a sincere attempt to abridge it’s regulatory machinery and cut through the bureaucratic red tape for the betterment of the driving professional?  In it’s mission statement the FMCSA succinctly and purposefully states:

Our primary mission is to prevent crashes, injuries and fatalities involving large trucks and buses.

Medical professionals who decide to perform commercial driver medical evaluations are required to follow certain qualification standards in the evaluation of commercial drivers to insure public safety, and must now pass an examination to become certified through the recently established National Registry of Certified Medical Examiners (NRCME).  The NRCME was mandated by congress and went into effect last year on May 21, 2014.  The hope with the creation of the NRCME was to further improve the driver certification process by using only trained and certified medical examiners, who apply FMCSA driver medical standards in evaluating commercial drivers to improve public safety and decrease fraud, and directly link the National Registry with state and federal driver databases.

Well then I ask, is the goal of ensuring public safety, still achievable or even palpable with the new proposed rule “as written”?  The fact that the current Diabetes Exemption Program will be dissolved in the process is really not the issue here.  As a lot of us see it, the main setback here is that in it’s current state or language, the proposed rule actually fails to meet the standards already established by the FMCSA itself for the Diabetes Exemption Program.  So doing away with the Diabetes Exemption Program is not the problem here.  We can do away with the exemption program, but with the current proposed rule as written if passed, we will not maintain the same level of safety.

In reality, regardless of whether the driver goes through the FMCSA’s current Diabetes Exemption Program, or is evaluated and certified entirely by the medical examiner interacting with the treating clinician or primary care giver as suggested in the new rule, the fact is, it remains an exemption process.  The burden will only now be shifted to the medical examiner, and probably will not necessarily be alleviated for the driver either, that is, if the treating clinician properly evaluates and medical examiner certifies accordingly.  Then we need to ask, once certified how do we enforce this entire new process in lieu of the current Diabetes Exemption Program, to ensure that the driver using insulin remains compliant?

If you remember Johnny Depp’s movie “What’s Eating Gilbert Grape”, I can certainly ask the same of the FMCSA.  What’s Eating the FMCSA?, because a lot seems afoul with the new rule.  But to be fair, the FMCSA does rely on medical expert opinion from the Medical Review Board (MRB), the Medical Expert Panel (MEP), as well as the Office of Medical Programs within the FMCSA itself to help with the interpretation and application of it’s medical regulations and recommendations.  The FMCSA ultimately decides what recommendations made to the agency by it’s medical experts to accept.  It publishes notice of proposed rules such as the current rule at hand and submits it for a period of public comment.  Why does the FMCSA need such a wide body of medical experts to help it understand medical issues like insulin and diabetes and many other medical conditions?  The simple answer is it’s complicated, both understanding the medicine and to properly apply it through the legal system without over burdening drivers, and simultaneously maintaining public safety.

So I ask again, What’s eating Gilbert Grape?  What’s really eating the FMCSA?  Less I feign an answer, I’m afraid that what ever I say now would just be speculation, so your guess is as good as mine.  However, as a medical professional, I and many others see a lot wrong “medically” with the new proposed rule as written, and I hope to have some of those colleagues contribute their thoughts to the next post.

Memorial Day is here.  To be continued…..