Commercial Driver Medical Examination| Rules and Regulations

FMCSA NPR Qualification of Drivers; Diabetes Standard- My Comments

U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Notice of Proposed Rulemaking
Qualification of Drivers; Diabetes Standard
[Docket No. FMCSA-2005-23151]
Submitted by:
Randolph Rosarion M.D.
120-10 15th Ave. St. 6
College Point, N.Y. 11356
email: doctor@dotmedicalexaminer.com
Contact number: 718-701-5949

Randolph Rosarion M.D. a certified DOT Medical Examiner listed in the National Registry of Certified Medical Examiners (NRCME) is a Board Certified physician in Physical Medicine & Rehabilitation for 20 years, who also practices Occupational Medicine. My practice Sands Point Medical Rehab is located in College Point, Queens New York and my full contact information can be found at http://www.usdotmedicalexaminer.com. I would like to submit my comments here as an individual in response to the Federal Motor Carrier Safety Administration (FMCSA) Notice of Proposed Rulemaking (NPRM) docket number [FMCSA-2005-23151-0098] issued on May 4, 2015. The NPRM proposes to permit on an annual basis drivers with well controlled insulin treated diabetes mellitus to operate a commercial vehicle in interstate commerce if a Treating Physician (TC) certifies that the driver is stable and well controlled on his insulin, and a Medical Examiner (ME) listed in the National Registry of Certified Medical Examiners (NRCME), working in conjunction with that TC certifies that the driver meets all other qualification requirements otherwise. Currently a driver using insulin is prohibited from driving a commercial vehicle in interstate commerce unless he or she is granted an exemption from the FMCSA. If the NPRM is passed and 49CFR part 391 is amended as the FMCSA is proposing, the current Diabetes Exemption program would no longer exist.

My viewpoints as a physician and a Certified Medical Examiner (ME):  I agree with FMCSA’s proposal to eliminate the current Diabetes Exemption Program, and I believe that from reading many of the other comments already posted, and from talking to others in the industry that this is a view point shared by most commercial drivers, motor carriers and driver advocates alike. For the most part the current exemption program is costly and burdensome and likely discourages many qualified and experienced drivers from pursuing their goals.  I started performing commercial driver medical examinations 7 years ago, prior to the compliance date of the NRCME on May 21, 2014.   I continue to see many drivers today in addition to the patients I care for in my regular medical practice. When it comes to the evaluation of drivers using insulin, I find that these drivers quickly become discouraged once I start discussing the exemption process and provide them a copy of the Diabetes Exemption Package. In fact, many would claim that they were not even aware of the existence of an exemption program. Those that do move forward and apply, (and in my experience they have been few and far), often become lost to follow-up. This is especially true with the CDL Self Certification requirements now in place in all the states.  I have seen drivers contemplating returning to the trucking profession, but because they are on insulin and do not wish to bother submitting a lengthy application, decide to give up their CDL altogether. So removing the Diabetes Exemption Program, an apparent barrier to many drivers makes sense, and seemingly will help bring more qualified drivers to a much-needed industry.  However, I do have reservations on how the NPR seeks to replace the current exemption program. This is what I would like to discuss here, and would like to thank the Agency ahead of time for the opportunity to do so. Before I start though, I would like to comment on how I came about discovering this NPR in the first place. It came about while looking through the FMCSA website and looking at www.regulations.gov.  It did not come as a memo or a letter to MEs as was the case in previous bulletins regarding obstructive sleep apnea (OSA), or technical instructions on how to complete the Medical Examiner’s Certificate (MEC), or how to add a Medical Examiner Administrative Assistant. Although it is clear to me that the Agency is not required to notify MEs or others in any fashion other than what is required by law, as was done in this current public comment period for this NPR, I do feel that at minimum a concurrent letter to all MEs listed in the Registry would have been appropriate. After all the NRCME which was mandated by Congress and created by the Agency places a significant onus on the ME.   A NPR such as this one on the Diabetes Standard if passed will completely change the way MEs are required to certify commercial drivers using insulin.   It will also increase the responsibilities placed on the ME, since the Diabetes Exemption Program will no longer exist, and the FMCSA will no longer play a central role in the insulin driver certification process. That role will now be that of the ME. Therefore, it is my opinion that all MEs should have been made aware of this particular NPR directly.
Concerns I have with the Notice of Proposed Rule (NPR) and suggestions made:  Treating Clinician (TC).    I will begin by addressing FMCSA’s definition of TC and the role they will play in the certification process of commercial drivers using insulin.   The last page of the NPRM describes how the FMCSA intends to revise 391.41 (Qualification of Drivers and Longer Combination Vehicles), and 391.45 (Persons who must be medically certified) and the addition of the new regulation 391.46 (Physical qualification standards for a person with insulin treated diabetes mellitus).   The definition of TC is found in the text of 391.46 and the FMCSA describes the TC as “a physician or healthcare professional who manages and prescribes insulin for the treatment of individuals with diabetes mellitus”.  The TC is to evaluate the driver using insulin prior to the annual or more frequent examination that is required by 391.45 with the ME .   The TC is to determine that within the previous 12 months that the driver has had no severe hypoglycemic episodes, and has properly managed the diabetes. The driver on insulin is required to monitor and maintain blood glucose records as determined by their TC, and submit those blood glucose records to the TC at the time of their evaluation.   The ME who will ultimately certify such driver is responsible for obtaining written notification from the driver’s TC that the driver’s diabetes is being properly managed.

I am concerned that there lacks a clear definition from the FMCSA as to what the written notification from the TC to the ME should entail.   Since the monitoring for driver compliance will now be left to the TC, and since the FMCSA has no jurisdiction over the TC, how will the ME know that proper care and preventive measures were taken to ensure driver health and compliance.   If I were to imagine a best case scenario in this TC and ME interaction, I would give the following as an example.   Ideally the ME should receive a complete report as to what the blood glucose logs actually showed or any particular trends that would be helpful in determining the driver’s ability to manage the diabetes properly and show compliance.   The TC might also note in his or her report whether or not any hypoglycemic episodes (moderate or severe) was experienced by the driver, and that
the driver knows to carry a rapidly absorbable glucose while operating a commercial motor vehicle (CMV) and checks his or her blood sugar one hour prior to operating a CMV, after eating a meal and periodically every 4-6 hrs while driving.   Also, that the driver has been educated and trained in hypoglycemia awareness and understands what corrective measures to take to remedy a potentially life threatening or hazardous situation.
Finally, that the driver has been educated in the possible systemic side effect of diabetes, that can occur, especially when the diabetes is not well controlled, and is screened annually for conditions such as diabetic retinopathy. Given such a report from a TC it would be quite straight forward for most ME to safely certify “an otherwise qualified driver” who is using insulin.   However, what was presented here is the best possible scenario, which in my experience both in treating patients and certifying commercial drivers is the exception rather than the rule.   Even if the TC were to perform his duty in a responsible manner, he or she is usually busy, and may have more pressing issues at hand.   Also, TCs tend to be somewhat partial or sympathetic to their patients needs (genuine or not), to expedite an encounter and may even “fudge” or do whatever it takes so that he or she is able to attend to the next patient and save face.   Also, because they have not been trained
in the examination of commercial drivers they usually are not familiar or sensitive to the whole driver certification process and it’s importance.   They often equate commercial driving with regular passenger car driving or with driving a taxi or some other vehicle such as a van or “box truck” with livery or commercial plates as is often the case in New York City where I reside.   So then, how is the TC able to seriously and earnestly evaluate the driver on insulin and present the ME with a note that includes most if not all the items detailed here in the best case scenario, when they do not necessarily even know what the FMCSA is and why this doctor or chiropractor, PA or nurse who is not involved in the care of their patient keeps bothering them about “Driver John or Jane” who just wants to work and make a living? Obviously this relationship between TC and ME needs to be better defined and improved upon within the text of the NPR or there will be confusion, further delay for the driver, and the NPR will not be a means for improved driver health and public safety.

Some suggestions on how to improve the TC and ME interaction: 

(a) As mentioned in the best case scenario above, the TC should provide ME with supporting documentation of properly maintained glucose logs, proof of proper diabetes management and compliance, driver hypoglycemia awareness and preparedness by carrying rapidly absorbing glucose at all times and proof of yearly preventive care to screen for the long term side effects of diabetes such as retinopathy. In other words most of the provisions currently in the exemption program remain necessary.   The only way to assure that the driver is being properly certified is for the FMCSA to require the ME to obtain such documentation from the TC. In my opinion the FMCSA failed to address this pivotal point by not specifying in detail the documentation that MEs should require from the TCs. The NPR literally leaves the ME unable to properly certify a driver on insulin if ME simply receives a note from TC that says, “driver manages his insulin and diabetes properly and is fit to drive commercially”.   Also, the FMCSA has no jurisdiction on the TC, but can audit, sanction, and remove MEs who certify drivers improperly on a repeated basis.   The purpose of the NRCME was to create a group of examiners trained and knowledgeable with the demands of commercial driving, FMCSA regulations and how CMV drivers physical examination and medical conditions affect safe driving and public safety.   The FMCSA needs to give MEs the tools they need to properly evaluate the CMV driver on insulin so that the ME will not have to rely on the “hearsay” of the TC.   This is a key and critical point for me as a ME and probably for others who have read this NPR carefully.   In my opinion it requires modification by the FMCSA and that modification alone if made, would make the NPR that much more acceptable, and will allow for a safer certification process. Also, that will allow the ME to meet FMCSA expectations.   These expectations from MEs were stated
in the NPR by the FMCSA and I quote:

“ Essentially, in issuing a MEC under FMCSA
regulations, the ME will reflect his or her evaluation that such drivers are free of
complications that might impair the ability to operate a CMV safely in interstate
commerce”.

(b) The FMCSA can help educate the TC on the importance of their role as diabetes care specialist by designing digital and printed information that the ME can share with the TC, or the FMCSA can provide the ME the tools to do so and the ability to use the FMCSA logo or emblem in such educational documents.   However it’s done, apparent FMCSA involvement would probably carry greater weight than if these materials were conveyed solely from the ME to the TC.
(c) The ME with or without suggestions from the FMCSA can design or write a certification letter or “clearance” letter that includes the description of the duties and requirements placed on the commercial driver, as we currently have in the current Medical Examination Report Form (MER) that is used by all MEs.  This will further help educate the TC as to the demands of commercial motor vehicle driving. It might emphasize to the TC of the importance of answering all questions truthfully and completely, and thank them for their participation, and remind them that their contribution will help their patients live healthier lives and stay active longer in the work force, and that their involvement will also help improve public safety.   As discussed earlier, such document should contain at minimum all the provisions that currently exists in the Diabetes Exemption Program.   A list or series of checkboxes that the TC can use to certify that driver manages his or her diabetes properly, such as blood glucose testing, HgA1C results, hypoglycemia awareness and prevention might facilitate the process for
the TC.   Once the form is completed, the TC would have to complete and sign it and provide the ME with all supporting laboratory and diagnostic tests performed on the driver with regards to their diabetes.   The ME would reserve the right to request additional testing such as formal visual field perimetry screening and testing and others, if the ME believes it is necessary for proper certification of a driver using insulin.

2. Hypoglycemia-The need to undergo hypoglycemia awareness training

On the subject of hypoglycemia and hypoglycemia awareness the FMCSA has stated that the proposed rule has no requirement for hypoglycemia awareness training because the annual or more frequent ME certification exam and TC’s evaluations provide sufficient time to intervene should it be deemed necessary.   The importance of hypoglycemia awareness training is well accepted in the medical literature.   I will refer the FMCSA to the American Diabetes Association (ADA) website, the ADA studies cited by Health and Safety Works, LLC ( Elaine_M_Papp_-_Comments ) on this NPR.   I agree with Health and Safety Works that the omission of moderate hypoglycemia by the FMCSA in the NPR is not only erroneous but presents a significant safety concern.   The studies which were cited from the American Diabetes Association (ADA) clearly show that in moderate hypoglycemia, although the driver is able to treat his or herself, both judgement and safe driving are impaired.   The ADA studies regarding moderate hypoglycemia are important despite the emphasis placed by the FMCSA in this NPR on the risks of severe hypoglycemia, as reported by the 2006 and 2010 Medical Review Board(MRB) reports.   if the full statement of the MRB report is read carefully, after indicating to the FMCSA that they allow insulin treated diabetes mellitus drivers to drive CMVs if they are free of severe hypoglycemic reactions, the MRB also said that such driver should have no altered mental status or unawareness of hypoglycemia, and manage their diabetes mellitus properly to keep blood sugar levels in the appropriate ranges.   Although one of the main distinction between moderate and severe hypoglycemia rests in the fact that in moderate hypoglycemia the driver tends to be able to treat his or herself but is unable to do so in severe hypoglycemia, the fact remains that the driver’s mental status and judgement is affected, albeit to varying degrees but nevertheless possibly enough to still interfere with safe driving.   Therefore, the need for the TC to submit to the ME documentation and proof of proper hypoglycemia awareness training by the driver is critical and should not be undermined.

3.The operation of CMVs with hazardous materials or carrying passengers and 391.64 

As far as the ability of ITDM drivers to operate CMVs involved in carrying passengers or hazardous materials the 2012 ADA study “Diabetes and Driving” reference by the FMCSA in the NPR was done primarily on non-CMV drivers, and as such I do not believe can be used in assessing safety in this specific types of driving. However, I concur with the FMCSA that the risk posed by a driver with stable well controlled insulin treated diabetes are low, that there is no evidence to support restricting the type of driving they are able to do. Furthermore, as stated by the FMCSA the current exemption program allows insulin treated drivers to qualify
for passenger and hazardous material transport.   From my point of view as a ME, I see no reason for that to change, and support continuing to allow the insulin treated driver to operate all types of CMVs, unless new studies performed on CMV drivers state to the contrary.   I will defer further comment on this matter to the motor carriers involved in hazardous material transportation and the motor coach companies involved in passenger transportation.

391.64
As far as the remaining drivers involved in the grandfathering program after the termination of the 1994 ITDM waiver program, they should be held to the same standards as all ITDM drivers and I concur with the FMCSA that 391.64 would be redundant if the NPR is passed.   With the withdrawal of the Diabetes Exemption Program, so too should 391.64 be eliminated.   The remaining drivers from this program (and I am not sure of the number and how many are still active) would first see the TC and then be certified by the ME in the usual manner if the NPR is adopted. I do not see how they would be affected adversely, if certified like all other ITDM drivers.

4. The role of the annual diabetes eye examination with opthalmologist/ optometrist

The FMCSA asked for comments specifically on the need to be assessed by an ophthalmologist or optometrist as a condition of passing the physical exam.   Unfortunately, I can not answer this question with a simple yes or no.   However, in my opinion not having an exemption program should not mean a driver using insulin does not ever need to see an opthalmologist /optometrist.   Depending on driver health and how well the diabetes is
managed, it may be necessary more frequently in some than others.   What would be eliminated though is the burdensome process, the automatic signed statements and quarterly reports found in the current exemption program.    A dilated eye exam is generally recommended to properly assess the retina or back of the eye, especially in diabetics.   Most ME probably do not routinely perform dilated eye exams with their opthalmoscopes and generally do not have specialized equipment such as digital photography in their office. This is the speciality of eye specialists such as optometrists and opthalmologists.   On the other hand, a driver who presents to the ME for an examination (whether he or she has ITDM or not) can pass the DOT physical if his or her visual acuity, peripheral field of vision and color vision perception meet the standards, and receive a MEC providing no other conditions are present that would impair his or her ability to operate a CMV.   However, I don’t think that this is the relevant question to ask here in an individual with ITDM.    The ADA states that people with diabetes are more likely to develop problems that can lead to blindness than people who do not have diabetes.   Of the two types, non-proliferative and proliferative, non-proliferative is less likely to cause blindness but can still progress to fluid leakage into the macula, macular edema, and blurry vision that lead to blindness.   With the more serious proliferative retinopathy, neo-vascularization, and scarring that occurs can lead to retinal detachment and blindness. Good glycemic control and regular eye examinations are recommended by the ADA as a standard of care for diabetics.   The frequency of screening is yearly, and the ADA states that evidence for less frequent screening every two years in diabetics with no retinopathy at the outset is not yet supported by current research.   So, given the recommendations of the ADA, and from the Clinical Practice Guidelines (CPG) used by medical centers (CPG can be found at sites such as http://www.guideline.gov, a national guidelines clearing house, and http://www.Pubmed.org, yearly retinopathy screening is generally accepted as a best practice recommendation and standard of care for diabetics.   The FMCSA should require the TC to perform yearly eye examinations for the ITDM driver or send him or her to an eye specialist to perform such examination and provide the results to the ME.

Diabetic retinopathy study
A recent study cited by the ADA at their website : Progression of diabetes retinal status within community screening programs and potential implications for screening intervals, by Leese and colleagues. Diabetes Care 2015;38:488–494 – http://care.diabetesjournals.org/content/38/3/488 will be referenced here.  The study was done in 354,000 patients who had exams in one of seven eye screening programs in the U.K. between 2005 and 2012.   It was done to watch the progression from no retinopathy to various degrees of retinopathy in people with diabetes and to determine how often they should have an eye exam.   Patients with no retinopathy or background retinopathy (defined as mild non-proliferative retinopathy) were followed for four years to see
if they progressed to what was termed “referable retinopathy” (moderate or worse non- proliferative disease) and or macular edema or “treatable retinopathy” (which is the more serious aforementioned proliferative retinopathy).   The results showed that 16,196 out of the 354,00 studied progressed to referable retinopathy or the moderate or worse non-proliferative type of retinopathy. In the patients with no retinopathy in either eye 0.3-1.3 % progressed to referable retinopathy and less than 0.3% progressed to treatable retinopathy (or
proliferative retinopathy) after 2 years.   Those with mild background retinopathy in both eyes 13-29% progressed to referable retinopathy and 4% to treatable retinopathy.   The results of the study indicate that diabetics can be screened into various risk categories based on the degree of retinopathy they have to assess the need for eye screening.   Those with low risk can be screened every 2 years, moderate risk every year and high risk two times per year.   Limitations of the study is that it was a retrospective chart review looking back at
the records of patients who already had eye exams and not a prospective study that could look at the effects of changing the intervals of the eye examination with the occurrence of retinopathy.  To return again to the question posed by the FMCSA regarding the need for an ophthalmologist or optometrist evaluation as a condition to pass the DOT physical, I think that the recommended standard of care as described by the ADA,
the research supported in the literature, and the CPG used in medical training that I and other physicians have received all concur that diabetics are more at risk than the general population and should be screened, and at the minimum once every year.   The ADA and the current CPG and research do not yet fully support less
frequent screening. I would therefore strongly recommend the continuation of the yearly eye examination of the driver with diabetes by an optometrist or opthalmologist regardless of whether or not the CMV driver passes the commercial driver medical examination.

5. Enforcement for compliance of driver with insulin ITDM versus economic burden

The FMCSA has stated that:

“FMCSA has determined that the inconvenience and expense for drivers, and the administrative burden of an exemption program are no longer necessary to address concerns of hypoglycemia and meet the statutory requirement that drivers with ITDM maintain a physical condition that is adequate to enable them to operate (CMVs) safely.

This is the reason given to eliminate the Diabetes Exemption program, and as previously stated I concur with the FMCSA.   However, with regards to continued monitoring of the ITDM driver, and enforcement of compliance I believe that such provisions should be maintained even without the current exemption program, and that they are practical, and do not present an undue economic burden for the driver.   Whether we are discussing truck drivers, police officers, fireman or any other persons with ITDM, the overall health and well being of that person rests in their desire and ability to properly monitor and treat their condition.   The ADA supports glucose monitoring, glucose logs, hypoglycemia awareness and carrying a rapidly absorbable form of glucose in case of emergencies.   The provisions of the current Diabetes Exemption Program require that.  Those provisions should not be eliminated in the NPR. Relying on the driver alone to honestly report his condition without any enforcement measures in place is not a guarantee of compliance and does not improve public safety.   That is the reason it is necessary for the TC to provide the ME with more than just an “OK to drive” note. As a physician who also actively treats patients, I can never accept such a note from another physician. Why would it be any different for me as a ME?

What needs to be done to enforce ITDM driver compliance with TC recommendations?

There are many ways to go about it but ultimately I do believe that a modification of sorts needs to be made to the Medical Examiner’s Certificate (MEC).   I have discussed some of these ideas with Health and Safety Works and I reference to you their contribution to this NPR with regards to the training of roadside inspectors to check for glucose logs and verifying that driver has a rapidly absorbable form of glucose, as well as indicating the requirement for these items on the MEC, as is currently done for corrective lenses or the SPE certificate. Without the exemption program the FMCSA will not directly oversee the driver with ITDM.   The driver in turn may only see the TC and ME once a year, unless there has been a roadside event or driver’s health changes and he or she goes to the TC and is referred back to the ME.   Even then, the ME may remain in the dark unless TC or motor carrier refers driver back to ME.   This is again the reason why it should be a requirement for the ME to obtain complete documentation from the TC.   The TC should be made aware by ME at the time of the initial evaluation of the driver that any changes in the driver’s health status should be reported back to the ME.  The FMCSA contends that reasonable persons like those with ITDM have every incentive to manage their condition well, because failure to do so will lead to adverse events like a hypoglycemic episode that can potentially cause them to lose their CDLs.   I disagree.   I believe that this argument is likely posed to make the case that there is no real need for enforcement once the driver is cleared by the TC and certified by the ME. From my experience treating patients (not just those with ITDM), most do not follow their physician’s instructions.   Patients, if they do take their medications at all, will vary dosage, frequency and generally report what they want, unless they were frightened or worried about some adverse event.   They may alter or embellish their treatment regimen with the use of over the counter supplements or perhaps obtain medications from friends and families or the world wide web.   Interestingly enough, after evaluating commercial drivers over many years it one day dawned upon me that not only are they like my regular medical patients, but that a majority of my medical patients drive professionally for a living.   I just never placed much emphasis on their job description as truck drivers until I started evaluating them as a ME.   So apparently, they are one of the same for the most part, whether they are truck drivers, police officers, office workers or medical or law professionals.   To say that CMV drivers or others would behave a certain way because of the fear of losing their jobs, would be like assuming that most reasonable people would not take the chance and use illicit drugs at times, so therefore there is no need for a drug and alcohol testing program.

I wish to thank the FMCSA for the opportunity to comment on this very important rulemaking. Please contact me with any questions or concerns.

Randolph Rosarion M.D.
Board Certified Physical Medicine & Rehabilitation
phone: 718-701-5949
email: doctor@dotmedicalexaminer.com
web: http://www.usdotmedicalexaminer.com
Blog: http://www.dotmedicalexaminerblog.com

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