The Mayo Clinic and the American Transportation Research Institute (ATRI) recently released a joint study to gauge the experience of medical examiners, and trucking industry professionals (drivers and motor carriers) with the National Registry of Certified Medical Examiners (NRCME).   The Mayo Clinic conducted the survey in the winter of 2016, two years after the NRCME went into effect on May 21, 2014, and released a sample summary of it’s findings on April 17, 2017.  The study looked at 1,242 medical examiners from all 50 states, with 44% of examiners in the survey indicating that they have performed commercial driver examinations for more than 10 years.   The full survey is yet to be released in peer reviewed journals.

Part I- Mayo Clinic Sample Overview Summary of Findings Mayo-NRCME-White-Paper_Brief_April-2017 (1)

1. Examiner Satisfaction with national Registry

Although most examiners reported that they found the process of training, testing, and getting certified simple enough, though somewhat “onerous”,  they complained of the lack of FMCSA guidance in making certification decisions for more complex cases.  There was “great polarity” of examiner attitude toward the NRCME as the survey puts it.

• only 16% CMEs saying that they are very satisfied with the Registry
• 10% were very dissatisfied
• 27% were “neutral”.

In regards to the need for retraining every 5 years

• 43% examiners responded favorably
• 25% not favoraibly
• and 31% were undecided.

It was also reported that 14% of examiners either already stopped or plan to stop examining truckers as soon as this coming year.

2.  Examiner and driver Exam experience

Most examiners felt confident in performing examinations but the time it took to complete an exam varied greatly.   In the majority of examiners surveyed:

• 67% said the average exam took 30 to 45 minutes to complete
• 18% took a 10 minutes or less  (from the drivers perspective, 26.6% interviewed said they spent 20 minutes or less with the examiner and of those, 6.5% said they spent 10 minutes or less).  This was:

“…an insufficient time to complete all required processes of a DOT physical.”

Mayo Clinic Survey

The survey also added:

“Drivers certified by chiropractors were more likely to have important medical checks omitted with only 18% of examiners who were chiropractors indicating that they always or frequently performed a hernia check, or examined the diver’s chest with a stethoscope.  NPs, PAs, and MD/DO groups reported performing these checks 87% of the time always or frequently.”

Most examiners (more than two thirds) reported occasionally asking for additional materials related to a driver’s health condition prior to completing certification.   The next most common replies in the survey was rarely asking for documentation, followed by asking in almost every case, and finally a very small percentage that never asked for any documentation.

The full link to the survey is listed above.

Part II-ATRI National Registry of Certified Medical Examiners Impacts:  Driver and carrier Experiences ATRI-Mayo-Clinic-NRCME-Impacts-04-2017

The ATRI report begins with background information reviewing 49 CFR 391.45 -Persons who must be medically examined and certified, the importance of identifying medical conditions that may impair the safe operation of a commercial vehicle, and a synopsis of observations and reports by the National Highway Traffic and Safety Administration (NHTSA), Independent state studies, and the Congressional action in 2005 that enacted the Safe, Accountable, Flexible, Efficient, Transportation Equity Act (SAFETEA-LU) that mandated the FMCSA to create, develop and maintain a National Registry.

Prior to the implementation of the NRCME CMV drivers could see any doctor of their choosing.   Many opted to see their personal physicians, who were not generally knowledgeable of FMCSA rules and regulations and in applying those rules to CMV operators.   Although the need for a trained pool of medical examiners was long sought after as early as in 1978 by the NHTSA, it probably took a horrible motor crash in 2000 that implicated the lack of medical examiner training and poor medical certification tracking to push the agenda forward.  The NHTSA reported that the driver involved in the crash had multiple disqualifying conditions and should have never been certified, and without proper driver certification tracking, it was very difficult to prevent “doctor shopping” and the fraudulent issuing of medical cards.  Undoubtedly, something needed to change, and some sort of Registry needed to be established.

This portion of the Mayo Clinic-ATRI survey looked at 902 drivers and over 300 motor carriers. The driver survey had 33 multiple questions related to demographics and medical certification.  The motor carrier survey had 10 multiple choice questions.   Most of the drivers in the survey had a CDL for more than 10 years and as a result  had considerable experience in the medical certification process.  Nearly half (48%) of the drivers were instructed by their employer as to which medical examiner to see, and 19.3% of drivers who chose their own examiner used the NRCME.    Most drivers went to an outpatient clinic or office for their exam.

1. Who Certified the drivers?

• 51.1% of drivers were certified by medical doctors (MD/DO)
• 16.8% by advanced practice nurses (NPs)
• 13.3% by chiropractors (DCs)
• 13.1% physician assistants (PAs)

2.  Driver experience during medical examination

• 46.8% spent 30 minutes or longer with examiner
• 6.5% spent 10 minutes or less with examiner
• 34.3% of drivers took more than 15 minutes to complete the medical examination form (complaining of vague wording and duplicate questions on the form)
• Similar to the Mayo Clinic survey of examiners, drivers also found chiropractors more likely to omit examination procedures (i.e clothes removal, hernia checks, chest exam with stethoscope and lighted eye exam) than other medical examiners such as NPs, PAs and MD/DOs
• The three most commonly reported driver health conditions were hypertension (37.6%), diabetes (18.6%) and obstructive sleep apnea (14.6%)
• Most drivers (52.1%) received a 2 year certification and (41.5%) received 1 year. About 1.2% were denied a certificate altogether and the remainder (5% or so) was divided between those receiving 3 or 6 months
• Main causes for delay in certification were due to the need for drivers to provide additional medical records (60.4%), and to treat a medical condition (22.6%)

3.Driver satisfaction with examination quality and with certification process

• 48.5% of drivers were satisfied
• 25.8% were dissatisfied
• 25.6% neutral

4. Driver satisfaction with National Registry’s impact on medical examination quality

On the contrary:

• 57.4% reported no change with quality since NRCME
• 34.7% reported worsenning
• A mere 6.2% drivers reported improvement of the  examination and certification process since NRCME was implemented

Most drivers (63.3%) reported increased cost of exam since NRCME (A view that is corroborated in the motor carrier survey section as the one “tangible” impact reported by drivers).   The majority of drivers (78.2%) reported that they have not made any lifestyle changes (i.e smoking cessation, weight loss etc.) as a result of new regulations in the books such as those for obstructive sleep apnea screening.  There is great discrepancy between driver perception as to what they think is necessary both subjectively and objectively in the examination process.   Apparently, some see only profit motives with some examiners or the lack of understanding of federal regulations as reasons for many examiners requiring additional, or as they sometimes see “unnecessary” testing.  They referenced the lack of clarity of FMCSA standards causing confusion in both examiners and drivers.  Interestingly though, some of these drivers also reported preferring their primary care physician to make fitness determination for them, as opposed to a trained and certified medical examiner, because their personal physician has a “better” understanding of their medical history.

5.  Motor carrier concerns over the medical certification process

Of the 300 motor carrier respondents only 18 carriers (0.06%) stated that they had no concerns over the medical certification process.

Concerns included:

• Certification delays caused by request for additional testing
• Driver confusion over regulatory changes and how it affects their ability to maintain their medical certificate
• Concerns regarding “unqualified” or “incompetent” medical examiners ranked as the third most important issue by motor carrier respondents

Click here for a synopsis of the ATRI driver and motor carrier concerns.

The concern over the quality of medical examiners is of great concern and causes delays and increased cost to motor carriers and fleet owners.  I do not think that the statement “incompetent” was meant to say that these examiners are incompetent in their own profession (i.e medical, nursing or PA), but incompetent in the execution of their tasks as certified medical examiners.  It is  a strong statement, hence it’s inclusion in the title of this post.  However, to better explain the meaning of incompetence here it is probably best to read what Clayton T. Cowl M.D. , M.S. (The Mayo Clinic Chair of Division of Preventive, Occupational and Aerospace Medicine) said in regards to his study:

“Those examiners who are performing only minimal examinations may have received substandard training or are not taking their role seriously. The key seems to strike a balance between meeting the regulatory intent of the examinations and communicating with drivers ahead of time to minimize confusion regarding the need to document clinical stability. This is particularly true for drivers with multiple or complex medical conditions from whom medical examiners do need more documentation in order to make a certification decision.”

Clayton T. Cowl M.D.

On the other hand, many of these motor carriers have in place what they say are effective policies and procedures to streamline the certification process, including proprietary electronic medical record (EMR) platforms that trigger reminders to drivers to bring certain documentation or tests with them prior to their medical examination. Since most of these drivers go to the clinic that is mandated by their employer, and those clinics are presumably integrated into the employer’s EMR platform, one has to wonder where this process is failing exactly.  Perhaps this could be prevented or minimized if communication was improved between motor carriers and the clinics or examiners that they contract with.  Consequently, when carrier interviewees were asked about the quality of the examination process since the NRCME was implemented, they stated no improvement, and that they made no change in their own part of the examination process because they have to continually review and monitor medical examination reports for errors, which was estimated to be at about 7% of all medical application forms.

Other concerns include:

• Medically unqualified drivers becoming certified
• Too rapid changes in the certification process

The motor carriers suggestion for improvement to the NRCME certification process included allowing medical examiners access to a driver’s prior medical exams to reduce doctor shopping, have medical examiners report their result to the NRCME daily and a somewhat confusing but intriguing statement:

“Increased accountability  for areas where subjectivity may occur to force CMEs to err on the side of  caution rather than risk potential liability if a driver is subsequently involved in a crash”.

ATRI

Increased accountability by whom?  Driver/Carrier? FMCSA? Medical examiners?

Summary:

The survey overall was revealing and informative and everyone involved in the transportation industry should make an attempt to read it in it’s entirety, especially when the full study is published in peer reviewed journals.  It’s not a controlled study, the sample size was small (only, 1,242 MEs, 903 drivers and 300 motor carriers were surveyed), and as a result it has it’s inherent biases like any other study of it’s kind.  The Mayo Clinic ATRI study surveyed a very small population of medical examiners, drivers and motor carriers.  A recent article in Transport Topics showed the number of certified FMCSA medical examiners at around 52,000.   The American Trucking Associations  (ATA) estimates the number of For Hire carriers alone registered with the U.S. Department of Transportation at 586,014  (The industry sector represented in the Mayo-ATRI study was mostly For Hire at 76.6%).    Finally, according to the ATA the number of truck drivers employed in 2015 was at 3.5 million.

We should not jump to too many conclusions, but to me it does seem in reading this study that most medical examiners are not pleased with the NRCME, and a significant number are not thrilled about recertification.   Drivers and motor carriers, however, seem even more displeased with the NRCME.  They do not see improvement in examination quality (more than a third reported worsening exam quality), but are certain, and without a doubt of the rising cost for the DOT exam.  There is frustration over what is seen as unqualified and incompetent examiners.   To many drivers and carriers the NRCME has made it even harder for drivers to get a physical and has burdened them with excessive rules and regulations that are changing at a pace much too rapid.   Some drivers even yearn for the good old days, when you just strolled into your family doctor’s office for a cold or neck pain remedy, and slyly slip that DOT medical examination form in, knowing that your long time doctor or nurse will just fill it out, so as not to displease you or keep you from going back to work.

Well, all I can say is that the NRCME is almost 3 years old and we have come a long way from the unregulated wilderness that existed not so long ago.  There are currently an estimated 800,000  active physicians  in the U.S. and almost 4 million active truck drivers. Leaving additional examiner groups (NPs, PAs and DCs) aside just for the moment, do we really want all of these untrained and uncertified practitioners without direct and immediate accountability to a Registry potentially evaluating all these drivers?   In this day and current administration bent on deregulation, “throwing away the baby with the bath water” so to speak, is not only foolish, but palpably catastrophic.