Just a little bit about our logistics for today. I'm going to start out with, I'm going to put that up there. Christine Heidach was hoping to come with us. She's lead of medical programs, FMCSA. She was not able to, so what I have are about 15 of her slides. Information, I don't know, sorry. Okay, so what we're going to be doing. Starting out, Chris has given me about 15 to 16 slides, official FMCSA messaging. I will present it as FMCSA messaging without a whole lot of interpretation by personal opinion or anything along those lines, so this is what FMCSA is telling us. Then I'll kind of expand on FMCSA's comments based on how it's going to affect the medical examiners, how it's going to affect employers, how it's going to affect drivers. Talk a bit about research, where Dr. Hegeman is going to comment on one of the research projects FMCSA recently did. We'll talk about some of the periodic training, new forms, new issues, new regulations that are coming down the road. Then Dr. Berneking will be speaking about the draft, and you're going to hear me saying draft. If he doesn't say draft, I'm going to beat him upside his head, but it's a draft ME handbook. It does not mean it's been approved, it does not mean you start using it yesterday. It is just another piece of information. We'll talk about the benefits and the, how do I say this nicely, disadvantages of this new handbook. Then after that, we have Mr. Steve Fleury. He is an attorney from the Philadelphia area who does employment law. We'll talk a little bit about a couple of cases that have impacted commercial driver companies and the medical examiner to some extent as well. I think they're two interesting cases, one I actually have a little more contact with than the other. What does FMCSA want us to know about? What's going on in rulemaking? What's happened with the alternative vision standard? A little bit about the driver exam forms, have they changed or going to be pending changing? Periodic training, hopefully some of you or most of you have at least done your periodic, the five-year refresher training, as opposed to that 10-year training and recertification. We'll talk about what it means, what you'll have to do, how to get it done. Medical examiner handbook update very briefly from FMCSA, registry keeps going down, coming back up, it's getting better. Reminders, the National Registry Part 2, still in effect, and then some research updates from FMCSA. Rulemaking there's not a whole lot going on, the most recent was the alternative vision standard. Remember, this is an alternative standard, it does not supersede the original vision standard, however, it does supplement it. So the original was changed a bit, and then there's a kind of secondary standard for those who don't meet the primary, very much like what we're doing with insulin-treated diabetes. Exemptive date was March 22nd, 2022, which means by that date, everybody should be using it. Website is on that screen for more information. They're currently in the process of converting all of those drivers who had been in vision exemption programs. There is no longer a vision exemption program. If you are an examiner, and you happen to have a driver who doesn't meet the vision standard, do not, do not, do not certify them under an exemption. The vision exemption no longer exists, you can only certify them under that alternative vision standard if they cannot meet the primary standard. And that does mean, if they can meet it by getting glasses, they don't fit into that. If they can meet it because they chose to have one eye for distance, one eye for near, it doesn't matter if they are virtually unable to meet that original standard. That is the only situation where you certify them under the alternative vision standard. Medical examiner's form has been updated primarily just to have the new date placed. That should be approved. We know that the new form, the old form expired, 3-30-20-23. We have approval or, I'm sorry, go back to this different form. This one has been approved, has been updated, now has a new expiration date. You should be using the new form with the new expiration date, that's the medical examiner's form. However, if you have a few of the older ones left, that's going to be okay for a short period of time. There's been no substantive changes on that form. Some of the issues they're finding on the forms. The skill performance evaluation certificate has been a real problem for FMCSA. They're going back and finding a lot of situations where the individual needs an SPE, it's not marked off. Or they're finding it where the SPEs are noted and there's nothing in there. So you need to be very careful. Skill performance evaluation certificates are only used for individuals who have an amputation or potentially an impairment, and I'm going to talk about it in the next couple of segments. Amputation always needs an SPE, impairment of a limb may need an SPE. That's where you need to use some judgment. The other thing is with hearing exemptions. They are still granting hearing exemptions. If a driver wears a hearing aid and can meet the standard, they don't need an exemption. If they don't have a hearing aid and don't meet the standard, which is they can't meet it in either ear, remember it's two eyes, one ear, four limbs. So if they can't meet the hearing standard in one ear and they need a hearing aid, you mark off they need a hearing aid. If they still don't meet it, then they may be eligible for an exemption, and then they have to go ahead and seek that exemption. If the exemption is granted, they can then operate. If the exemption is denied, that's where everything stops. But you shouldn't ever be marking exemption and hearing aid. Five-year periodic training, it was released. Most of us should have already been doing it at this point in time. Examiners had until December of 2022 to complete that periodic five-year training. FMCSA is looking carefully at those who have not completed it who are now overdue. If you're overdue and you haven't gotten information on how to complete it, please check with FMCSA. Go on your NRCME webpage, your site, make sure they have a proper and correct email for you. A lot of the problems are that MEs who are on the NRCME did not have current contact information. If there's no current contact information, they can't find you. So you need to have that completed by now. Ten years has really been starting. Examiners have been getting notification of what's out there for that ten-year retraining. You go through an entire retraining, the same requirements that you had before. You then take the test, the exam, through the same two organizations as before. They will then tell you if you pass the test, that's your ten-year recertification. So it's five-year refresher, ten-year periodic. Most examiners who had their expiration dates in 2023 for their certification have until December to complete that ten-year retraining retesting situation. Notifications have been sent out to everyone, and we'll talk about details on what's in those notifications, and then ME should wait 24 hours after uploading their new training requirement. Now, how do you get retrained? It is the same types of organizations that have trained originally. So that means if they can provide CMA, if they can observe the core curriculum, that's you can issue certification. There is no approved FMCSA and RCME training programs. There are no endorsed FMCSA training programs. They have to be able to provide CMA, and they have to be able to follow the core curriculum. Core curriculum has not changed. We have to make sure that a lot of what we look at is guidance, it is not requirements. The Medical Examiner Handbook was published for public comment. There were a lot of comments. Unfortunately, a lot of them didn't say a whole lot. A lot of arguments about sleep apnea, a lot of arguments about making it tougher, a lot of discussions about it's not enough, it's too much, and all those other kinds of good things. In the next section, we'll talk about exactly what was in that ME Handbook draft. What AECOM commented as we need more, we need things missing. Next step is that it has to go through final review. Any substantive comments FMCSA has to comment on, that will then be published again in the Federal Register, and at that point, that will go forward and become the official Medical Examiner Handbook. What many of you may not have realized that in the process of modifying the Medical Examiner Handbook, they also modified the Medical Advisory Criteria. That Appendix A that we always look at, while they never really publicized that that was being changed, that was also being modified to be consistent with what the ME Handbook was saying or not saying. I'll go into some detail of what the changes had been. This is still just FMCSA comment, not a lot of editorialization at this point in time. The Registry Update was launched in February of 2022. If those of you are not getting information from NRCME, make sure your emails are current. If you are not current, if you are not certified, refresher training, you will be pulled off the Registry. And if you're pulled off the Registry, any exams that you do from the time you are no longer valid to the time you get pulled off, don't count and got to start all over again. So those examiners are not going to be happy. The companies are not going to be happy. Make sure you are currently proper information on the NRCME with appropriate contact information. They're going to be doing some enhancement on monitoring. We've talked a lot about what happens when. You disqualify, you give a three-month certification, you do something else, and then suddenly the driver goes to a different examiner and gets a two-year certification. The expectation is with this enhancement, FMCSA will be better able to track those inconsistent certification determinations. Go back to the driver, pull the information, say, did you provide the same information to examiner A and examiner B? And if you did, that may be fine because it could be a difference of opinion. But also at the other time, it's going to be, is the driver withholding information or, B, is the medical examiner not doing the right things? So those enhancements should help. It will also help FMCSA pull those examiners who are not following process, are not following regulations. Remember, guidelines are guidelines. They are shoulds in most cases. They are not absolutes. I've said this about five or six different times. You need to make sure that your information is current. You need to accept the new rules and requirements of security. We don't want to have the National Registry whole database go down again like it did a couple of years ago. FMCSA uses that information. Your business state must be the state where you are licensed, except in a very few situations, the military being the primary one. So if your license is in California, your business address needs to be in California unless there is a reason, and they will probably kick that back to find out why. Reporting requirements reminder, it is still midnight local time, next calendar day. It is not next business day. It is not three or four or five days later. You have to put something in, close of business, following business date. That includes determination pending. If you put a driver in determination pending status, you still need to report that. So FMCSA knows when that non-certification, that determination, that exam is no longer valid, and again, you have to start totally over. So make sure you remember to enter that information. NRCME 2 kind of keeps being extended. The whole idea behind that is once everything is fully implemented, the employer, the drivers will not have to carry a medical examiner certificate. In most cases, if they have a commercial driver's license, they will be in the NRCME system, but the states haven't quite been ready. So once again, that has been extended, and that now goes out to June of 2025. So we still need to continue to issue the medical examiner certificate to all commercial motor vehicle operators who have a CDL. I'm separating that out because remember, you have a whole bunch of drivers that have vehicles between 10,000 and 26,000 pounds. Show of hands. How many of those drivers have to be in the national registry? If they have a non-CDL, but they're operating a CMV, and I'll explain all my acronyms in a second, do they need to be entered in the NRCME? How many say no? I'm giving you a hint, okay? If you remember, you have three different categories. Who needs a drug test? Generally, it starts with those who need a CDL, commercial driver's license. Commercial driver's license, 26,000 pounds or more gross vehicle weight rating, 75 times fast. They need a CDL. They need a drug test. They need a commercial motor vehicle medical examination. Simply operated vehicle, an interstate commerce, let's make this more complicated. Interstate commerce, that's between two states, through two states, driver or pointer that's being transported. Somebody is taking this row of chairs from Pennsylvania to New Jersey, it's interstate commerce. If they go to the Franklin Bridge and they stop and somebody else gets out of their truck and gets into this truck and crosses state lines, they're both still interstate commerce because it's what's being transported that's the key. It's not the individual. Interstate motor vehicles between 10,000 and 26,000 pounds do not need a CDL. They may not need drug testing. They do need a medical examiner certificate. Non-CDL operators do not need to be in the National Registry. However, recommendation is if somebody comes in and you're doing it under federal law, federal guidelines, put the results of that examination in the National Registry. What that will do is if they change jobs, they have a medical examiner certificate. They can take that to another company that may require a CDL. We can take some questions in a bit. We talked about this going up. Recently published research, FMCSA on their website and again I'm giving you lots of resources so look at all the links and you can get the source documents. Did some research on the effects of medical certification and that was on safety links and then there was another one on the seizure standard. So we'll talk about both of them in just a minute. The research and then there was one on high blood pressure and the medical certification of CMV drivers. FMCSA just said, yeah, these are a couple of research projects we have done. When I start my session, I'll give you some more details on those research projects. And then on fatigue, National Registry, future research, looking more into the length of certification and how that affects safety and then a project on the skill performance evaluation certificate. Your contact information for FMCSA, they are not always the easiest person to reach. A lot of information is on the website, the medical programs website. There's a lot now on the National Registry website. A lot of the information that was behind the firewall, only available to examiners is now kind of in front of that firewall. So the information on training, the information on frequently asked questions, the information on how to complete the forms, the information on what's the guidance on reflective sleep apnea, you can find all that now on the website. It's been much cleaned up a lot but not perfect. So that, I had a question I heard, I thought, maybe just me echoing. All right, so we're going to move on. That's what FMCSA wanted to make sure that you were aware of and some of the other basic information. Now we're going to go on to what you want to really know. I also serve as Chief Medical Officer as Norfolk Southern. I am not speaking on behalf of Norfolk Southern. However, I'm here as President and Chief Medical Officer of Acumetics. We talked about what the agenda is going to be. What does everything that I just said really mean to us? How do we implement it? How do we follow it? How do we make certain that we're keeping ourselves and our companies, our clients, in good standing? How do we make certain that drivers are remaining safe to the best of our ability? Research updates. Length of the MEC. This, I think, may be kind of an interesting research project, but does it really mean what we think it means? The longer the MEC, the less likely the driver was going to have a crash or a safety violation. That was correlated to say, okay, if the driver gets a longer certification, they have less medical issues and they have less crash or violation, therefore they're probably safer. It was recognized that that really was more of an observational study and there may be lots of limitations, so we can't necessarily draw conclusions from that single finding. But that's what they found, longer certification, less risk of having violations or crashes. So what they were trying to point out is that, yes, having the certification examination has some value. Maybe, maybe not. Next one, and Dr. Cagney's going to very slowly walk to the microphone. But this was examining the seizure standard for commercial motor vehicle drivers. And this was a really good study, and I'm not just saying it because I'm friendly with Kurt. But there were a lot of recommendations, because right now the seizure exemption still exists. There have been a lot of discussions about potentially making the seizure standard go a similar way to the vision and diabetes standard. To potentially have the medical examiner make more of that determination of should the driver be medically qualified or not. So this study was like bringing up a few, what they found, and then what were the recommendations that came out of it. So Dr. Hegman? Just a couple of things. One is we basically updated the evidence base, and we also had a medical expert panel. We did not deal with the issue of trying to push this issue onto the examiner. Right. Desks, to be very clear. Yeah. Especially because we brought up the issue that we've got variable training and experience medically. And these are complex individuals, of course, where neurology input may be helpful. The provoked seizure issue, you might want to know that the seizure community does not consider that to be things like post stroke or something like that. They literally have narrowed this definition down to reversible causes. And once you narrow it that way, you realize, of course, as long as you avoid the cause or the factor, you won't have recurrence risk as far as we know. So there aren't quality studies on that particular topic. The stroke topic, we did find a number of studies and what is out there shows late, no surprise, late occurrence of seizure after stroke is associated with ongoing risk for years subsequently. So it's really quite a strong marker for subsequent risk. And the data on recurrence of seizures after epilepsy, both treated and untreated, show that we should not become more liberal in terms of the timelines for our certifications because, if anything, the confidence bounds have become extremely tight out six, seven, and eight years in terms of risk and we can see that the risk persists. Sleep epilepsy, we found more studies, the risk of those converting to seizure while awake is 13 to 31 percent depending on the studies. So you can imagine that's quite high and consequently should not be considered something to just wave away for, to use a pun. The panel, the medical expert panel, advised that multiple leptogenic seizures should be something added into the criteria as markers of higher risk and the available data on surgery for seizures shows ongoing risks which are quite high regardless of treatment or non-treatment. They pretty much almost all need treatment. The medical expert panel gave a number of opinions, these are some of them, to try to help clarify this situation including advising we should be specifying amount of time to be avoiding that provoking factor for provoked seizures and clarifying that we need to be off the medication if it's a medication and provoke seizures such as tramadol and it would be helpful for examiners if there was more examples given on what constitutes resumption of low risk for seizure recurrence such as that last bullet there. There are online seizure risk calculators out there, they're not validated yet, but the projection is they will be and they may be informative going forward. The anti-epileptics, as I think most of us do know, have significant potential for cognitive impairment and right away that begets involvement of neurology and some judgment and so forth in terms of potentially certifying individuals as well as issues of drug-drug interactions. These of course get to levels that I think most of us, maybe I'm sure not all of us, but most of us, or at least me, I become uncomfortable with when you get to that level of complexity so indeed that would be I think one of those recommendations where we'd be relying on neurology. And definitions as I've suggested earlier have evolved and continue to evolve. We think of seizures as kind of a constant in our lives but that's not the case. They change the terminology and some of it for good reason. There are also surgical procedures and devices and other things. There are significant advancements coming out of course in terms of seizure management control, not different than most other medical conditions, and these are going to have to undergo some sort of risk assessment if you will. Epidemiological studies, risk of recurrence, and that sort of thing. Almost all of this stuff is untested other than a relatively narrow issue of some seizure surgery issues. Thank you very much. So I think the important thing to think about with seizures is it still requires an exemption. There's still risk. It has been found in previous medical expert panel recommendations, previous medical review board, that we've really got to be careful about even referring a driver for a seizure exemption. So when you think the driver is eligible for the exemption, generally it's at least two years seizure free, stable on medication, at least eight years seizure free otherwise, then maybe you can go ahead and refer them. It's looking at the medical expert panel recommendations and we'll talk about that a bit more at the medical examiner handbook. One of the nice things about the ME draft handbook is it includes many, but unfortunately not all, of the medical expert panels. These are information sources that examiners are expected to look at by FMCSA. FMCSA will say, why doesn't an examiner look at it? Because you don't tell them they're supposed to. So they're getting a little better at telling us what we're supposed to look at and consider, and we'll talk about the wording they use to alert us that it is not a free-for-all. Rulemaking, there's nothing imminent rulemaking on the horizon. At least there wasn't when I put the slide in. There's a new form that was proposed on Thursday. We'll talk about that. It is a non-insulin treated diabetes optional Medicaid form. Looks very much like the insulin treated diabetic form. So right now the, you know, what do you do with the non-insulin treated diabetic? Maybe, and Dr. Berneking will give you the details of the latest guidance, but that new form will go a long way to helping us obtain the information that we would need to decide certify or don't certify. And what's nice about it being a true optional form from FMCSA is it gives us that permission to ask those questions. So when someone goes back and says, how come you're asking me? Because FMCSA said that I can. Much easier to blame it on them. A bit more about the alternative vision standard. You know, we've gone through rulemaking, we've gone through funnel rule, we've had the webinar. I'm primarily including this because hopefully by now all of you know about the alternative vision standard. You should never, ever be marking exemption. And I know there's at least one person in this room who knows how much I scream and yell when I get a exam form that says certified by exemption. So no, don't ever do that again. Please. The important thing is that the driver cannot meet the medical standard. I continue to see the forms, driver has vision of blankety blank, does not want to get new glasses. I don't care. If he cannot meet the vision standard, then and only then is he eligible for the alternative standard. FMCSA believes that the driver would rather go ahead and get the glasses than have to come back and be recertified every year. Well, most of them have high blood pressure, sleep apnea, diabetes, and they're going to get recertified every year anyway. They can't be corrected for LASIK or something else. One eye. They can't have one contact lens for near, one contact lens for far, unless both of them meet the vision standard. Okay. Alternative vision standard. Only if they cannot possibly meet the vision standard. You do not give them anything, including determination pending. They are not qualified. They walk into your office, they're wearing a contact lens, vision in one eye is 2060, vision in the other eye is 2030. They don't have, you know, they're not qualified. End of story. When they come back, then they can be requalified. And I think I want to skip this. I think I've probably danced this one enough. Row test. How many of you are notifying the clients when you have a driver who's certified for the first time under the alternative vision standard? Okay. You're not required to. So it was kind of a trick question. If you were here for the MRO session and Dr. Martin had a trick question, that was a trick question. There is no requirement for the examiner to notify. There is nothing on the examination form because the employer doesn't get the examination form, but they're not required to. There is nothing on the medical examiner's certificate that says, this driver was certified for the first time under. The driver is supposed to tell the employer, this is the first time I was certified under the alternative vision standard. Oh, by the way, I think there's something you're supposed to do. Most employers have no clue about that. What I suggest you may want to consider, and again, this is going to be me doing my dance over here, not required, but you may want to, is at least for now and maybe even going forward, somehow communicate to your employer and communicate to the client. Remind the driver that unless you meet certain criteria, which means you've been operating intrastate, if you've previously had an exemption or a waiver, if you're involved in certain types of activities, you may not need a row test. But that's between the employer and the driver, and the driver's responsible for notifying their employer that this is the first time certified under that alternative standard. And then just my, you know, screaming at everybody. So I will let you read my screaming, and for those online, hopefully you can see that anyway. Okay? Must have that 5871. It is part of the medical examination. Updated medical examiners for a medical examiner certificate. New expiration date 3-21-25. The medication renewal form is in process. It has not yet been renewed. It currently expires the end of this month. It was published in the Federal Register. It went to OMB. They're waiting for official notice. It will be published when it's officially approved, posted to the NRCME website. Also, the forms have been relatively good at having them updated on the medical program's webpage. So you should be able to find that new form when it gets that new expiration date. For now, examiners can use the expired form as of, I don't know, 13 or 14 days from now. I don't think it'll be ready for another month or two at least. And by the way, for those of you that are looking at these slides, the handouts in there, if you can find it like I couldn't, when you go on SwapCard, scroll down past speakers, scroll down past, I forget what else, you scroll down past, but there's a place that says other documents, and there's handouts for these, for all three of these sessions, or two sessions with three speakers. This was a slide I really liked. I really liked it because it talked about the optional non-insulin treated proposed form that was presented by the Medical Review Board several years ago, never really acted on by FMCSA. And I gave you the form and said, well, it's not official and it's not required. It may be something you want to consider. Lo and behold, April 13th happens every single year. Those of you that know me, I always say this, right before AOHC, I know something's going to change. Usually it's major, this is minor. But now they have published the non-insulin treated diabetes mellitus optional information form. It looks very, very much like the same form we use for the alternative diabetes standard. It is a good tool. I urge you to use it. It's still in draft form. They're now seeking comment of is it acceptable, does it have value. ACOM will be submitting a comment that says, yes, it does. Thank you very much. We encourage everybody's use even though it's optional. So we'll write that up somehow a little more flowery when the time comes. The website, again, is on the page. It's in the handout. Please look at it. Nothing saying you can't use it. What's real important in all of the OMB approved forms that are required, you cannot change anything. If it's a OMB approved form but it is optional, you can take a different form. You can't use that form and modify it. But you can certainly take the information from that form if you choose to because you're not required to use that exact form. So if you have other situations where it's not a commercial motor vehicle operator, for example, it's a forklift operator. That answers the good questions. That's not a formal required FMCSA form. I just have up here, you can go through the handouts, what questions are being asked. I don't want to take time on that right now. Periodic training. You know, very complicated chart of when it expires, who expires, when it expires. FMCSA is giving us kind of enough time to catch up. So if you've already gotten a full year notification, then you have a full year to take the test. If you expired already, they're going to give you a little bit longer. So if you expired in January of 2023, you get 12 months. February, you get 11 months and so forth. It goes down until it's, hey, you expired, you had enough notification to get this done. So that is the five-year, that's the 10-year training. The five-year training is also available. What the five-year training is really focusing on is most frequently asked questions. It is not all that difficult. I found it very interesting, and I say very, very interesting, because there were a lot of things in there that I didn't realize, or I interpreted different, or I think they're interpreting different. And we'll go through some of those things that were in the five-year refresher training. There was an entire resource manual. Okay, this is the periodic training, the five-year training. Everything's in here. Urge everybody, pull it off, print it out, rethrow it. It's really kind of interesting because it kind of reinforces what FMCSA has been telling us, in some cases, things that they haven't told us with some minor changes. So we'll go through some of those. Here we go. It's on the website. When you go on the website, you can download it, each and every little module. Also on the website, we have the training, your information on who can train, information on core curriculum, and information on training organizations. That's how you can find out what's going on. FMCSA has said that not only do they allow, but they encourage training programs to share this. So training programs will be sharing all of that periodic information. We're sharing with you right now because we're a training program, and we're communicating what's going on with FMCSA. There's four different modules. They have different scopes, I would say. What's the overview of FMCSA? Two is how do you maintain certification? Number three is frequently asked questions. Four is performing the exams, complying with the requirements. There's a lot of redundancy, but it's all in there. Periodic training overview is the, where am I looking here? We already talked about those. I'm just going to skip this slide because it's a little redundant here. And that's the resource version. The resource version has all four of the modules together in one document. Federal Register announcement, January 11, 2023, reminded everybody about refresher and the fact that the 10-year training is now available. Basically, it is the full test. It's a full training. Training organizations, same exact types of entities that have done it before. It's the same two testing companies. You're eligible to take your 10-year certification about nine years after your initial expires, but must take it by 10. And if you haven't taken your five-year and then your 10-year, you will be potentially removed from the National Registry. I don't want to say this is commercial. I'm just really more rebutting some other things people have been asking me questions. FMCSA does not endorse, FMCSA does not accredit any training programs. I know there are a few out there that have been advertising as being accredited by FMCSA. The only thing FMCSA, and I have permission from FMCSA to use this slide, is that they have to include accredited by a nationally recognized medical professional accrediting organization, provide continuing education, provides training participants with proof of participation, provides FMCSA with the contact information to those training participants, and provides training on the following topics, which basically is the core curriculum. And that is the core curriculum. So get your training. I wanted to go through some of the key points from the five-year training modules, things that I found a little bit on the interesting side. Emphasize that they must use their medical judgment. This is important because this is not going to be a cookbook exam anymore. The medical examiner handbook as proposed does not have a lot of details. You need to keep track, you need to keep up with current medical literature. You need to understand what's out there as far as medications and their side effects and interactions. You need to understand current treatments, current surgeries, current procedures, current testing. As a medical examiner, we are expected to know how to evaluate and treat individuals. That may or may not be true in every situation. Our role is safety. Our role is to determine whether the individual is at risk of sudden or gradual impairment or incapacitation. Over the duration of that medical certificate, there's nothing magic about a three-month certificate, nothing magic about six months, one year, two years. Everything looks good, you give them up to two years. We need to do a lot more thinking. My concern, and yes, now I'm editorializing again, my concern is we get less and less direction. And again, people who have seen me before know I dance from one side to the other when it's my opinion. But as we get more and more examiners who are able to use their opinion, their medical judgment, their medical training, which may vary. We're all occupational medicine health care providers. We have enough interest to be here right now on a Sunday afternoon when it's nice outside because we want to do the right thing. There are many examiners out there who are just like, this is a simple exam. If they look good enough, that's good enough. What I'm hearing happening is they look good enough, their doctor says they're stable, I'm going to certify them. That's going to make it harder for us to support. Why are we saying no? Because you're on three potentially impairing medication. My doctor says I'm safe. Because your hemoglobin A1C is running 10.9 and it was eight only a week or two ago, which is totally ridiculous. I'm sure that wouldn't happen, but even so. So we need to continue to use our best clinical judgment based on current evidence-based medicine, recognizing that with less guidance, we may see more and more discrepancy, more and more variance in how the other medical examiners handle things. Is it going to be a challenge? Absolutely. Do we need to do the right thing? Even more so. We need to do the right thing. We are protecting public safety. So what else? They reminded that the resources and advisory criteria are changing. Not great in many cases. The resource table is a really, really good resource, and that's down there. It has most of, if not all, of the medical expert panel reports. It has the interpretations. It has the frequently asked questions. So look at the resource table and skim through it. I really think you'll find it as an excellent resource. Again, is it a requirement to follow? No. Is it a resource FMCSA says you should be looking at? And I think that's important. FMCSA directs you to look at it. The expectation is, you look at it, you consider it. These are expected to be considered, but are not legally binding. They should not be regulatory in nature, but clearly guidance. A variance. A variance is anything from a skill performance evaluation certificate, to an exemption, to operating within an intercity zone. For a driver to be able to operate under an exemption, they need to have that exemption granted. So when you sign off on your medical examiner's certificate and check off, must be accompanied by seizure exemption. That driver needs to be informed. And maybe if the employer doesn't know enough, you need to tell them as well. But until they have that exemption, that certificate is not valid. They cannot operate under that variance until it's granted. Talk more about inter and intrastate, which I think I covered already, so I'm not going to reiterate it. But again, look at this, read through it. Keep in mind, it is not just the driver. The driver who stops at a state line and doesn't cross the state line may still be in interstate commerce if he's moving things across state lines. It's not the driver. There's a few that are exempted from that intrastate, interstate definition. Read through carefully. If you're not sure, check with your state DMV. The employers may or may not understand it. I had a very large employer one year I was working with, who was insistent. His drivers were all interstate drivers. And he wanted the medical standards from each and every individual state. But they moved product that was created in one state throughout the entire country. They were all interstate drivers. Right now, we have only two standards that are considered absolute disqualifiers, seizures and hearing. Examiners can qualify a driver who does not meet the vision standard or the diabetes standard because of insulin use. It doesn't mean you should. It just means you can. So you've got to use best judgment. You've got to document. I can't say the words more times than I can possibly say. Document it, document it, document it. Because if the driver's on insulin, and suddenly they've been certified for a year, only up to a year's permit it, and then they crash, and they're going to go back and look at you and say, well, why did you qualify them? Because I could. Again, doesn't mean that you should. Medications reminds us that just because it's permitted, there are very, very, very, very few medications that are absolutely prohibited. Medical marijuana. Suboxone is not named as prohibited. Oxycontin is not named as prohibited. Shantix is not named as prohibited. Fentanyl is not named as prohibited. Doesn't mean you should be certifying someone who's taking any or all of those medications. You need to really understand potentially impairing medications. What FMCSA in this handbook says, and again, I look for the permission. It gives examiners permission to disqualify a driver who's taking a potentially impairing medication. And you've really got to understand those situations. Again, permission. Sleep apnea. There is no requirement to test for sleep apnea, obstructive sleep apnea. There is no requirement that they must use their CPAP machine greater than 70% of nights, at least four hours. Doesn't mean that if they use it for 3.5 hours, 69%, you should disqualify them. Use your clinical judgment. But they now give us a tool. They now give us what they think is reasonable guidance for examiners to be using. And that is the 2016 Medical Review Board recommendations. This, I thought, was kind of interesting, how they spelled out amputation versus impairment versus skill performance evaluation certificate. If a driver is missing three fingers, it is not considered amputation. It does not fall under 391.41B1. If they are missing all five fingers or the entire hand, then it's under 391.41B1. And they must have that skill performance evaluation certificate. If they're missing only one finger, it's an impairment. It's up to the examiner to make that decision. Missing a pinky may not be significant. Missing a thumb may be important. Missing a thumb and a forefinger may be important. As an examiner, you have a little bit of discretion in that type of situation. If it interferes with normal driving tasks, then you certainly would go ahead and have them fill out the SPE under the impairment, under the 391.41B2. Otherwise, you have to use some discretion. 30 days, as an examiner, you only have 30 days to change your profile, to update your state of licensure, to update your email. If FMCSA is trying to reach you for whatever reason and they can't, that is grounds for removal from the National Registry. You need to have a correct phone number, correct name. So they can reach you, so you need to even review an exam. If a driver comes in and says, I want an exam, you can perform that. It is not our role to say, do they have enough command of the English language? It is not our role to ask how old they are. That is up to the employer. Driver comes in and says, I want an exam under FMCSA, just do it. Putting it into the National Registry system, if they tell you they operate a CDL, pop it in there. Not going to be our problem when they come back and say, now I needed it. Can I do it all over again? No. I did your exam. I entered it in the National Registry system. It's there. They can find it up that way. You should verify the driver's identification, needless to say. The driver is not domiciled, does not live in the US. There are ways of just putting entering none. There are options in that system for the drivers who are from outside the US, but still may need that exam for various reasons. They may be coming into work, may be getting a commercial driver license permit as part of their whole process. We can still do the exam at that point in time. No parameters, hemoglobin A1c. There is no magic number for hemoglobin A1c of whether the driver should be certified or not. Use clinical judgment. What I always like to say is I look at not just what is their current A1c, but what was their A1c. If they were hemoglobin A1c of 12, and now it's 10.1, I'm feeling pretty good. If it was eight and it's now 9.9, I'm a little concerned. So think about what that test means. What is that actually measuring? What was the interval between prior test and current test? Has this person's blood sugar control gotten really, really bad? Or, gee, has there been a really good improvement? Use common sense, best medical judgment. As far as asking additional information, examiners are encouraged to ask for additional information on the non-insulin treated diabetic. We now have that optional form that will soon be approved, hopefully, that we can use to get that additional information. Again, we're not responsible. Can they speak the language adequately? No. Can they speak English sufficiently for us to do an exam? That's the essential piece. If you can't communicate with the driver to ask the history, review the history, discuss medications, give them directions on how to be examined, then you cannot adequately complete the exam. Can you use an interpreter? Absolutely. Can it be a family member? Yes. Can it be an employer? Yes, if that individual agrees to it. So you can use an interpreter, but it's not our job to say, can they speak English sufficiently to read street signs? That's the employer's responsibility. Same thing with the 21 years of age. If the individual's 18, they may be involved in a pilot program. They may be involved in a program with the VA system where they can be under 21 and operating. They may be involved in a pilot program where they can be operating interstate through some other kind of program. So again, if they ask for an exam, you just do it. Don't disqualify them because they're 19 years of age. Pulmonary function testing, there is no requirement for pulmonary function testing. There is no requirement if the person is over X number of years of age and smokes. It is really up to the examiner. If they're sitting and walking back and forth and pacing and not having any problem, if they get off the table and start wheezing and bending over to catch their breath, you may want that PFT. That is using clinical judgment. How do you assess whether the individual is safe or not? Can't put drivers, you are not prohibited from conducting non-DOT drug and alcohol testing if you feel it's appropriate to do so. However, if you do obtain or order a non-federal drug test, you should wait for those results to come back from the commercial driver. If you're ordering a federal test because it's required, it's a pre-employment setting, you get the drug test and you do the new higher commercial driver medical exam. In that case, you do not have to wait for that drug test because it's not being conducted because of a suspicion that there's a problem. It's just a routine test that becomes a responsibility of the employer to make sure the drug test is negative before they put them on the road. Key points, I'm getting up to number four already. When auditing, they found there was just a lot of situations. There's not enough information to understand that the medical history's been reviewed. So when I talk about document, I don't just mean so if litigation occurs. It also means if the driver comes back and suddenly he is disqualified. Two weeks later, what happened? What was the information that you used and what is the information that the new examiner used? Well, if the new examiner, for some reason, has a whole different story, FMCSA is able to go back and figure out what differed. Was there different information given? So it's really important to document what you're doing and how you come to your decision because there are no cookbook answers. Driver's address must be their current address. So if their driver's license says they're domiciled in Pennsylvania but they're currently living in New Jersey, you put in their Pennsylvania driver's license and you put in their New Jersey address and FMCSA and state driver licensing agencies have to deal with the difference. But you want their current address. So if they need to be reached, they know how to find them. Conduct a search on anybody English we're not worried about. Compare the medication list on the exam form to that optional medication form. That optional medication form, another great tool for us to be using to find out not just what meds are they taking, but theoretically, what are the underlying medical conditions? Those medications should give you a hint of what they're being treated for. Talking about the 391-64, that alternative, I'm sorry, the grandfathering clause for both the vision and diabetes. There were two old pilot waiver programs, really, waiver programs where the drivers were qualified under 391-64. Those are totally going away as of last month. So there should be no driver still being qualified under those older programs. Determination pending. You must enter information into the National Registry system. Important to think about determination pending. There's really two situations. One is the driver has a medical examination, you need more medical information, but you think they're probably safe. Do they have a current valid medical certificate? Yes. That valid medical certificate allows them to continue to drive up to 45 days with that determination pending status. So they're on the road. They don't have a medical certificate at all, then you can probably use that medical determination pending and not worry about them driving. If they should be disqualified, maybe. A lot of this may depend on the employer because sometimes you have an individual who's not driving, doesn't have a current valid medical certificate, and you want to give him a couple of days to get that information back to you without having to start the exam all over again. But in most cases, you probably want to disqualify that driver who does not meet medical standards. So do they meet medical standards? Do you feel they're safe to continue driving while they get you that information? If the answer is that you don't think they're safe, they don't meet medical standards, you should not be using that determination pending. With the exception of if they're going to be trying to qualify under the alternative vision standard and they don't currently have a valid medical certificate. FMCSA said that is one situation where you can use that. ME Draft Handbook. Go here. I'm going to let Dr. Berneking talk about that. And I'm going to finish a couple of more slides, and then we're going to take a break. We're going to come back, we'll finish up the updates, and then Dr. Berneking will talk more about the handbook. So I just got to keep on using this slide. I mean, it's like it's getting old. It's been at least 20 years I've been using the same thing. And every time I keep saying, yes, I think it really will be getting worse. It's getting worse, not better. ME Handbook, remember, not final, not, not final, all guidance. Look at it carefully, think about it. You have AECOM comments and you have the Draft Handbook as well. Okay, Qualification Advisory Criteria. We had comments on the Advisory Criteria. There were a lot of changes that were made on that Advisory Criteria. The Medical Review Board met and made recommendations on changing the Medical Advisory Criteria. That is the shoulds. There's that little Appendix A that says, this is how we, FMCSA, expect examiners to interpret and apply the regulations. They changed a lot of them. They've eliminated the one on vision. They eliminate the one on diabetes when they put that alternative standard in place. But they changed lots of other ones. In this situation, they kind of highlighted the fact that the five fingers is considered the amputation. As far as cardiac, they added, implantable cardiovascular defibrillators are installed to address an ongoing underlying cardiovascular discharge and are likely to cause syncope or collapse when they discharge. What they took out was the fact that the driver should not be certified if they have an implantable defibrillator. They took out the fact that the driver has a normal resting and stress EKG with a cardiac abnormality. So it's not just what they changed in the Handbook, which was real guidance-y guidance, but they also changed that medical advisory criteria. I'm talking about sleep, or respiratory. You know, a whole big paragraph about all these respiratory disorders that may cause, may contribute to respiratory incapacitation. FMCSA, Medical Review Board, recommended adopting the 2016 recommendations on sleep apnea. Instead, pretty much all of the statement on respiratory was taken out. Blood pressure, took out all the numbers. So for blood pressure, medical advisory criteria, there's no longer numbers included in that advisory criteria, but there is a, amazing, table, which is incredibly confusing and inconsistent within itself. We'll talk about that fun piece later. Musculoskeletal talks about transient muscular weakness, coordination, ataxia, took out essentially all of that. From the advisory criteria. Seizures, currently it talks about five years seizure-free, 10 years off medication, so forth and so on. Proposed, when a driver has a medical history of epilepsy, may certify seizure-free for 10 years, but you can look at it a little bit more if you're not really sure. 12, they deleted the statement that says this exception does not apply to methadone. Now it's interesting, the medical review board recommended adding suboxone to the, this does not apply to. So suboxone will be taken out. There'd been a little bit more information was added, which recommends getting more information from the treating provider. And then for alcohol, which had one simple statement, they've now made it a little more complicated, which is not bad. Talks about, you know, you can be testing a non-DOT test. As with any condition, certify a driver for less than 24 months if you think you need to. So I think this is a really good time to take our break. We'll take, we have about a 15-minute break. We will convene promptly at quarter of. We'll finish up the NRCME updates, talk about the handbook, and then hear a little bit about some legal cases. And have time for questions at the end. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

medical examinations

commercial drivers

medical expert panel

sleep apnea

non-insulin treated diabetes form

National Registry

pulmonary function testing

clinical judgment

Qualification Advisory Criteria

alcohol testing