This is the Commercial Driver Medical Examiner update session. We don't have a moderator. Dr. Berniking and I will just introduce ourselves. So I will start. I'm Dr. Natalie Hartenbaum. I am here on behalf of AcuMedics, which is my consulting practice, full disclosure. I am also the Chief Medical Officer of Norfolk Southern Railroad. We're going to be covering a lot of material. Do not be concerned that the handouts are all the material that we're covering. There was a lot of material I wanted to provide, so the handout's rather extensive. Today we're going to actually fit everything into the next two hours with a 15-minute break in between. The first thing we're going to start with is Chris Heidach, who is the Program Director, I think, of the medical programs, would love to be here, but she was unable to come. What she did do was provide her slides to me to present on her behalf. So I'm going to really be very close to what she's put in the slides, reflect her notes. This is not going to be my opinion, this first section of our presentations. Then we'll go through the examiner handbook. How many of you have actually looked through the 2024 medical examiner handbook? How many of you think it's really an improvement over what we had before? How many of you think it's going to really help making consistency throughout all the medical examiners? What I'm going to try to get through this morning is really the highlights, the big changes that I've come across in reviewing that, that I think examiners really need to be aware of. So we'll go through that. And then the second part of the next hour, Dr. Bernikin will be bringing some case presentations going through how do we handle A condition, B condition, C condition, given the various guidance we've had over the years, whether it's what the old handbook told us, whether it's what the medical expert panels recommended, or what information we have in our 2024 ME handbook. So starting from the FMCSA presentation, we're going to talk about maintaining your certification on the national registry. I know a lot of you have had problems recently because all of a sudden you've gotten a notice that said you are not on the registry and you cannot perform exams and you need to take X, Y, Z steps to correct that. It's really important that those of you that are due for training, due for retesting, due to update your medical license in the national registry system, do that. And I'll go a little more detail as we go along. That includes the noncompliance issues, the notice of proposed rulemaking. There is something called an emergency removal, which is if the FMCSA thinks you are really presenting a public safety risk, if they allow you to remain on the registry, you'll be removed immediately. There are some medical forms that have been updated, talking about those. And this is something that Chris added at my request, because I am really, really, really getting tired of seeing medical exams that are submitted state only. Why does it say state only? Because the driver is not 21 years old. You all may have heard me say before, whether or not the driver is 21 years of age, which is a requirement for federal interstate CDLs, is not our responsibility as examiners. Whether the driver can speak English is not our responsibility as a medical examiner. Our responsibility as an examiner is to do the exam if the driver comes in. The state's regulations, medical standards, may mirror 49 CFR 391 41, the federal standards. The companies need the drivers to meet those standards for intrastate drivers, so you examine them under intrastate. English, can you communicate enough to do the exam? If you can, then do it. If you can't, you can't do it. It's simply that easy to think about. The other thing is that, how to maintain certification. First of all, maintain your medical license. Just because you've updated your medical license and you have it in your pocket, the National Registry won't know that. You have to submit that. You've got to update it. A lot of what Christine has sent in is a reminder. Go on the website. You've got to go on at least once a month. If you don't do an exam, you've got to submit it once a month at least. Look at that red line up top. It will tell you things that are due. Look at your task list. It will tell you things that you have to start doing and working on. Don't ignore it. Make sure you have correct information. Make sure that you have a current email address. FMCSA communicates with examiners by email. If you changed employers and you changed your email address, they have no way of reaching you. You will have no way of being notified that you're at risk of being taken off the registry. And then the retraining, updating, you've got to get that retraining done. At four to five years, FMCSA is the only group that can provide that training. It cannot be done by AECOM. It cannot be done by any other group. FMCSA provides it. It's free. There is no CME attached to it. It really focuses on what questions have the FMCSA been getting over the preceding several years. The nine to ten year training program, this is where you can go to the two approved training centers. I'm sorry. Third party training can be anyone, including AECOM. And just a little plug, we'll be redoing the course, totally redoing the course. It'll be available in October, doing a session in Chicago, and then recording it after that. And right now, our current course does still meet the requirements, still does meet the core requirements, core curriculum that FMCSA put out. So the periodic training and testing, every nine to ten years, you have to have that completed. If not, you will be taken off the registry. Noncompliance, they'll remove examiners, as many of you have probably heard of or had experienced. You will be removed from the national registry. You cannot do exams during that time. Any exam that you do is invalid, which means the driver has to be examined again. It means the employer has to pay for it again. Doesn't make anybody happy. If you submit things late, if you don't submit it within close of business, I'm sorry, midnight the following day, calendar day, not business day, calendar day, that is noncompliant. If you don't report no exams submitted during, performed during the month, that is noncompliant. If you don't pass the ten-year, the five-year periodic training, the ten-year periodic training isn't in the system, that's noncompliance. There will be other things that will be looked at as we go, as they go forward in the program, which is looking at are there discrepancies, are there failures, are there inconsistencies between what you submit to FMCSA, driver's license address, things like that, that FMCSA subsequently sends to the state driver licensing agency. If the states kick it back because it doesn't match, they're going to reach back to the examiner to say, correct this. If you don't correct it, that could be reason for being removed from the registry. So you've got to carefully watch what that task, what that problem list might be. How do they determine if you're in compliance or not? How do you determine if you're not in compliance? Just check your national registry. Check and make sure that there's no spending tasks. Make sure there's no notifications. Make sure they have the correct email address. If all of that happens, you should be okay. And then there are two different things, which is notice of proposed removal, where they will send you a notification that you're going to be removed. That's a time to take care of what needs to be done. Once you're removed, you cannot be reinstated for 30 days. You've got to correct everything. You can't say, oh, I've done one, but I have two more to go. No. Everything has to be done. If everything is done, it's not a guarantee that you're going to be reinstated or reinstated right away. It may depend on how egregious the errors were. It may depend on how long it took you to address them. So there's a lot of discrepancy, and there's a lot of people who have been in that position, and they have a very, very small staff. So it's not going to happen overnight when you say, oh, now I know. The 30 days is really meant as a motivation. What FMCSA doesn't want people to say is, oh, it's no big deal. I'll let it lapse, and I'll take care of it the next day, and suddenly I'm reinstated. There is a penalty for becoming noncompliant. As I mentioned earlier, the emergency removal notifications are if FMCSA believes that the examiner presents an imminent risk of public safety risk. As they're reviewing the exams, they will be starting to review the exams. If they find examiners who are consistently qualifying people who have a vision of 20-50 without considering the alternative vision standard, if they find people who consistently are being qualified with an amputation without having the skilled performance evaluation certificate, they will be flagging that, and that may be grounds for that emergency removal. Emergency removal, there is no advance notice. It's reviewed that you're off until you correct everything, and it may be retraining. You have to do everything they advise you to do. If you don't do all of it, you're not going to be reinstated. I think I kind of covered most of this. Public search, the MA is removed, and the National Archives will track the time frame and not allow the request to come back more than 30 days or any less than 30 days. We talked about the training. We talked about the documentation, so we're good there, and then FMCSA reviews everything. If the decision is you're reinstated, they'll notify you by email. Again, they have to have your email, and if the answer is no, we're not reinstating you and you need to do more things, that will be in the email. Okay, there's still some research going on, and there was a recent study looking at the length of medical certification on safety and what they've looked at to find out how long drivers have been qualified and whether or not there's a relationship between crashes and length of certification. There was also a study going on about the seizure standard. There's been a lot of discussion for a number of years over whether or not the seizure standard should be modified, whether or not it should be very much like the alternative vision and alternative diabetes standards, so that research is ongoing, and then also looking at the safety of operators who are deaf or hard of hearing. Right now, they need to meet the hearing standard in one ear. It's not both ears. It's vision is both eyes. Hearing is one ear. You know, limbs, you have to have all four of them working or a prosthesis to be qualified, so they're looking at whether or not there needs to be a different program in seizures, and then for hearing, there is the exemption program, and the question is whether that should be changed as well. Looking at blood pressure and commercial drivers, what's the relationship to qualification, and then the length of certification on safety research, and then driving with limb impairment. So, they're doing lots of different studies, and the links to those, I'm not going to go into the details, are at the bottom of the slide. What I'm hoping to do, and I mentioned the links, is today is give you resources. We can't go through everything, so as long as we've given you at least this is where you look, this is where you can get some more information, we're hoping to accomplish at least something. A couple of new forms, the non-insulin-dependent, non-insulin-treated diabetes mellitus form. It is an optional form. It is just like the optional medication form. It's a really good way to get structured information. You can ask for office visit notes. You may or may not get everything that you need. By using these two forms, it gives you the information that's most likely to be most useful and most necessary to make your qualification determination. Strongly urge you to use it. It looks an awful lot like the insulin-treated diabetes required form for those individuals that are on insulin. So, again, not required, but strongly would urge you to use that. The FMCSA, the 58, 75, and 76 have been updated. You should be using updated forms to the best of your ability. You can use the exhaust supply that you've had if you've had it printed out, but if you're printing out on a regular basis, please just use these. It's removed the grandfather drivers, grandfather drivers 391-64. Those drivers would have been in the insulin or vision waiver program. It no longer exists. Those who have been in the vision exemption program, it no longer exists. So, you should never be qualifying somebody under 391-64 anymore. They're gone. And then the current versions of the form are placed on the website. They are now good through 25. So, please check the website frequently to make sure you do have the most recent form. Restrictions. This is one of the problems that we'll talk about a little bit when we look at the new handbook. If a driver is missing a limb, they are required to have a skill performance evaluation certificate. If they have limb impairment, they're not required to have the SPE, but they may have the SPE. So, if they are missing an arm, they're missing a leg, they're missing five fingers, that's the entire hand in their mind, they need the SPE. That's a common error that they're finding. They're also responsible for making certain that when it's a hearing exemption, for example, if they have a hearing exemption needed, they don't require hearing aids. It's one or the other. Don't check off both. And then they have to have the SPE before they can start driving. We don't issue the SPE. We don't fill out the forms in most cases. Occupational medicine physicians are examiners. But they have to have that, and it's important that their employers know. It's important that drivers know that until that SPE is granted, that certificate, medical certificate, is not valid. You know, again, this waiver exemption that's gone, that 391-64, accompanied by vision waiver, diabetes waiver, doesn't exist. Exemption doesn't exist. And then there's webinars on both the new vision and diabetes standards. And that's the link for those. Drivers under 21. I think I've already given my story on that. It's up to the employer to take that responsibility of can this driver do what they're doing. There is a pilot program now for drivers who have been in the military who have been operating certain types of vehicles that can drive if they're under 21. There is right now a request for some schools allow someone to get a commercial license permit, a CLP, at age 17. So with a CLP, that's going to start at age 18 in some cases. You want to make sure that we are doing the evaluation under the federal law. Most states have adopted the federal medical standards. If the driver meets it, that's fine. If the driver does not meet the federal medical standards, that's where you might want to consider having it under state only, intrastate only. If that happens, you have to know, you as the examiner must know what are the medical standards for that state for intrastate drivers. In some states, it's very specific. You know, California wants you to disqualify. And then the driver will go to California's DMV and they will individually be assessed as to whether or not they're relevant, they're appropriate for the intrastate limitation. So you have to know what each state permits as that intrastate medical restriction. It's not as easy as, oh, they don't meet federal, let them go intrastate. English proficiency said pretty much the same thing already, which is if they can't speak English, enough for you to do the exam. Even if it means using a translator, that's okay. It's up to the employer to determine whether or not they can communicate adequately in the English language to work with state troopers, to work with employers, to work with shippers and other stakeholders, other people they'll be interacting with. That's not our job. Our job is only, can we communicate sufficiently in order to be able to do the examination? Contact information, the medical programs website, the national registry website, hopefully you have both of those linked and stored in favorites and everything else you can get to it quickly. And some phone numbers. Do they answer the phone all the time? No. It is really busy. It's a very, very, very small staff. And there's a whole lot of examiners who have lots of questions. Sending the email, it will get there faster. It still will take some time to get a response. Don't expect a response overnight. I'm not going to answer a lot of questions on Chris's material. If you do have any, email them to me and I can submit them and try to get those questions answered for you. So now we're going to move forward a little bit on the medical examiner handbook. The fun stuff. Again, I've already given my disclosure. And the handout. Handout, a lot of material. I couldn't see talking about the medical advisory criteria and in the handout giving you only one, three and five. So in the handout, all of the new, and there's a lot of new medical advisory criteria. It was kind of snuck into the new handbook. People didn't realize that that was part of the handbook rulemaking. So it's changed a lot. I'm not going through every single issue, every single form that I want you to be aware of because we don't have enough time. So there's a lot more information in the handout than we're going to talk about this morning. I'm going to highlight what I think are the key issues that examiners need to be aware of and where there's the most confusion. I did include some other information, which is references that should have been included in the handbook that were not. For example, there are certain guidance information that is in the periodic training, but it's not in the medical examiner handbook. So I think that's fair game to be considered. One of the main things examiners need to think about is what information, what resources should I look at? Not that I'm required to look at them. Not that I'm required to follow them. But what resources should I look at, should I consider in making my medical decision, which is a risk assessment. The assessment for this is, do they meet the physical qualification? It's not a fitness for duty exam anymore. And think about the physical standards are, they don't have a medical condition likely to interfere with safe operation of a commercial motor vehicle. That's what our job is. What tools do you use? I say use every tool you have. I will include the ones that the FMCSA kind of has supported and a couple that they haven't exactly. And I'll figure out, I'll point out how you can get around some of that. And legitimately say this is not FMCSA official guidance, but this is information that FMCSA indicated I may consider in my decision making process. The few bits of guidance from the medical examiner handbook I will point out are the ones where FMCSA either specifically says these individuals should not be qualified, not very many of those, or more likely than not should not, unlikely to meet the medical standard. Now, again, that doesn't mean they can't be qualified. It doesn't mean you shouldn't do an individualized assessment. It doesn't mean that you shouldn't get all the information and say, yep, you're right, they're schizophrenic, but they've been really stable for 20 years. They've been on the same meds for 20 years. Maybe that individual, you do want to qualify. You've got to do that individualized assessment. So medical examiner handbook. Now, I have a lot of snapshots of the handbook because it's not my words, it's theirs. This handbook has about the information on the regulatory requirements, and it's a 2024 edition. This replaces all prior editions. So saying I'm looking at the 2014 handbook to make my decisions is probably not the right thing to say. It doesn't mean you can't use it and look at it as a reference and say, okay, is information here still reasonably applicable? But you cannot rely on that in your decision-making process. Overall impression, the original handbook had 260 pages, this has 114. So obviously there's a whole lot less material. It is very, very different than the 2018, 2019, 2020, 2021 drafts. So looking at those old drafts, get rid of them, forget they were there. Some of them went way overboard in very specific guidance. This is what you should be doing. Others were not exactly consistent with different parts of the handbook. So get rid of all the old ones. There's a lot of education on what is cardiac disease, what are the different kinds of cardiac disease, what is the symptoms of ABCD, what does this medication treat. I'm hoping it's things that everybody in this room knew from their medical training. It has very little on waiting periods, almost none. There's very little, if none, on duration of certification, except when it's absolutely required, like if there's an exemption, like if there is a skill performance evaluation certificate. Then it goes into duration of certification. Otherwise it's up to the examiners, 30 days, 60 days, 90 days, use your judgment. When is more frequent follow-up required? When is it applicable? It describes something which I thought was really always lacking, which was the drivers need to be able to meet both driving and non-driving tasks. The non-driving tasks you could find in the skill performance evaluation application. You could find it on the optional medication questionnaire. You can now find it in the medical examiner handbook in two places, not just one. So the driver has to be able to do both driving and non-driving tasks and the examiner cannot put restrictions on the driver aside from requiring exemption, seizure hearing, requiring corrective lenses, or requiring a hearing aid. It includes the revised advisory criteria. I urge you, read through the new advisory criteria. A lot of them are very, very different. I'll try to highlight as much as I can this morning of where those differ. The handbook is organized by order of exam components. Thank you, Mike. Overall impression, a lot of consideration for a medical examiner when making a physical qualification determination shall include but may not be limited to the following. So a lot of things to tell you to think about, but it doesn't tell you what to do with that information. You need to use your medical training, your medical judgment. And then ME should evaluate on a case-by-case basis to determine whether the individual meets the fill-in-the-blank physical qualification standards. That's a lot of what the new handbook says. So you really need to understand that and you need to be comfortable making that risk assessment. If you're not comfortable making that risk assessment, you probably shouldn't be doing those examinations. If you don't understand, and I've said this, whether it's an MD, DO, nurse practitioner, PA, or chiropractor, if you don't understand the diagnosis, prognosis, treatment, interactions of these conditions, you probably shouldn't be doing this. You've got to do a risk assessment. You've got to use your medical training and medical knowledge to make that. The handbook also has a lot of read-between-the-lines, where it talks about, this is abnormal. Okay, does that mean I shouldn't qualify? Probably. But you've got to still go back and do that individualized assessment. Other common questions, has the treatment been shown to be adequate, safe, and stable? That was not in prior drafts. I think it's an important question. Is the driver's medical condition stable and controlled? Is it likely to have caused them to be sudden or gradual impairment or incapacitation? Those are your basic questions whenever you're doing your assessment. Whether they've been evaluated by a specialist, whatever it is. Is their family doctor still treating them with insulin, even though their A1C is running in the 12s? It's the best they can be. Well, maybe you need to have a specialist look at this individual. That's one of the key questions. Has the etiology been confirmed? Well, if they passed out twice, do you know why they had a syncopal episode? Is it been corrected? Or is it still syncope of unknown origin? Well, guess what? That's a concern. What other evaluations do they need? Are they still symptomatic? Well, if they're still symptomatic, and that symptomatic will interfere with operating the commercial motor vehicle safely, maybe they shouldn't be certified. These are all really important questions, but we've got to use our judgment, our medical knowledge to look at the answers and say, this is good enough, or nope, this isn't good enough. I don't want this person driving next to my family, and I don't think I have the ELISA and SARA test in this slide set, but that's how you might want to think about it. And does the individual demonstrate compliancy with ongoing treatment? If you have a person who's been hospitalized multiple times because they stopped taking their insulin, because they go off their psych meds, is that person stable and controlled? I would say probably not, but again, that's your assessment. My answer isn't the same as everybody else's. You have to do that assessment, and you have to document it, because my fear is that we're going to see more and more lawsuits against examiners when there's a crash. We're going to see examiners pulled into EEOC complaints. It's the companies that have the deep pockets, but I really think we have to be prepared, and there have been some lawsuits, not a lot of them, but there have been a number against examiners or against clinic networks. So again, this replaces all prior drafts, all prior versions. This is the new medical examiner handbook. This is the one you have to refer to. They tell us that they provide guidance to the medical examiners, advisory criteria, the bulletins, interpretations of guidance, guidelines, and the medical examiner handbook itself. This is what they offer as our guidance. The guidance does not have force of law. It is not binding on the medical examiner. The medical examiner does not have to follow what's in the medical examiner handbook, but should certainly consider it. They can choose whether or not, and they talk about additional guidance is available to the medical examiner in the guidance portal. This is the guidance portal. It includes the interpretations, the regulatory guidance, the frequently asked questions. It does not include the medical expert panel reports. It does not include the medical review board reports and recommendations. Some of the old handbooks included some of them. Some of them included none of them. Right now, this specific part in the handbook does not mention it. However, what they do talk about is any expert panel mentioned the medical examiner handbook. It's not our problem. We have no liability. This was a group of experts that we pulled together. It was their opinion, and they were responsible for the accuracy. So, FMCSA does not endorse any of the expert panel reports. However, is it reasonable for a medical examiner to consider it? Yes. Should a medical examiner know where they're at? Yes. Should a medical examiner at least be aware of what the content is? Absolutely. But you're not doing it because FMCSA says you have to. We're looking at what a panel of experts have done an evidence-based review and come up with conclusions. Same thing when we're looking at medical review board recommendations. These are a panel of experts that FMCSA has put together to advise them. Doesn't mean it has to be followed, but it's something that should be considered. Now, what's interesting is this whole discussion on MEPs and MRB reports is the only one that's even mentioned in the medical examiner handbook is the 2016 obstructive sleep apnea recommendation from medical review board. That's the only one. Now, this is what I was talking about, the medical regulations and guidance resource links is a resource list that FMCSA put out about two years ago. It's really pretty good. It includes MRB discussions. It includes medical expert panel recommendations and reports. It includes a lot more of these questions. It's not in the handbook, but it's in the periodic training. I'm going to consider this as something FMCSA said that a medical examiner may consider. Anything that's in this link, you may consider because it was in our five-year training. Privacy, this is always a big question of, well, the company paid for the exam. I can't give it to the driver. Yeah, you can. The ME should provide that information. If the driver says, I want a copy of my exam, you give it to them. You can't say the employer has to make a decision. That's up to the individual. I want my medical record, you give it to them. There were certain situations where you can release medical record to someone else with a consent. It does not include the employer. As an employer, I shouldn't be getting the long form without a consent signed by the driver for the examiner to release that to me and or any third parties that I'm working with. You do have to release it if FMCSA comes along and says, we want a copy of your exam. You do have to release it if the National Transportation Safety Board comes along and says we want a copy of that medical examination. In most other cases, you need a release to provide that long form and any other supporting materials which are part of the record. Use of the optional medication, use of the optional diabetes mellitus form are part of this permanent record on that exam. Any other information, the required insulin-treated diabetes form, part of the permanent record. That's all part of it and needs to be provided if requested. Exemptions, medical examiners do not grant exemptions, bottom line. You can require an exemption to be obtained in order for the examination to be valid, but you yourself cannot issue that exemption. Maximum certification, two years, we know that. What we don't often forget is that for hearing loss, if they're getting an exemption for hearing, it can still be 24 months. For everything else that's exemption, the other variances, it's one year. Hearing's a little different there. You can certify for less than 24 months if more frequent monitoring is required. That's a decision by the examiner. There is nothing that says a driver who has non-insulin-treated diabetes needs to be certified one year. However, again, this is me, and I'm going to dance over here maybe, saying if this driver's been in and out of the hospital refusing to go on insulin, and his doctor's kind of, okay, maybe we'll let you slide, and he's having nephropathy, he's having peripheral neuropathy, he's having retinal changes, then maybe that person needs to be followed more closely. It's not that you're required to give a one-year certification, but if the doctor's seeing him, if his treating provider's seeing him once every three months, don't you think you might want to double-check and make sure he's still stable and controlled at least every year? That's the examiner decision. I'm going back and over and over again. You've got to use your medical judgment. What's the appropriate duration that this person is likely to remain stable and controlled without checking in? If they've been compliant for 20 years, great. They bring a note in, and they say, I haven't been seen in my office for the past 12 months. I'm going to be a lot more concerned about that driver. Again, you've got to use common sense. Talked about driving and non-driving tasks, not limited to a single employer. So when you sign that medical certificate, they can work for Mom and Pop's trucking company, they can work for Schneider National. You can't look at it, oh, they only work day shift, oh, they only lift five-pound packages, oh, they only do this. That medical certificate allows them to work for any trucking company that will accept, or any bus company that will accept that medical certificate. And aside from the restrictions listed on the certificate, you can't put any on there. Why are we doing the exam purposes? Physical qualification. Do they make the medical standards? It's not physical fitness. It's not preventive health. Do they meet the medical standards, ability to operate the commercial motor vehicle safely? Driving and non-driving tasks. We talked about the driving and non-driving tasks. There's a lot of them. So when you go through and you think about, oh, this person can't bend, how do they inspect the vehicle? How do they load it properly if they have a shoulder problem? We now have that information in the handbook, and that was really one of the big problems some employers ran into, is examiners were appropriately disqualifying somebody who couldn't lift or couldn't reach. And EEOC said, why not? And it was hard kind of pulling out the reason why not, because it wasn't in the handbook in the past. Now it's very clear. What about guidance? Is it advisory? Is it not mandatory? May choose to utilize? FMCSAs use a lot of words, and they all mean about the same things. Recommend, consider, may, should, could. They're really more permissive. They're not directive. For all the most recent regulations, that's the link for it. It does change periodically. If you don't subscribe to the Occupational and Med listserv, please do, because when regulations are changed, things come out. When new forms come out, we'll post it on there. When new regulations potentially come out, please watch for that, because we need to submit comments. It's important that the medical examiner submit comments when things are changing significantly. And we've had a bad habit of not doing that. 13 standards, they do not address every condition. There's really nothing that directly, in the regulation, that addresses renal disease. There's nothing in the regulations that address non-insulin treated diabetes. We used to have a statement that said the person can't be using, cannot require insulin for control. So that really did, in a way, cover that non-insulin treated diabetic. It's not in the regulation anymore. So they tell you where you can address diabetes. And there's lots of places to evaluate diabetes problems. So medical standards, I'm not going to read through all of them. Don't have time to. If they haven't changed with the regulations, haven't changed at all. So we're not going to talk about the regulations. They're just here as the introduction to the medical advisory criteria, which for vision, there weren't any. That was totally removed. What they do indicate in the handbook, which is really important, that the examiner is not required to do the road test. There's nothing requiring the examiner to do anything about telling the driver who needs to tell the employer that they may need a road test. My recommendation, my thought, my plea, is if you have a driver who is newly on, qualified under the alternative vision standard, that they've never had a waiver, never had an exemption, they've probably never had a road test, just let the company know. Because what I'm seeing right now is a lot of companies that don't realize that a person is being certified under the alternative vision standard for the first time, and have never had that road test. Or when they find out they need it, they get all, well, what do I do? A lot of the training programs will give them a road test. There are other ways to get that done. Some employers do it on their own, if they know it's needed. And it's the driver's responsibility to notify his employer. Do we know it's going to happen? Probably not. If the driver does not meet the vision standard, and they walk in your office and they do not have the completed 5871 form, they should not be qualified. They should not be placed in determination pending. They should be disqualified. And remember, you've got to submit that disqualification determination by the following day, calendar day. If they come in with the 5871, but you want more information, in those situations you can put them in determination pending while you're waiting for that information. The exemption program, the grandfathering, they're gone. The only other option is that alternative vision standard. They do note that the use of biopic or telescopic lenses are not permitted. What is not in this handbook is what had been in a prior one, that the use of the chromatic lenses for color vision are not permitted. So a little bit of a plug if you're doing exams on people in the railroad industry, engineers or conductors, chromatic lenses are not permitted by the FRA on initial testing. Another little thing. It's not in the medical examiner handbook for highway. So it doesn't mean it's okay. Examiners have to make that individual assessment. On hearing regulation unchanged, the advisory criteria. They talk about some testing may be done under the ISO, International for Standardization hearing test criteria. It tells you if it's done under ISO, you have to convert it to ANSI because that's what the regulation talks about. I haven't run into a lot of clinics that are using the ISO criteria, but just in case, it's there. Notice I went from one to three. Two is in your handout. Reminds everyone if the drivers do not meet the hearing requirement by using a hearing aid, they may be eligible for a hearing exemption. If you send them for a hearing exemption, check off, requires hearing exemption or write in hearing. Do not check off, requires hearing aid. The whole point is they don't meet it with the hearing aid, even if they use one. It doesn't matter. Those two things need to be mutually exclusive. And then, you know, information on the exemption. That's the link for that. That's part of the advisory criteria. Lot more on the exemptions, lot more on, you know, other things in the later portions of the handbook. Blood pressure. Has no current clinical diagnosis of blood pressure likely to interfere with the ability to operate a commercial motor vehicle safely. There's never been numbers in the medical standards, okay? Many of us have seen the 2021 version, which had some very, very different blood pressure guidelines. We all knew the older medical advisory criteria that had very specific recommendations on managing blood pressure. Now, my question is, does the next slide sound familiar? Now, what's familiar should be Federal Motor Carrier Safety Administration's Cardiovascular Advisory Panel Guidelines, 2002, adopted the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure from 1997. These are the blood pressure guidelines that we have been using for the past lot of years, okay? And it goes into 140, 159, 90 to 99, one year. Those of you who have been doing these exams for at least a year and a half should be pretty familiar with those. Those were the old blood pressure guidelines. We're back to what they used to be all over again. But they're guidelines. It does not mean if the blood pressure is 160 over 92, you have to disqualify them because the prior time they were 164 over 95 or 96. These are guidelines. Does it mean you should qualify somebody whose blood pressure is 200 over 120? You've got to use your medical judgment. And as we go through, it's very much the same type of guidance that we've had before from 2002. And then, of course, annual certification is recommended if the examiner does not know the severity of the hypertension prior to treatment. Recommend, look at the side effects, that makes common sense. And medical certification for secondary hypertension based on the above stages. So we have guidance that looks like old guidance, which is inconsistent with current treatment criteria in some cases. We are a public safety exam. It is not a preventive medicine exam necessarily. So we shouldn't be disqualifying someone because they're at risk of having problems 10 years down the road. Are they likely to have a problem operating a commercial vehicle over the duration of that certification? That's your job. The argument is going to be having employers who say, oh, nope, they're just too above. We're going to disqualify them. That's your decision. Blood pressure taken during the exam should be reused, not the notes they bring in from their doctor that say their blood pressure is 180 over, oh, I'm sorry, 120 over 80, and every time you see them, it's 160 over 110. You know, if I'm that scary that I'm going to raise their blood pressure, then they're going to be very nervous also when they're rushing to meet a deadline, when they're operating in snow and ice and other inclement weather conditions. So again, it has to be while the exam is being done. And then this is where we might want to think about end-stage renal disease, because yeah, it may fall under the hypertension crisis, maybe, or the hypertensive standard. Cardiovascular regulation hasn't changed. Implantable defibrillators are installed to address an ongoing underlying cardiovascular condition and are likely to cause syncope or collapse as a result of the underlying cardiovascular condition, as well as when they discharge. It no longer says implantable defibrillators are disqualifying in the advisory criteria. As you go through cardiovascular section, it lists tons and tons in all of the cardiovascular conditions of this is what they are. This may be the symptoms. This is how they may be treated. But then the examiners have to evaluate on a case-by-case basis to determine whether the individual meets the cardiovascular standards. That's our guidance in most cases. But this is one of those read-between-the-lines. ICDs are installed to address the underlying cardiovascular disease. Likely to cause syncope when they discharge. They terminate but do not prevent arrhythmias. Okay, I'm getting an idea that may not be the great idea. Individuals remain at risk of syncope and collapse from the underlying condition and the discharge, and therefore does not satisfy cardiovascular standards. It's not in the advisory criteria, which is a little more codified, it's more required to be followed, but it is in the handbook itself. So to me, this is a read-between-the-line. You don't qualify someone who has an implantable defibrillator or an implantable defibrillator pacemaker. The combination devices go to the same way. Now, but, this is where things have changed. If the defibrillator's been disabled. Now, disabled because it's no longer needed or disabled because the driver says, I don't want it turned on anymore so I can get my job back. That goes back, and believe me, we saw that happening. The examiner has to go and say, has the underlying condition resolved? Is the person still at risk of syncope and collapse? If the answer is yes, it doesn't matter. If the answer is no and they've been stable and controlled with the device turned off for three months, six months, maybe a year, yeah, pretty good. So again, not turn it off today and qualify them tomorrow. Turn it off today and let's make sure they remain stable and don't have any additional arrhythmias. And the underlying condition that was causing it is no longer there. Cardiovascular tests, yep, we have exercise tolerance tests, we have a cardiogram, pretty much says as determined by the treating provider. That's all, folks. What about an MI? I like this little read between the lines. Cardiologists recommend an exercise tolerance test four to six weeks after the MI and then every two years. I don't think so. I don't think so. Doesn't say examiners need to require it. Doesn't mean the examiners need to do anything about it, but you might want to think about it. Bypass, highest risk in the first three months and then they reclude after five years. Do we want to worry about that? Maybe. Do we need to do something in five years? Maybe. You've got to use your clinical judgment. Is that person having underlying conditions? Are they at risk of having an additional MI because they're a diabetic who's poorly controlled? Or was this really an isolated event and they're at lower risk? Heart failure, normal is 55 to 70, slightly below normal, 40 to 54, moderately below normal. At what point am I going to worry about them being at risk of having an arrhythmia? At what point am I going to be worried that they can't do the essential functions of a commercial motor vehicle, operator, both driving and non-driving? That's up to you to figure out, guys. Respiratory, same regulation. It lists obstructive sleep apnea as it have always had before. It emphasizes now talk to the treating provider. Do not accept, please, a note that says may drive your medical professionals. Get the office visit notes. Get the diagnostic studies. Do the evaluation of do you feel this individual's at risk of sudden or gradual impairment or incapacitation over the duration of their certification? What do we do for obstructive sleep apnea? Refer multiple risk factors. The risk factors that are in the handbook are different than the risk factors that the 2016 Medical Review Board recommended. Which ones do you use? Tell you which one you use in a minute. Do you retest for moderate or severe? Well, that's up to the treating provider or if the person's having symptoms again. So there's not necessarily a requirement to retest. Considerations, multiple risk factors. Are symptoms likely to interfere? And if they're diagnosed with severe, moderate, severe sleep apnea, has the treatment been shown to be effective, safe? Same kind of things all over it. This is, I think, another read between the lines. This is the only place they refer specifically to an expert panel or an expert report. With respect to OSA, FMCSAs do not include screening requirements, waiting periods, maximum certification, dot, dot, dot. For additional guidance on screening, diagnosis, and certifying individuals with moderate to severe, not mild, one source the ME could consider is the November 2016 OSA Advisory Criteria, and they include the link, okay? So my feeling is this is in the medical examiner handbook, which means you need to know about it, you need to look at it, and you need to use it as your starting point. Doesn't mean it's your end point. Neuromuscular, no, the same thing as the regulation had been before. I see you're looking at your watch, and I'm doing well. We just did that one. And this is where it's, again, a little different on the Advisory Criteria. Once the person's been diagnosed, they have established history of that disease. Doesn't mean whether it's active or not. If they've been diagnosed with fibromyalgia, steadily not cured, they have fibromyalgia, you evaluate them. If they have rheumatoid arthritis, even if it's in remission, they still have that condition, so you evaluate them under this medical standard. What do you look about the nature and severity, the degree of impairment, whether symptoms are likely to interfere with, and you know the rest of that sentence. Some common sense things. This is the one place where it kind of points out that you can certify them for less than the maximum period if you think that they may be progression of the disease. You can do it anywhere, but that's part of the Advisory Criteria for this one particular standard. Can they do driving and non-driving tests? And yes, those tables are in that section all over again. Not limited to single employer, not limited to vehicle. We've got to keep that in mind when we're doing the musculoskeletal assessments. And you can't restrictions. Medical certification, I think I just said that one. Grip strength. You can value grip strength. There's no specific test required, and no specific test grip measurement that we should be considering. Examiner needs to use common sense. Can they hold on tightly, or if it goes over a big bump, are they likely to let go? Are they missing some of their digits, but not all of them? We'll talk about that in a minute. So there's really a lot of different things to consider on the musculoskeletal, but we don't get a whole lot of information, because they don't really tell us what musculoskeletal tests that we should be using. The hand foot one is loss of hand to foot, arm, leg, or has been granted a Scale Performance Evaluation Certificate or has an impairment of. That's the one and two. Now, what is new in the Advisory Criteria here is they define what is a loss of a hand. Loss of a hand is all five fingers. It doesn't mean that they have five fingers gone and they have the rest of the hand itself. They've lost the hand if there's five fingers missing. If they're missing anything less than five fingers, they may fall under regulation number two, which is impairment of. And I hope most of you would realize that if you're missing your pinky, it probably is not going to significantly interfere, and they may have a little bit of an impairment, but it may not be enough to rise to the need for this SPE. On the other hand, if they're missing a thumb, in most cases, that's going to be a much more significant level of impairment, and they probably will need the SPE. That's something examiners need to evaluate. So again, if they're losing fewer than five, evaluate whether they're impaired. If they're losing five, must have that SPE. Reminding over and over, because I'm still seeing it, the SPEs are only for fixed defects of an extremity. It is not for spine. It is not for anything else. It is fixed defects of an extremity. Very. If loss of limb, must have the SPE, and I think this is a little bit redundant. There's more on the SPE itself in section seven. No established diagnosis of epilepsy. Regulation hasn't changed. Talk about the advisory criteria, basic start, and guess what? This is what we've had before. So we're back to that five years, single seizure at the diagnosis, taking anti-seizure medication. So if they're on the anti-seizure medication, they cannot be qualified except by the exemption. They've had a single unprovoked seizure or loss of consciousness. Medical examiner evaluates whether or not it's likely to recur. Keep on talking about recurrence and progression. It's recommended for at least that six-month waiting period. That's not new. Single unprovoked must be seizure-free and off anti-seizure medication, five years. Not new, but it's in the advisory criteria. Single provoked non-epileptic or loss of consciousness may certify once they've fully recovered if it's caused by an underlying, I recognize, condition that has been addressed. So if we know why they had it, because they have a lesion in their brain, it doesn't mean the problem's resolved. If they had it because they were on medication, if they had a fever, now of course, if they were withdrawing from alcohol, we now can pop them into a different medical standard and potentially evaluate whether they're qualified or not. So do we know why they seized? What's the risk of recurrence? And again, if they've had that history, off seizure medication, seizure-free with an established diagnosis, that's where we're looking at 10 years. Unsure, send them for an exemption. Childhood seizures, look at that history, is it just childhood, not going any further, and then they do point us out to that seizure. I like this one, it's another read between the lines. Cerebellum brainstem not associated with increased risk of seizures. We're not talking about recurrence necessarily, but are we concerned about them having a recurrent brainstem or cerebellar lesion? Cortical and subcortical, not to interrupt critical, subcortical defects are associated with an increased risk of seizures. So does that mean we should be more conservative in qualifying somebody who has a cortical or subcortical? Yeah, probably. And the greatest risk of recurrence is within that first year. Does that mean we should be waiting a year to certify them? Probably. But is it required? Absolutely not. Two more loss of consciousness kind of, sort of categories, it really doesn't fit there perfectly, but narcolepsy and idiopathic hypersomnia. They both fall under the loss of consciousness and they do not satisfy criteria 49 CFR 391 41 B8. So narcolepsy is disqualifying according to the medical examiner handbook. Not by diagnosis, but by what it means of loss of consciousness. Diabetes, I'm going to go start diabetes and we'll finish diabetes after the break. There is a medical advisory criteria, so that's gone. I can't discuss that. Maximal certification is 12 months. There's a form for insulin-treated diabetes. I've mentioned the non-insulin-treated diabetes. There is a webinar on this. And the medical advisory criteria is the entire regulation of 391 46. It's all included in there. Now, the one thing I wanted to point out here is on that proliferative and non-proliferative. It really depends on how you read that sentence. So I have clarified as of earlier this month, if the person has severe non-proliferative, it's disqualifying for insulin-treated. Not for non-insulin-treated, but that's another whole story. We can talk about that because that's up to the examiner. If they have any degree of proliferative diabetic retinopathy, that should be disqualifying. So it's not severe non-proliferative or severe non-proliferative. It's severe non-proliferative or any proliferative diabetic retinopathy should be disqualifying. For dialysis, we can evaluate that under the diabetes standard, because that's often one of the underlying causes, but not always. So we have to try to figure out where else we can fit dialysis in. Considerations, what's the cause? Do they have any symptoms pre-dialysis, post-dialysis, et cetera? Are they compliant with their schedule? Are they having symptoms? The same kind of questions. Has treatment been shown to be effective and safe? Non-insulin diabetes, really pretty minimal section. Can be qualified for up to two years. Evaluate on case-by-case basis. The symptoms may fall under another medical standard. Doesn't really help us a whole lot otherwise than that. Same kind of questions. Are they safe? Are they stable? Do they have symptoms? Have they seen a specialist? What's not in the medical examiner handbook, but certainly something we should be using because it was published, it was sent out to examiners in a bulletin, is the optional non-insulin treated diabetes mellitus form. Strongly urge you to use that form. Mental health, okay, regulation unchanged. Advisory criteria, confusion, drowsiness, weakness may lead to irritation. All these symptoms we wanna worry about. So we gotta find out from the treating provider, are they having any of these symptoms? And then somatic and psychosomatic complaints should be fully evaluated. Another one of those read between the lines. It's highly unlikely that individuals who are highly susceptible, you've gotta go talk to the treating provider to get that, to frequent states of emotional instability that give a few diagnoses would satisfy the physical qualification standards. Doesn't say you can't qualify them. It doesn't mean go ahead and qualify them. It means you probably aren't gonna wanna do it, but make sure you do evaluation on a case-by-case basis. Look at the medications, the medications used to treat these conditions. They may be likely to interfere with their ability to drive a commercial motor vehicle safely. So it's really the same thing that they're saying over and over again, which just makes common sense. Is the medical condition, is the treatment likely to interfere with operating the commercial motor vehicle safely over the duration of the certification? If you think they're probably fine for six months, certify them for six months and then re-evaluate them. If you think they're gonna be stable for two years, nothing preventing you from certifying for two years. These are some of the conditions that may be associated that you may wanna worry about. Ask the treating provider, make sure they're documented, and then make your decision. And again, once again, that's the same thing. It looks like I'm going backwards. Oh, that was the schizophrenia, unlikely. And then dementia. Therefore, an individual with dementia may not have the ability to drive a commercial motor vehicle safely due to cognitive deficits. Doesn't say doesn't, just says may not. So as an examiner, you gotta do that case-by-case assessment. Drugs, does not use any Schedule 1. Talk about marijuana a lot more tomorrow. There's been a lot of changes in the marijuana situation, or will be as of Tuesday. And regulation here, again, is unchanged. The advisory criteria, examiner may, an examiner cannot physically qualify someone who's using a Schedule 1 drug. So if they're using anything Schedule 1, which right now is marijuana, they cannot be certified. If it's anything else, the examiner may request a non-DOT drug test to aid in evaluating that qualification standard. You may use a substance abuse professional, but you don't have to in having them evaluate it. You probably do on someone who's knowledgeable about substance use disorders to evaluate that individual, unless you're good at doing it yourself, to say, are they stable, are they controlled, are they likely to relapse? No current clinical diagnosis of alcoholism. Now this I found really interesting, because initially the advisory criteria was pretty minimal. We have a lot. Current alcoholic illness or instances where the individual's physical condition is not fully stabilized, when in remission, they may be certified, as long as they're stable. You may request a non-DOT alcohol test, not urine, please, to find out whether or not they seem to be impaired. The problem is going to be when they're in their office, they're not on duty or subject to duty, so theoretically they could have gone to lunch, have a cocktail, come to your exam. You would hope they wouldn't do something that stupid, but does that mean they're heavily drinking or not? They may need an evaluation by a substance abuse professional, not under federal drug testing rules. Reminders about CBD, 0.3% by weight of THC does not make it or makes it a non-schedule one substance. It's not grounds for disqualification. The examiner may request a non-DOT drug test, and this is the statement from ODOPSI, which basically says it's a buyer beware market. If the driver buys a CBD and it pops positive for marijuana, nobody really cares at this point. It's a positive drug test, end of story. It's not regulated by FDA. It doesn't really have good control over how much is in there. Maybe adulterated with all different kinds of stuff. Their problem. Right now, DOT tests for marijuana, does not test for CBD. Now, this was an interesting one I found. Talking about schedule two drugs, FMCSA notes the reference to methadone, which never quite fit in. Was it a regulation or was it part of the advisory criteria? It used to be part of the advisory criteria, and somehow over the years, it crept up and was like this exception does not apply to methadone. It's not there anymore. Methadone is no longer considered disqualifying. Most medications are not considered disqualifying. Suboxone is not considered disqualifying. Use of these medications does not automatically disqualify someone from operating. It doesn't mean they should be driving the vehicle. Do you want someone who's taking OxyContin, who's taking morphine constantly, who's taking amitriptyline and Benadryl, and let's throw in some gabapentin to make it even better? Doesn't mean they should be qualified. You've gotta use your knowledge. You've gotta use the understanding of what are the side effects of these medications, and the medical examiner makes that decision. In the handbook, suboxone, naloxone, or combination does not automatically preclude. The examiner makes that determination. DOT-regulated drug and alcohol testing is only applicable to those who hold a CLP or a CDL. So drug testing under DOT is only those who have driver's license. Other than that, it's a non-federal test. And then this may occur at the same time as the medical exam. Otherwise, it should not be done at the same time, the federal testing, unless you get really lucky and they get pulled for a random at the exact same time that they happen to be scheduled for a physical. There's no such thing as a periodic drug test. And I think forms are updated. Make sure you check for your forms. And we're gonna stop right here because I've hit my 60 minutes, and we'll have plenty of time. So I'm not gonna take questions now, but we're gonna take questions after this finishes up, which only is about five or six more slides. Do some questions, do some cases, do some more questions. So we'll take a break. We'll come back in 15 minutes. Thank you.

commercial driver medical exams

Dr. Natalie Hartenbaum

Dr. Bernikin

2024 Medical Examiner Handbook

vision standards

cardiovascular conditions

obstructive sleep apnea

diabetes

mental health

drug and alcohol use