All right, going to get started for this final part of the handbook review, we've gone through most of it. As you continue through the handbook, it talks about how do you complete the form, very detailed instructions. A lot of it is not new. It's what we've been doing all along, hopefully correctly, so I want to point out a couple of things that either I've seen or FMCSA has pointed out have been problems with people doing it correctly. One is the driver health history. When you're going through the health history, don't look and say, oh, you have blank. I'm going to have to disqualify you because they're going to say bye, and it's going to be an incomplete exam. What you want to do is go through the entire history, go through your entire exam, then make your decision. Then you go ahead and submit the results, disqualifying, qualified, qualified for a short period, or even determination pending. You have to complete it once you start it. It really needs to be completed, and you need to go ahead and record it and submit it at 5850. Testing, pulse height, weight, and so forth, it doesn't require BMI, but there's lots of things that suggest you should be evaluating the BMI. All right, medical examiner, determination pending. Let's talk about determination pending. This has been an ongoing problem. What this means is the person meets the medical standards technically, but you want to have a little more information. You think that they're safe to drive for up to 45 days, and that's when you want the information brought in by. It does not mean that they are on insulin and don't have a form, or they don't meet the vision standards and don't have the 5871. You need to know that if they don't meet the standards, you don't use determination pending. Determination pending is good for if they have a current valid medical certificate. It allows them to keep operating during those 45 days on their old certificate. If their old certificate expires in 30 days, that's all they got. They can't keep going until the MEC expires. The MEC should not be signed. It should not be given to the driver. All that is is that's a holding place to prevent you from having to do an entirely new exam. Keep in mind, if you do a new exam, that new exam is what's going to be the exam of record. If you have a driver working for company A, and they come in for you, and they want to have the certification, and you want more information, and you think that they're safe to drive, and you disqualify them, then they lose the other certificate. If you give them a three-month certificate, and their old certificate's six months, they can only drive for three months. So the new exam takes precedent. Now on the other hand, if you put them in and qualify them, so if determination pending, they have the old certificate, you disqualify them, they have to stop working immediately. That old certificate is no longer valid. So you've really got to think about it when you use determination pending, when you use a short certificate in an individual who already has a valid medical certificate. That's the 45 days. That's the only reason you can amend an exam, determination pending. Other than that, it needs to be a new exam. You initial and you make the changes on the initial report form, and you can amend it if it gets past 45 days. Beyond 45 days, they need an entirely new process. That becomes an incomplete exam. FMCSA changes it in their system. They will notify you. You can or cannot change it, and yours doesn't make a difference, but that's the 45-day determination pending. The state form is the same thing as the federal form, except it doesn't have applicable straight variances, or it has no determination pending. If you're self-qualifying under state only, you have to know the medical criteria for that state, as I mentioned earlier. This is not of, oh, they're not 21, or, oh, they have an implantable defibrillator, so I can't qualify them under federal. I can qualify them under state. No. The medical has to meet the federal. They don't meet federal. Check and see if they can meet their state's medical standards. In most cases, use the federal section. There should be very, very, very, very, very few situations where you're going to use state only, because you have to know what those state requirements are, and there are very, very, very, very few that really vary from federal. The medical decision is a responsibility for the examiner or admitment. The medical examiner, I was a dean, I didn't belong there, the medical examiner is responsible for making that determination. If the medical examiner works for a motor carrier, the motor carrier should not influence you on certifying or not. They should not be saying, please only certify for a year. If you feel that driver is going to be qualified for two years, certify them for two years. That's your determination. The motor carrier can require them to have a new certification after a year, but they shouldn't be telling you what to do, and the medical examiner should not be placing any restrictions at the request of the motor carrier. Recording it, this is, I like to include, there have been drivers who are not very happy with the outcome, and so they do begin to threaten. If they do, you can certainly go ahead and notify FMCSA, it's Alex Keenan, and provide all that information listed if you feel threatened by the driver who doesn't like your decision. That's my email address. At this point, we're going to stop the discussion on the handbook, specifically, going to turn it over to Dr. Berniking, who will introduce himself, and I'm going to quickly change this so I can get mics up, and then we're hoping to have about 25 to 30 minutes for questions. Where are we? That's yours. I'm going to turn my mic off, and it's yours. Thank you. So I have no disclosures, sad, but true. I certainly don't probably have the name recognition that Natalie does, so a little bit about me real quick. I work in Michigan, used to work for Concentra for a long time, but now I work for a hospital system as their medical director for their occupational medicine services. I do a lot of bread and butter, including being an aviation medical examiner, and I'm also in the Army National Guard still as a flight surgeon, so with that, I am not speaking on behalf of any government agency. Those are objectives. I'm not going to read them to you. We're going to try to do a little bit of a case-based approach. So this 29-year-old comes in and discloses that history to you, taking a couple of medications. You do your UA. He's got a bunch of sugar in his urine, and you check his finger, and it's 95, so it doesn't look too bad. So again, what's the regulation? I like to make sure everybody's awake. Is it they have no clinical diagnosis of diabetes? There is no regulation. No diagnosis of diabetes requiring insulin, or all drivers have to meet 391.46 now. So if you've been paying attention, let's see. So how many people would certify for two years, based on that information? Nobody. How about a one? Less than a year, disqualify them. There's no really right answer. We'll talk about this. So here's the handbook. And they specifically say that non-insulin-treated diabetes is an example of a condition without a specific standard, and that the regulatory requirements do not apply to non-insulin-treated diabetes. Therefore, you can give them a two-year certificate. Now just because you can do something doesn't necessarily mean you should do something. So the examiner, again, case by case. So what should you be thinking about? So I'm hoping that most of you out there that do these exams are familiar with diabetes and its treatment and its complications. So these are just some things that I would think about, whether the driver's symptomatic, whether they're compliant, whether they're taking their medication. I see a lot of their A1C was 5.6, and that's all the documentation there is. If you look at the ADA, they don't really think that A1C should be used as a determination for fitness or duty. But I see that all the time. I'm actually more worried about the guy with an A1C that's pretty much normal than I am about the guy that's running 7.8. Because I'm worried more about that guy that's 5 or normal that's probably having some lows. And lows kill you quick, highs kill you slow. So again, there is an evidence report, it's pretty dated. So in the real world, this is what happens. This guy got his last driver medical exam three months prior. The ME gave the driver a one year certification, but there was nothing else attached. You can look this up. Nothing. So this gentleman was operating a motor coach, carrying 50 people to a casino, right? Everybody likes going to the casino. And he came into the curve and kept on going. And when he realized he was going the wrong direction, he swerved and over he went. Nine people that were planning to go have fun at the casino didn't make it home that night. Why? Why? Well, let's see. FMCSA did, or I'm sorry, NTSB did some testing afterwards. The driver had a glucose of 373 and his A1C was 12.7. And of course, they're going to conclude that the driver's diabetes was present and contributing. Because he probably had, with sugars like that, probably had some blurry vision, maybe had some cognitive slowing. With that blurry vision, it's kind of hard to stay between the lines, right? They make kind of a telling remark here. Not all certified medical examiners recognized by FMCSA have the knowledge, skills, and experience to adequately do an assessment. Natalie talked about this earlier. If you're not comfortable with the disease process in question, and you don't know how to address that, you shouldn't be doing these exams. Bottom line, okay? I'm a retread family doc, right? I've been doing OCMED for a long time, but I'm boarded in family med. And I find that my family med skills are pretty helpful with this, because I have to stay current on current diabetes treatments, current hypertension guidelines, et cetera, et cetera, because that's what I get tested on. OCMED, not so much. You guys, you know, you have to seek out that information. But FMCSA was very particular about this, right? They clearly recognized the examiner was not comfortable with certifying a driver with diabetes appropriately. So what did we learn from this? Obviously, just because they are not on insulin doesn't mean that it can't interfere with driving. Document, document, document, okay? I see these exams all the time, and I can tell you that for the most part, 95% of the documentation on these is crap. Reviewed, discussed, as above, are probably not good things to put in a medical record. This is a legal document, a medical legal document, with all the implications that comes with that. Could you comfortably go up on the stand, or in front of an investigator, and justify your medical decision making based on reviewed, A1C 8.7, and that's it. That's not for me to answer. I encourage you to use, like Natalie pointed out, the MCSA 5872, it's a great tool. I use all those forms. I also look at the medical record if I can get at it. So for those of you that belong to large, multi-specialty areas where you can see other medical records, you can use them if you get consent, okay? Make sure your consent says, mine specifically says, I am going to look at your entire medical record when you come see me, including for all your other doctors, and I will use that in making my medical decision making. If you don't like that, don't sign the consent. Okay, let's move on here so we have time for questions. A 59-year-old driver with a history of heart disease, had a cabbage, takes pretty normal medications post-cardiac event, and says, I'm fine, doc. So again, this is what you have to do, that's the regulation, I'm not going to read it to you. Can't have active heart disease, that's going to kill him. Again, are you going to certify him for two years? One year? Are you going to disqualify him? Looks like most people want more info. So the handbook is pretty vague about this. What they're emphasizing here, though, is this is a case-by-case basis again. There is no pigeonhole. Not one guy that had a cabbage is like another one, all right? I'm going to ask him about his, how he feels. I'm going to look at how often he's seen his cardiologist. The guy that's coming back to see his heart doctor every year is probably not a big deal, but the guy that's going in, you know, every year or two for, or I'm sorry, every couple months because he's having issues, that's the guy I'm more concerned about. Look at the medication side effects, all right? This is a little, you know, this is from the 2013 guidelines, or I'm sorry, the cardiovascular table. They talk about stress testing, and you can see there's a couple of them here, and they kind of contradict each other. So we've got the 2007, and we've got 2013. The top one talks about stress testing. Bottom one doesn't mention it at all, but what do you do with that? I talk to the cardiologist, because I'm not a cardiologist. I ask him. I also look at the medical record, because the cardiologist is going to probably tell me he's fine, but I look at the medical record. So again, this was a real-world thing, too, as well. The driver didn't tell anybody about the history, so unlike the guy that when I started talking, you know, he didn't tell anybody, so we had to reconstruct it. He had had an MI with a CABG, had last seen his cardiologist in 2018, just didn't go back after that, and at that 2018 CDME, he marked all questions no, and no abnormalities were noted on exam. Got a two-year certification. So how would you like to be that guy, looking at that? So he lost control, crashed through the median barrier there, seven people died, and more horribly, they died in the fire that resulted from that crash, the driver included. So in addition to the injuries suffered in the crash, he had a fairly dramatic physical exam finding from here to here, from his CABG. I would say that's something pretty obvious on physical exam, but the examiner marked that that driver was normal. I would really not want to explain that when the NTSB comes knocking on my door and say, why did you give this guy a two-year card? So let's go back again and point out what the handbook says, because this is important. It specifically points out the need for a full exam, including visualization of the body and in conducting an inguinal hernia check for males. You have to touch the driver, you have to look at him. I can't tell you how many times I get a driver that comes and says, why am I getting undressed? Nobody's ever done that for, it's like, because it's a physical. We're doing it. If you've had me do that before, well, then go back there. You have to look at the guy. I've had this, I've run into this situation. I've seen drivers that have told me they don't have any surgeries, they pull off their shirt and wow. Some of them, they forgot, some were deliberate. So again, if you don't like touching your patient, this is probably not the profession for you. So in the end, the driver's ischemic heart disease was identified as present and contributing. The driver in the slip seat had an interesting tale to tell about that the driver had been complaining for a few days up to the crash that he was having some chest pain here. Maybe a better exam might have identified the fact that the guy had heart disease and hadn't been back to the cardiologist in a while, and maybe he should have gone back. Again, we recommend review of records, trust but verify, right? You've got to believe your driver to a point, but in this case, I would have gotten more records. And again, get consent if you're looking at other records through an EMR or an EHR of other specialties, okay? We'll finish up with this one, and then we'll go to questions. 59-year-old guy, said he was depressed for years, takes those medications, smokes and drinks a case a week. So this is the regulation, basically. We're talking about the mental health issues and the medical stuff. Natalie went through those earlier. I'm not going to repeat those. The medical advisory criteria, though, does go ahead and point out, and again, the medical advisory criteria, they're not regulations, but they are codified. So deviating from those as an examiner, you can do that, but I would be very careful about documenting why you deviated from that, and I'd have something pretty solid evidence-based to back that up. In this case, they specifically talk about side effects and interactions of medication should be considered, okay? Medical certification depends on a comprehensive assessment of overall health and informed medical judgment, okay? About the impact of single or multiple conditions on the whole person. Don't pigeonhole people. I don't qualify anybody that ever smoked marijuana for at least three months. I don't care what the circumstances are. That's not a good answer. Case by case, alright? Your drivers are all individual people, treat them that way, alright? The MTSA 5895, they specifically mention, is a great resource for getting medications. A current list of all things. So a lot of times you'll reach out to a specialist and they'll tell you all about the guy's heart disease, but they won't mention that he's also on Respiradone for his schizophrenia. That 5895 form specifically has a spot for that treating clinician to list all the other stuff too. And I can tell you a real-world case about where that was important as well, but we won't do that right now. Again, some clues for you. The driver doesn't seem with it, doesn't really seem to want to participate. You can look at it. Another thing that's handy is looking at drug testing frequency and results. Why are they coming in to see? Why is this guy coming in every couple months for a drug test? That seems a little off. Sometimes, like my record, I can see they're coming. Oh, he's coming in for follow-ups. Did he disclose that on his medical exam? Somebody that's seen multiple specialists bouncing from job to job, from examiner to examiner, those are some clues. Again, I've kind of hit both of the three points on the right. So again, this guy was no longer happy being on this planet and decided to take action. And he rammed it into the side of the state capitol building. Not sure if that was a political statement or not. Was going about 75 when he hit the building. Long history of mental illness, frequent job changes, incarceration. Guy should have been nowhere near a tractor trailer. But he was. I'm going to skim through this so we have time for questions. Again, this is a medication. We're good? OK. So this is a driver that takes the typical stuff that I see in my practice. He's got trazodone because he can't sleep. But he's taking modafinil because he can't wake up. And he takes hydroxazine as needed. That's a great combination. He's pretty compliant with his CPAP, though. And he's seeing his cardiologist. He's doing fine. This is a pretty typical thing, right? And at first glance, this looks like a guy that's doing the right stuff. He's seeing his heart doctor. He's taking his meds. He's using his CPAP. I see guys like this all the time get certified for a year or more. Again, there's the regulation. I'm not going to read the regulation. Natalie went through this as well. You can request the non-DOT drug test, the non-regulated drug test. I personally do not. There are a lot of pitfalls with that. Non-DOT drug tests are regulated by state and local regulations. Just because we say they're non-regulated, that means they're not regulated by the feds. But the states and the local governments have a lot to say about that. And depending on the state you're in, you could run into some pitfalls. Also, what about the guy that lives in a different state than you're practicing in, but the company is in a third state? There's a lot of pitfalls, legally. Also, with privacy things, you want to make sure that that record is not released to the employer, because it's, you know. If I need to have an assessment done about whether somebody's got a drug or alcohol problem, I'm going to send him to a specialist. If the drug and alcohol specialist, the psychologist, psychiatrist, wants to drug test him, that's on them, just like I don't tell the cardiologist whether or not he needs to do a stress test. Again, the handbook is very vague. But again, I would keep hammering this. Each individual should be evaluated on a case-by-case basis. Do the right thing. Take a history. Talk to them. When you pencil whip these exams, that's what you get, is a crappy result. You need to take a comprehensive approach to medical certification and consider any additional relevant health information or evaluations that may objectively support the medical certification decision. Not the letter from the doc that says, he looks good to me. He can drive. It's probably not, in my humble opinion, the best medical record to be reviewing that would be objectively supporting the certification decision. FMCSA is very clear. I'm the dummy that signs for it, not the specialist. The guy signing his name on that certificate is the guy that owns it. So again, consideration with the ME. Is there information available? Why are they taking these medications? What are the side effects? Pertin negatives being documented. Is it adequate, safe, and stable? Stable. He takes his hydroxyzine PRN. To me, that does not imply stability. I'm doing pretty good, but every now and then I have a really bad day, and I need to take my medicine. I don't know if that's stable. I'm a death on, this is me. I'm not speaking for anybody else but me. I'm death on meds. Look at the, I see these all the time, trazodone. But I only take it at night, doc. OK, you take it at bedtime, but you get up eight hours later, more than half of it's still in your system. You may not feel buzzed, but it's still there. Hydroxyzine, see that all the time. Hydrocodone, marijuana, OK, it's legal in my state. People from Indiana beat a path to my door to buy the stuff, because it's not legal there. 22 hours, longer in a chronic user. So a guy says, I smoked a joint on the weekend. I was off duty. We're going to run into this situation more and more as the law evolves. Benadryl, nine hours. So anyway, meds are dosed to an effect with the goal of a steady state. That's why there's the dosing interval. So taking it at night is not a good answer, in my opinion. It may not be treating the problem, because the dose isn't high enough for that. But it's still in their system and can still affect their performance. The number one drug found in air crashes, diphenhydramine. Fatal air crashes, diphenhydramine. So there's some other resources for you. This will be in your slides and handout. So what does this mean? Legal doesn't mean safe. Again, just because you can do something doesn't mean you should. PRN use, is that stable? I have to have a serious consideration for me. I have to think about that, and I have to really look at some records. Oh, checking the state drug databanks is probably not legal, by the way. I run into this a lot. Examiners say, well, I looked at the databank, and he, mm-mm. In my state, I know that is illegal, even with a consent. There has to be an intent to treat, and they have to be your patient. There's a doctor-patient relationship. Doing a physical qualification exam in my state is not sufficient to establish a doctor-patient relationship, because I have no intent to diagnose and treat a medical condition. And even if he is my patient, unless I'm going to treat him, I should not be searching with a medication requiring me to search that. I should not be doing that. If you are doing that in your state, I hope you know the laws that you're dealing with, because that is a big no-no. You can get that information other ways. I just get the medical record from the doc. There's a record in there of how many times the drug was prescribed, how often they were filling it, how many were prescribed, how many refills they got. It's there. You just got to do a little bit. Another really good resource is this FAA do not fly list. FAA recommends five times a dosing interval pass, or five times the half-life. So if you take that trazodone that he takes only at bedtime, doc, because I can't sleep, that's, what, 50 hours before you should drive again? Oh, and then the last point I'm going to make, drivers now think marijuana is legal. They'll check no to that question. Ask. So in this case, this was a real guy. And the modafinil was hanging me up, because I thought, well, he's got narcolepsy. And I actually had to work quite a bit with the sleep specialist. And he ended up discontinuing that. We got him an MSLT. And he had no evidence of, or I'm sorry, he didn't need an MSLT. He had a maintenance of wakefulness test to demonstrate that he could function without that modafinil. And then after the test was done, he actually went back to take it a couple of days. And he said he hated it. It made him feel he didn't realize it. And he's stopped it since. So this was a success story. The trazodone and hydroxazone were discontinued. And after an appropriate period of time, he did go back to commercial driving. This guy did everything right. And when I took the time to sit down and explain to him why I was doing this, he was very accepting of this. And he said nobody had ever told him this before. So my lesson learned that I pass along to my clinicians is take some time and talk to your drivers. When you explain the why to them, and you take a little time and tell them that you're concerned about their protection just as much as you are about the general public, most of the time, they will accept that. Not always. I get my fair share of angry guys, too. But if you rush through it, and you act like you don't care, that's when you get the drivers you're going to have to call safety about. All right. So the handbook is, again, the same conclusions Natalie's told you. It's provide some general information, but it's not going to dictate the specific course of action to you. The meta handbook reinforces that you have to have case-by-case consideration of each driver as an individual. And they will use this word, using current knowledge and standards of care. Again, if you don't like this new reality, maybe it's time not to do these anymore. I know that sounds harsh, but that's what it is. So I am done. Thank you for your time. I could go on with these cases forever. We've got tons of them. But I want to make sure we all have time to answer questions. If you have questions, can you make me live again? Two microphones in the middle aisle. If you, I'm going to stand so we don't cause buzzing. I'll go on this side of the room. Am I on here? OK. The microphone's live. Can you hear me? Yep. I'm Mark Bodo from Seattle. I am not a DOT ME examiner, but I do independent medical evaluations for the state of Washington. And I've come across a very vexing problem. This was with a bus driver I saw several months ago. And in the city of Seattle, there is some strange politics. So anyway, his complaint was that passengers would come onto the bus sometime in downtown Seattle where he drives his bus and smoking fentanyl and other narcotics and even blowing it in his face. And he was complaining that it increased his pre-existing migraine headaches, which I said, sure, that makes sense. Well, the problem is I tried to elevate this to various places. First, not knowing it too much, I tried to go to the FMCSA, but this is not interstate, so it's under the Federal Transportation. And I left them some messages, emails, and so forth. No response whatsoever. And this occurs very frequently. It's twice a week, and he's got to shut down the bus and then get a new bus and have that cleaned out. This is a safety issue not only for the bus driver, but for other passengers. And no one wants to do anything about it. Someone mentioned, get a hold of the county executive, which I did that as well. Zero response. Where do I go from here? If you really feel passionate about it, contacting the Federal Transit Administration and talking to them, they don't really have medical standards. But it's really the employer. I mean, there's not a whole lot you can do about it. Maybe the driver should go complain to the station. Nothing's happening. And it's the politics of Seattle. The police don't do anything, because that's the way the city was working. As sad as it is, I might tell that guy maybe he needs to rethink his choice of profession. Well, no. I mean, he's near retirement. He's been a bus operator for 25 years. He's near retirement. He doesn't want to quit. He'll lose his pension. That's not an option for him. But his option is that he has to stop working and take off. And he has a disability, if that's what you're evaluating him for. And the employer has to recognize he can't be working if he has to keep stopping the bus all the time. I'm surprised they're putting up with it. But there's really not. I mean, we've got to keep stay within our lane. Your lane is, is he disabled when this happens? Yes, he is. Is this the right job for him? Maybe, maybe not. Is this the right thing to be done? Probably not. But you don't really have the, I mean, employer, county, transit agency, FTA, if you really want to. Anyway, his migraine headaches, I don't, I'm not, you know, like I said, I'm not an examiner. But his migraine headaches didn't appear to be disabling. And it wasn't my job to take him off the job. But I'm just trying to see if I can get some headway to get some help to get this to be addressed. It's really up to, it's up to him. Yeah. It's really up to him. If he wants to. It's not up to him. It's up to the society in that area. I mean, there's totally no response. It's a safety issue. There's a lot, I mean, there's a lot of things we were, wish were different. But there's only so many things that we, you know, you can go up to the Federal Transit Administration. They, you know, are a granting agency. They're running a safety agency in Department of Transportation. But, you know, the only thing is just maybe contacting them. I think the only thing I could do is maybe get more involved with the politics and speak to some politicians. That's probably. Got to change the system. It's not safe for the public or for the operators. Well, good luck. Yeah, exactly. Sorry you're having to go through that, but good luck. Question behind? Actually, the gentleman in the blue shirt was actually next because he sat down. I saw him. Thank you for the presentations. In the ACOM blog, someone brought up about a cannabis attestation statement. Do you see that having a place within the DOT? I mean, case by case situation each time. When you say cannabis attestation, what do you mean by that? They, I can't remember what it says exactly, but it basically says while they have a medical examiner certificate, they will not use cannabis products. Basically, they're signing their life. There's a million situations, but we hear people say, I was on vacation. I tried edibles up in Michigan. You know, I don't use them now. I just, I mean, there's a million different scenarios. I used it a few months ago. So that's a case by case basis, right? You're not permitted to use a Schedule I drug, right? So my approach is, and this is not maybe Natalie's approach, but my approach is I do a lot of inquiring about their use, their pattern of use. If I can, I'm going to look in their medical record, and maybe they told their family doctor that, yeah, they like to eat edibles all the time. I catch that a lot. And then they come and tell me they don't, and then when I confront them, they're like, oh, well, yeah, I guess I do. But I also run into the new driver that has never used it, or has never been a driver before, right? This 18-year-old kid coming in, he wants to drive for the road crew this summer. And those guys, I might say, okay, you know, again, I got to look at what they're telling me, look at them personally. The guy that's coming in with a big old weed T-shirt on, I love Cheech and Chong, is probably not going to get a card, but. And if I have a question, I'm going to refer them. But a lot of times, for those guys that are not drivers, they're not violating a standard, they haven't committed anything, I'm going to probably lecture them. Say, this is your come to Jesus thing, and I'm going to document the hell out of that conversation. And I'm probably not going to give them a two-year card right out of the gate, either. I'm going to bring them back and say, hey, how did, you know, we talked three months ago, how are things going? For the guy that's already a commercial driver, he's done. More than likely, he's done. Again, I'm going to listen to the story, and I'll be sympathetic, because things happen. But it's going to be pretty rare that I personally will certify somebody who is an established driver under FMCSA regulation that I'm going to give that guy a pass, because the bar is higher for him. And you said you don't do non-DOT drug tests on them. I personally do not perform non-federal drug testing on a driver, because of the pitfalls that I mentioned before. But FMCSA says that it's an acceptable tool for a non-federal test. You do not do a regulated test, so you've got to be careful. Yeah, we have done it, the non-DOT. And the employers are refusing to pay. Most of the exams are paid by the employer, so it usually comes up out of the driver's pocket. Yep, yep. But I usually will send it to a specialist. If I have a concern, I'm going to send it to a specialist. The key issue is new hire versus current employee. Current employees know what the rules are. New hires may or may not. They may not realize it has to be so many forever before. It's one of the reasons why we're not doing hair testing, because the hair testing goes back so much longer. We have to be aware that this all may be changing shortly when they reschedule a cannabis. Now, what I would do, and some clinics will do, is they'll educate all drivers. This way, you're not running into a situation of, well, I didn't tell him, or is this enforceable? Can I take this in court, that attestation that they may sign? So if you just give all the drivers information of, as you're for information, schedule on medication such as cannabis is not permitted in Department of Transportation federal operations, period. End of story. This includes anything that may be consistent with state law. And I think that's the big problem. People don't realize that just because it's legal in their state, they can use it, especially on the pre-employment setting. Secondly, it's that they understand also, and I'm really concerned of CBD, because CBD is not properly labeled in many, many situations. So they go ahead and use CBD thinking it's safe because it's THC-free. It's not THC-free. And then they get popped a positive, either as an employee or an employer. And I do utilize the substance use professionals, not in their capacity under DOT, but separately. Correct. Gentleman in the back. Yes, thank you for your presentations. I have more of a philosophical question. I'd like to hear. Those are for the bar. Yeah. I'm just kidding. I want to hear your commentary on the following thought process I've had. The regulations, which you've already pointed out, are in fact codified. Use the word likely to interfere. In my medical legal experience, the word likely means greater than 50%. So someone's Framingham data shows they have a 25% chance of having a stroke or heart attack in the next 10 years. That's unlikely to interfere because that's 25% in 10 years, not 51% over the term of the card. That makes a whole lot of stuff not really against the regulation. Because you've got to, in your own mind, say is there a 51% chance that in the next year they're going to be incapacitated? How would you respond to that line of reasoning? I use a slightly different line of reasoning, which is greater than the general population. That's what I'm really comparing them against. The challenge with looking at that 50% over the 10 years, looking at the Framingham profile, is if it happens to that person over their certification period, over their two-year period, everyone's going to be in a lot of trouble. So it's really hard to assess whether it's truly going to be that 10 years, that five years, everybody's different. That's population stuff. So I just really look at the stability and control. I work very closely with the treating provider. I make certain that the treating provider is aware of what the regulations are, what the guidance is, what the recommendations may have been from expert panels, depending on the situation. And I really work with them. Is this person at risk? Is this person more likely to have a sudden or gradual impairment or incapacitation over the next 10 years? I'm sorry, one to two years. That's what we really have to figure out. So, not exactly answering your question, but it's, you can't do that percentage because it really is a shorter term issue that we're worried about. So, you're using the phrase more likely than average. More likely than the general population. Okay, more likely than general population as opposed to the legal definition of the word likely to interfere. Yeah. I echo that. I don't, I wouldn't. The only thing I, I would completely echo everything she says. I really look closely at the medical record. You know, if the car, you know, if the specialist is seeing this person every three months, there's a reason for it. Then I'm going to probably see them that often too. If they're seeing them once a year, then probably not as concerned. Assuming that's at the direction of the specialist, not because the driver's just not showing up. Exactly. Thank you. Yes. Hello. My name's Nikki Patino. I'm from the city of Chicago. I have two questions. One is vision. One is hearing. So, one on the vision, there's the vision sheet and there's the diabetic sheet. So, having someone with diabetic retinopathy and it says proliferative, but it says inactive proliferative after they had a vitrectomy. Which shows the fundus is stable. Okay. So, the question comes up to a person who has proliferative diabetic retinopathy, which would be disqualifying. But they've been treated and it now says it's inactive. What I probably would do is wait a while and see does it stay inactive? Does it become a problem again? And it probably will. So, it wouldn't be a injection today, now you're doing good. It's let's see what happens over the next three to six months in your subsequent follow-ups. But it's been active for five years. Again, part of the whole story is what have they done? Have they really prevented it? What is happening over the next period of time? If it stays quiescent, that's up to you to make that determination. Are you going to certify them for two years? Definitely not. Now, they're a diabetic already, they can treat it with insulin so you want to have them followed more closely anyway. If you certify them because you think that the proliferative is truly not an active problem. Mike. Yeah, I have nothing to add. Yeah, I mean, there isn't a right answer. I mean, you can take the approach of you had proliferative diabetic retinopathy, you were treated, it's going to probably come back. It may not come back for, may have problems with it again for another five or seven years. Or you can say, you know, I'm just not comfortable with it. It's been significantly progressive. I'm not going to certify. And that's what this really comes down to. How comfortable are you putting your name on this medical certificate? And that's hard because these drivers bounce from person to person depending on their job, right? I can, you know, I have drivers that have been in my practice for years and I, you know, I understand them a lot and I encourage them. I'm like, hey, this falls a little outside of what most examiners might do. So if you don't want to have to deal with that, you should probably come back and see me because we know each other, if you can, okay? But if you see another examiner, I cannot guarantee you they're not going to do something different. But at the same time, most of these folks bounce from person to person. So you really have to get that record and you've got to look at it. And I don't rely on a specialist saying he's good. You know, he goes from taking his cyclobenzaprine three times a day one day and the next day he's fine. No. Yeah, I mean, the interesting thing about that one was because it was only one eye too. So then it would be, you know, is one eye sufficient? And then the worrisome thing is is whether they can see well at night and that's what. And did you say you had another question as well? I do. So I'm trying to figure out what would be considered discriminatory if someone is unable to pass the hearing test and gets hearing aids with the audiogram, is unable to pass the audiogram, but is wondering why I hadn't done a whisper test afterwards which is actually something that the FAA does. So I find it. Not sure I understand. So if they pass either way, then they're fine. No, so they needed hearing aids. So they went to get them and they had the audiogram and they didn't pass with the audiogram. With the hearing aids? Yes. Okay, but they passed the whisper test with their? They did not. Okay. Initially because they needed hearing aids. So they didn't pass with the whisper test. Yeah. They got hearing aids and they didn't pass with the hearing aids. They didn't pass the audiogram, but a whisper test was not done with the hearing aids afterwards, which is what the FAA allows right now. Yeah, I mean, I would do the whisper test first. If they pass with the whisper test, they pass FMCSA. With or without hearing aids? But this is afterwards, after they get hearing aids and then doing another whisper test. This is again, not a right or wrong answer. If they can pass the whisper test, done correctly, and that's gonna be the key thing, with their hearing aids in, they meet FMCSA criteria. But they already had the audiogram and they gave it to you. And now they've come back because they've been disqualified. They've now come back with their hearing aids. But if you made the decision before with just the audiogram. So again, you've got to dive into this. Did they get their hearing aids adjusted a little bit? Did they get a new model? You know, again, the hearing standard is pretty clear, right? I understand that they failed their first test. They went and got hearing aids. The audiogram didn't work out for them, but then they're coming back to you and say, well, I think I passed. Well, then go ahead and do a whisper test. And if they pass, you're done. If they didn't, then you can say, well, I'm sorry, you didn't pass this today. You need to go back and get your hearing aids looked at again, or get an audiogram where you meet the standard. I mean, there's nothing to preclude you from taking another look at somebody. The disqualification decision is not generally permanent for the rest of their life. It's at that moment in time. So I really try to give my drivers every benefit. I wanna keep them employed. I can't get my crap from Amazon if I don't have any truck drivers. So, you know, say, okay, go back to the audiologist, get your hearing aids tweaked, come back and see me, and we'll do it again. You're gonna pop to the question in the back. Can you clarify the address situation? So when a patient comes in, or driver comes in with their address and their driver's license, but tell us they have a new address they moved, and then I thought I heard you say that if the card doesn't match the driver's license, it'll get rejected? You were supposed to put the address where the driver can currently be reached. You may wanna have a note somewhere that says, driver's license indicates blank. I know there's no way to submit that, but this way, if FMCSA happens to come back, you can say, this is what we were told to do, is put the address where the driver can currently be reached. It's their responsibility to change it at the state. So we can do that in the comment section of the examiner. I suggest you hold on to that. I think there was another question in the back was upstanding first, and then we'll go back forward again. If I may, if I may, y'all. I'm Kirk Robe, Charles in South Carolina. Is the 5875, how legal is that? Because I'd love to put a print, a yes, no question on the bottom of the second page. No. Examiner feels comfortable. You cannot modify those forms at all. It's an OMB form. It's an OMB, if it says OMB with a number after it, that form has to be used exactly as it is written. But you can attach an addendum. You can attach an addendum to it. With your own form. Examiner feels comfortable with this person driving a big rig next to their family at 77 miles an hour. No, no. Whatever you want. Not on the same form. Up front, Mike. So you have a candidate who you think, in your clinical opinion, needs a assessment for sleep apnea. They're at high risk. You send them back to the PCP. The PCP uses a BS stop bang, or maybe he's not sleepy at work, so he can't possibly have it, and sends the driver back with that note. And now you have a significant disagreement of opinion between the doctors. I send them to the sleep specialist. I don't send them to the PCP. Just like I'm not going to send a guy with heart disease to the PCP. And I'm a PCP, so I send them to the heart doctor. If I got a question about a specific disease process, I'm going to say, with all due respect to your family doctor, I really think you need to see the sleep specialist. And I can tell you that when I use a version of stop bang, which tells me whether or not this guy needs further evaluation, and I send him to a sleep specialist, it is exceedingly rare that they come back to me with not having had some kind of sleep test done. And I will accept that note from a boarded sleep specialist, along with the medical justification in the record as to why it's not appropriate. And if it's based on objective information, versus the driver just says he's not sleepy, I will accept that. I think I have had that once in my entire career. But I would accept that, because he or she is the expert. But it's exceedingly rare. But I send them to the specialist. And I generally will say, you need a test, period, based on these parameters. If this primary care doc comes back and says, no, he doesn't, and they don't give me adequate reasons for saying no, I'll go back and say, this is all the information I'm using from experts of what I think you need it. You tell me where it's wrong. And if they say no, then I would send them to a sleep specialist. Well, the other reason I like to use a sleep specialist also is because I do a lot of stuff with sleep and transportations. Not all sleep tests are created equal. A home sleep apnea test is not the same as a polysomnogram. And not everyone is a candidate for a home sleep apnea test. Most examiners don't know that. It's not their job to know that. That's the specialist's job. Send them to the specialist. Specialists will look at them and say, oh, you've got heart failure. You can't have a home sleep apnea test. You need an in-lab polysomnogram. OK? Yeah. The problem comes up with in many cases, you can't get an in-lab sleep study until you've had an HSD first. Again, yeah. Absolutely. You and I worked on this with the ESAM. But there are probably a lot of drivers out there who have sleep apnea who have not been properly diagnosed. Part of the problem is trying to read a sleep study. And I have a number. I've read the home studies. And I'm looking. No, I don't think so. And I'll call one of the sleep docs I'm friendly with. And I'll say, can you just interpret this for me? He's sitting up the entire night. Is this a valid study? But the family doc will say, it's fine. And I'm like, no, it's not. So you've got to look at these sleep studies suspiciously. And as an aside, many states no longer update your physical license for your new address. They update it in the records for the police. But they don't issue you a new card. Correct. I will go back to FMCSA with that little tidbit, because I do think that's a good point. A couple more questions. And we have about three or four minutes left. Do you want to let him go? Let me? Yeah, hi. Joe Charlotte in a hospital-based augment practice. A question about the manicula vision and the vision evaluation report form MCS 5871. I had a driver who had normal vision and obviously had a problem. But his car didn't expire. And then he came to me and he said, I said you can't pass because one of your eyes, you're going to have to fill out that form. His car wasn't expiring. Could I put him on VP? Or I had to fail him. He's an established driver. Doesn't matter. It's their responsibility to not come in the last day. They need to come in. And the truth is, if he doesn't meet, let's go back. He doesn't meet vision standard. He doesn't meet vision standard. End of story. Now the question you're going to ask, and I'm thinking about a particular case I recently dealt with, was this gentleman may be able to meet the medical standards. He may just need new glasses. So 5871 isn't even relevant in that case. Bottom line, he does not meet medical standards in his office. He probably hasn't met it for three or six months. And for all we know, he memorized it on his last exam. And he didn't meet it back then either. He's a hard stop. Thank you. He's a hard stop. And the other question is when you're getting suspicious about somebody, have them do the eye chart backwards. And watch them do it. I see my medical students all the time looking at the eye chart, not at the patient. Like, you should know he's doing this. We can tell you all kinds of ways of meeting the test. Next question. My name's Crystal. I am a family nurse practitioner transitioning into occupational medicine. And I had a driver sent to me from his company because he wanted an accommodation to not drive at night because he was saying he was tired. Nope. Stop. Nope. OK. Hold on. Nope. I got it. This is what he told me. So I put him, I gave him the option to go back to a psychiatrist and discuss medication changes, whatever he chooses to do that's safe for him. So during that 45-day hold, he went to a psychiatrist. He got medication changes. He got the paperwork he needed. And he went out on his own and got his own DOT exam somewhere else. They passed him with a two-year card. On the last day of his 45 days, he sent all the information to me from the psychiatrist. And I was comfortable enough to give him a one-year card based off of everything that he told me. And so I told him that. I sent everything into the state. I uploaded everything to the registry. I guess my question, in that scenario, the state sent me something back saying, he's already approved for a two-year card. So I don't need this one-year card. Is this an interstate driver? Is it? Yes. Yes. OK. So it's utilities. So they will go on storm alerts. Yeah, they will go where needed. What FMCSA is supposed to be doing when you submit that is the newer certificate takes precedent. And that's what's supposed to happen. What you're talking about is an individual, similar case, works for a company A, has a two-year certificate, goes to work for company B, gets a one-year certificate, which expires before the two-year one does. And then what goes first? It's supposed to be the newer exam. So I just told him, here's my thing, is I didn't know how to handle it. I said, OK, the state might accept this. But on a federal level, I don't know what will happen when they run it. So you need to keep both parts. So that's kind of, I want to make sure I did the right thing in that aspect. Yeah, I'm surprised the state. And then it's up to the company at that point if they want to send him in a year, which is what I recommend, versus two years. Makes sense. OK, I just wanted to clarify. Yeah, FMCSA is not great with checking on the two different exams from two different examiners in a short period of time that do not have similar outcomes. When I kind of looked at doctor shopping, it was like it really needs to be more than a couple doctors before they actually consider it that way. As long as they provide the same information to the second provider, it's fine. They can actually go for a second opinion. But the second opinion stands, as long as it's the same information given from A to B. So we're out of time on the clock. So it's lunchtime. I don't want to deter anybody from getting food. And I think food is a- But we will take three more questions if he wants to. We're happy to. Yeah, I'll stick around as long as you will. We'll take those last three questions. But I don't want anybody to miss lunch if their stomach's growling. But I can stick around. I'd like to know how you handle the situation on the insulin treated diabetic form that gives us some discretion of clearing them if they have less than three months of the blood glucose documentation. How do you guys handle that? Look at the history. I mean, really, that's what I'm going to look at the history and see what's going on. I mean, if they have a week of blood sugars, are you going to- I don't think they're a week and a half. Again, is the guy a diabetic for 20 years and he just stopped taking his sugars because he didn't feel like messing with it anymore? Or is he newly diagnosed and put on insulin? He just physically doesn't have it because he hasn't been on it that long. Those are two very different circumstances to me. The new guy, well, I'm going to be bringing him back pretty quick anyway because he's new. The guy that has been doing it for a while and just decided to hell with it, I don't think I need to do it anymore, he's probably going to be judged under a different microscope. So that's kind of my take on it. OK, thank you. Yeah. Thank you for your presentation. Quick question. For drivers under 21 years of age, do we give them a one-year card or can we give them a two-year card? Examine them as if they were 22 years old. All right. All right, based on the exam. Examine them as if they're 22. The age is irrelevant. And then I'm on the border where one state is like 21 interstate. When it comes to age, ignore it. If they're 16, let them do it. So we mark the first bubble and not the second one on the card. No, you use federal form. The federal one. And you fill it out as if they were a 22-year-old. It makes no difference at all. All right, thank you. Yeah, age is not a medical qualification. There is nothing anywhere in the medical regulations that says age must be considered by the examiner. That is not your problem. Last question, because they're back there. So I recently did a recertification course. And other than adding the diabetes information, the insulin, and the new vision changes, the course mostly referenced the old manual from 2014, 2015. So my question in reference to that, how does the FMCSA interact with the organization doing those trainings? FMCSA does not contract the companies doing training. It's an independent company. What's being done is it doesn't meet the core competencies. And it does for ACOM. What we've done, which I thought we had done, was the introduction says, before you take the test, review the periodic training. Review the medical examiner handbook, the new medical examiner handbook. So FMCSA does not approve training. So there's no vetting. I'm sorry? There's no vetting whatsoever of these organizations offering. ACOM's current course meets the FMCSA's training requirements. It still does. If you're asking about other courses, it's like anything else. Buyer beware. I had a colleague that went to a course and was told in that course that somebody who has cerumen impaction by regulation must be disqualified, which is, of course, patently untrue. But I would encourage examiners that are looking for a course that they look at what are quality courses. And you've got to do a little research. But I know that ACOM's meets the requirements. And in the instructions, it says, current handbook does not include waiting periods. And that's the biggest difference is, does not include waiting periods and certification durations. Look at the new medical examiner handbook. OK, we're going to stop because they're taping in. So we've got to clean up. Thank you, everyone. Thank you very much.

medical examinations

commercial drivers

driver health issues

qualification pending decisions

medical examiner responsibilities

sleep apnea

thorough evaluations

collaboration with specialists

regulations compliance

driver safety