Welcome, everybody. Ask questions as we come to the topics, but in some cases we may say, please wait, please wait because what you're going to ask in Module 1 may be answered in detail in Module 3. And by Module 5, you may understand that our answer is going to be the exact same thing from 1, 2, 3, 4, 5. The other thing is we really are not going to discuss specific cases. How many of you are already certified or have been certified in the past? Okay. So you probably remember the trainings back from 2012 when it was, this is a waiting period, this is the measurement you want to get, this is the test you can certify with, these are the disqualifying factors. We have none of that anymore. How many of you have looked at the new medical examiner handbook? Okay. So what the plan today really is to go through that new medical examiner handbook. That is our new guide piece. So we're going to go through that. So let's start a little bit. What is the purpose for the course? The purpose for the course is to tick off two boxes. Number one, I took the training course required by FMCSA so I can take the test, so I can be certified, so I can do the examinations. Number one. Number two is going to be to give you what's most likely to be on the exam. Now, Dr. Berneking, he'll be presenting a number of the sessions as well. First of all, I'm Dr. Natalie Hartenbaum. I've been, I guess, teaching this for a few decades. I work in all different places. My current position for which I am teaching is as chief medical officer of Ocumetics, which is my consulting firm. I also happen to be chief medical officer of Norfolk Southern Railroad. I am not speaking on behalf of Norfolk in any way, shape, or form today. So, the second is to make sure that you know what is most likely to be on the examination. And it's a little more generic and a little more thinky stuff. It is not probably, and I'm going to say what I'm saying, probably going to be how long would you certify the person who has a cardiac event and needs to come back for a follow-up. Echo. That's not going to be on there. I can almost promise you that. You may get a how long should you certify someone who's certified under the alternative vision or diabetes standard or who has a hearing exemption. Those types of questions you may get. So there's some very specific, when there's a regulation, when there's not, it's more uh. The handbook came out in 2024, January. I took my exam in March of 24. It was a mishmash of questions from the old handbook and the new handbook. And I think the new handbook questions were more common sense of basics of what do you think. So, again, this is to give you the resources. The two most important resources that are in your syllabus with links to the source documents are the 2024 Medical Examiner Handbook. It's about 114 pages. We'll talk about it a bit more in this first module. And the Periodic Resource Manual. Back when examiners were required to have their five-year recertification training, which in many cases was given after an examiner had been trained and certified seven to eight years later, because it took a really long time for the FMCSA to get that out. Some of the information in there is already out of date because regulations have changed when it comes to alternative standards and some of the exemptions. And also the guidance officially from FMCSA has changed. So the purpose, take the exam, pass the exam. Two, to really talk about the difference between regulations and guidelines. For those who have been certified before, that was our problem. Most examiners looked at the guidance and said, oh, I have to do that. They would tell the drivers, I have to do this. I need this information. I can't serve more than a year, dot, dot, dot, dot, dot. The driver would call FMCSA. FMCSA would say, nope, that's not accurate. All kinds of problems. We've gotten to problems with EEOC. So bottom line is, we've got to understand and we're going to focus a lot on that of, this is regulation. And anyone who's taken some of my courses before say, no, I do. And this is guidance. I may walk back and forth, but you've got to keep in mind is a very big difference between the you have to's, regulations, and the may considers. And FMCSA highlights that in the handbook. The other is providing you with resources. Not resources you have to look at. Resources FMCSA has said to me, in public, at an AOHC meeting, that yes, examiners should be aware of. But examiners are not required to consider. Examiners are not required to follow. So there's a lot of information in your resources, in your syllabus. We'll talk about very, very briefly today that you should be aware of it exists. But to prepare for the test, you don't need to know those specifics. So what we're not teaching. You're all licensed health care professionals. You have to be to be on the NRCMA. You have to be able to do a physical examination. We're not going to discuss how to examine a patient. There are parts of the medical examiner handbook, which you will see, we'll talk about. This is a murmur. This is a holosystolic murmur. This is a stage 1, 2, 3, 4. If you don't know that by now, go back and read some basic medical books. We're not going to do that today. We're not going to teach you what a medical condition is, that cardiomyopathy is dot, dot, dot, dot, dot. If you don't know what cardiomyopathy is, you shouldn't be doing these exams. If you don't know what the proper treatment for this diagnosis, you shouldn't be doing the exams. If you're not aware of the side effects of the medications and how those medications may interact with other medical conditions or other medications, you shouldn't be doing the exams. That is an assumption from FMCSA that is licensed healthcare professionals. You know that. Although in the handbook, it does go over some very basic medical, like what is a stroke? What is a TIA? That's not the purpose of this course. We're not going to teach the side effects of every medication. First of all, medications change. Medications I'll teach you today. Tomorrow, there's going to be five new ones that you're going to have to Google. Just like I do every day, because what is that? What are the side effects? What is the incidence of the side effects? How might this medication interact with the next medication? You've got to learn that on your own. Appropriate treatment, same thing. Our role is not to guess whether or not the examiner is treating the patient, the employee, the driver properly or not, but understand does that make sense and are they likely to be stable and controlled for that condition in order to operate the commercial motor vehicle safely? We're going to use a lot of the same phrases over and over again because that's what FMCSA uses. We will not review every non-endorsed guidance as we mentioned before, nor will we be able to provide definitive certification answers on a driver with what should I do with a driver who has this and this and this and this because we can't give you the right answer. You can ask 10 very well-qualified, certified examiners and you will likely get 15 different answers. We can't give you, you could do this or you could do that because there is no absolute right answer and in order to have that right answer, you need to know that driver's full medical history. When did he start? What's happened here? Dot, dot, dot, down the road. So that's not the purpose of this course. Syllabus, as I mentioned, the two most important documents you need to review in order to prepare for the examination is the medical examiner handbook and the training resource module. We've included other resources. We've included websites that should probably be primary bookmarks for you. We've included information from the medical review board and we'll talk about the MRB in a bit. They are an advisory group to FMCSA, but in truth, FMCSA doesn't really listen to them. So most of the advice MRB has given is like, okay, that's nice. But it's in, the syllabus is in, the syllabus contains links to the MRB reports and I urge you to review them. Some of them are from four years ago, probably have some value. Some of them are from 2007 and probably totally out of date. So you've got to keep that in mind when you're looking at any of these reports. We include all the forms. We'll go over form completion. That's an important part of passing the test. We do have provided all the regulations current as of when I pulled them off the website. They may change. The links are there and that's why the links are important. The resource table, there's two different resource tables. One that FMCSA says is guidance that you should look at and the other is one that FMCSA didn't really mention, except in the periodic training. So to me, that means it's fair game to say I follow this resource table because in the periodic training, FMCSA said I should look at it, keeping in mind that some of the things have changed since that resource table came out. We'll kind of go through some specifics. And then frequently asked questions. The frequently asked questions are also in your syllabus with a link to the original source documents. Problem with the frequently asked questions, some of them date from audience participation. How many of you think that the frequently asked questions and the regulatory guidance may date from 2000, but no sooner? From 1990, but no earlier? From 1980, but no earlier? Well, guess what? Some of the regulatory guidance dates from 1977. Some of you probably hadn't even started high school. I know I was, yeah. Anyway, let's keep on going. What else do we have in each individual module? We have material relevant to that module. So the expert panel reports from that module are in your syllabus with the link to where you can find it. And then other material that we thought was relevant to include. We tried to primarily focus on information that was provided by FMCSA. These are our 10 modules. This absolutely follows in the medical examiner handbook. What was done was go through the medical examiner handbook. What are the key things that the examiners need to know? What other information have we learned along the way? That's what the slides are. We did not include the, this is a cardiomyopathy, this is da-da-da-da, we talked about. It's a tough agenda, just to kind of follow through. It's in your slides. We'll take a break this morning. We'll have lunch. We'll take a break this afternoon. Dr. Berneking and I will both be around for both breaks and lunch so you can ask the questions. But we're going to warn you, in most cases, if you ask us a question about a specific case, we're going to say, it depends. So far, so good. Okay, core curriculum. This is what you've got to learn. This is what they're saying is the core basics to do and pass the examination. Why is the FMCSA here? We can sort of say it in one sentence. FMCSA is responsible for drivers and highways that operate on interstate highways and interstate commerce. And we'll talk about interstate highways, interstate commerce. One of the big confusions, and this is one area I will focus on, are the confusing areas. What constitutes interstate? What constitutes intrastate? Why do I examine the driver differently? What form do I use if they're inter versus intra? For those of you that are new, it means nothing to you right now. But by the end of this session, I hope you'll know it. Second is understand the responsibilities of a commercial motor vehicle operator. I can tell you up until January of 2024, it kind of was very nebulous in the handbook of what does an examiner have to do from a physical perspective. In the new handbook, they include not once but twice the physical responsibilities that a medical examiner, that a driver may need to do. So I think that's really there. We'll talk about that briefly. How do you review and do the examination? Yeah, the forms we'll talk about. Getting diagnostic tests, we'll talk about the tests that FMCSA feels are reasonable. Not always with what do you do with the results of that test. And then what do you do when you decide whether a person should be certified or not? And then the reporting requirements. So review that in the handbook, but we'll talk about it today as well. Why are we here? We're here because of a crash that took place on Mother's Day back in the mid-90s of a driver who was operating a bus, taking a bunch of elderly women to the casino in New Orleans. If that's not going to get public outcry when there's a crash and a bunch of people get killed, I don't know what will. Turned out this driver had multiple medical problems. He happened to have had some THC in his system. Not going to spend a lot of time about THC, but that's certainly an issue with drivers and transportation in general. He happened to have end-stage renal disease, was seen in the ER the night before the crash and signed himself out AMA. The examiner who had examined him didn't look at a full medical history, but one of the PAs, I think it was a PA that saw him in the hospital, questioned, he's a commercial driver, perhaps should not be driving. His doctor, of course, had written, can't go back to work. So that's why we're here, and we already talked about all those things. This is the National Registry of Certified Medical Examiner homepage. This is one of your bookmarks. This is where you start. This is how you register to be an examiner, to make sure that you're on the registry list. It's where you have your medical assistants, and yes, medical assistants can play a role in here. You can also get a third-party administrator to upload your exams. This is where you start. What you need to do, register first to be on the NRCMA, then take a training program such as this one. And this one, as I think I mentioned, is being recorded and will become ACOM's remote course January 1st. You take the exam. Once you take the exam, you will sit there and it will say, ding, ding, ding, you passed. That's great. But until you get that certificate from FMCSA that says you passed with the signature on it, you cannot do the examinations. Any exams that you do prior to being certified and having that signature or certificate in hand has to be redone. We talked about the administrative assistant, a third-party organization. Examiners are required to upload their results from their examination by midnight the day after the examination. You can have assistants that upload that for you. You can contract with a third-party organization to do that for you. And there's a process that has to be done in order to have those exams uploaded by someone else. Just making sure I have my timeline here. There's no clock here. One of the resources that, coming through here you get the resource, let me go get this little thing right here. Go to the Resource Center. Resource Center is a great place to get lots and lots of information. The problem is some of it is out of date. It goes back to the very beginning of the NRCME and then some information from prior to that. It used to be available only to examiners. It is now available to the general public as well. When you look at this, and I'm going to go back because my eyes are not that good. When you look at it, the first part is the forms. So you can always get to the driver examination forms from that resource site. There's information for medical examiners on how to do certain things. There's frequently asked questions. There's information for training programs. There's bulletins that FMCSA sends out on a periodic basis. One of the requirements to stay on the NRCMA is to make certain that FMCSA has your current contact information. And the reason why that is so important is when examiners came due for their five-year retraining, FMCSA didn't have accurate information for all these people. And they had no way of notifying that they were due for training. There was also a problem as they began to audit examiners. And they're starting to pick that up this year. So if you change jobs, make sure that you have your current email address on file with FMCSA. So this is a lot of resource material. A lot of it is out of date. A lot of it is not, quote, endorsed. But it will give you some information and is really a good place to get the most up-to-date forms. Requirements of how to be on the NRCMA, complete training, take the exam, submit your determinations by midnight the following day, not business day, not work days, following calendar day. So you do an exam on Friday. You've got to admit that form, not the form, the results. And you do it through an online form by midnight that Saturday. It's not Monday. It's not business. It's calendar. You need to have that refresher training every five years and then the full recertification which includes the training program every 10. Regulations just to be aware, there are several regulations that govern this program. There's a group that are under the National Registry of Certified Medical Examiners. It talks about what you need to do to be certified. I kind of summarized it in four bullets. What do you need to do to stay on it? How can you be removed from it? How can you appeal if you are removed from it and get back on? That is not part of the medical examiner handbook, but I still think it's important for you to understand that background piece of how do you get on, where do you find your information. If you work in a VA, there's a very different system. The VA examiners can be trained through the VA system. They go through a different certification process. If you work for a VA and you're going to be certified through a VA, reach out to the individuals, the occupational health department at that center, and they can fill you in more on that process. This is not going to be something that's relevant for most individuals. Some of the reminders for certification on the NRCME. Every examiner in the office needs to be certified. If you have five PAs and two nurse practitioners that work for you, each and every one must be certified and on the National Registry to do the examination. It is not you can sign off on your additional staff. They need to be certified. If they're doing the exam, they sign off on it. If it's a state that you're required to do some oversight and co-sign, not for FMCSA. The individual, the licensed healthcare professional who is doing the examination is the one who signs off on that examination. Can't share logins, you can use the National Registry number for multiple offices if you're located in multiple offices. You must be licensed in each state in which you are performing the examination, however, the driver that you are examining does not have to hold a CDL in that state. Now I said CDL, which is probably wrong. We'll talk about it in a little bit because drivers who hold a CDL all need a commercial driver medical exam. But not every driver that needs a commercial driver medical exam, the exams we're talking about today, have to have a CDL. Go through some details on that afterwards. And you must keep your contact information up to date. And I don't know how many times I'm going to keep saying that. That was one of the major problems FMCSA was having. Little bit about this handbook. This handbook replaces any other prior handbooks. There are links to the old handbook of lots of places, including in the syllabus. However, if you want to look at it for historical information, great. But the guidance that was in that handbook is no longer endorsed by FMCSA. Is it a reasonable piece of guidance to look at? Probably not at this point. It first came out in 2010. It came down around 2012 because of some questions about sleep apnea. And it's been down for most of a decade. So is it really worth looking at? Probably not. A little bit about the handbook. It's 114 pages of content. There's about six pages of introductory material, an index and whatnot. The old one had 260. So you have a sense just from that of how much less material there is. Many differences from prior drafts. So if you've looked at the 2018, 2019, 2020, 2021, 2022, 24 drafts, or 23 drafts I think, they're all different. Some of them had a lot more guidance on neurologic conditions. Some of them had none. Some of them included all of the information from the medical expert panel, medical review board on sleep apnea. Some of them didn't. Some of them didn't. Doesn't exactly. Some of them said examiners may consider medical expert panel reports. Others didn't. One of the things that I really like is it includes what a driver has to do from a physical perspective in two places. I kept saying, why did you include, why didn't you include? They think they listen too many times because it's twice. So I think it's important. It does describe both driving and non-driving tasks. One of the things many examiners tend to forget is when you're certifying a driver, you are not just certifying them to sit behind the wheel and drive. You're certifying them to do driving and non-driving tasks. You're certifying them to drive for any company that wants to drive, have them drive for you, whether it be Schneider National or it's Mom and Pop Bread Company that happens to take the bread from Philadelphia into New Jersey. That's interstate commerce. It crosses into a different state. It's not the driver. Even if you have a driver that goes up to the corner of Pennsylvania, doesn't go over the bridge, and somebody else grabs that bread truck and drives it over, that's interstate commerce. It's the material being transported that defines inter versus intrastate. It has very little information on waiting periods, in fact, none, with very few exceptions. It has very few, you know, it is not recommended to qualify. There's a couple of statements that said it is unlikely that a person with blank would meet the medical criteria, and we'll talk about those very, very, very, very rare situations. There are a couple where it's a read between the lines, and while they don't say it's unlikely this person should be certified, eh, they're probably hinting at it. But you need to use your medical judgment to be able to understand that. What's my overall impression? There's a lot of considerations for an ME when making a physical qualification determination shall include but may not be limited to the following. If you go to every single medical condition that's limited, that's what you're going to see starting off. Maybe considered, not limited to. So it means you can start here, but keep on going afterwards. And we should evaluate on a case-by-case basis, which is why I'm saying that driver with hypertension, diabetes, this driver with diabetes and hypertension, and this driver with diabetes, it's all going to be different certification determinations, maybe, but you have different information you have to review to get to that right final determination, and it may not be right for everybody. Dr. Berniking and I talked last night about a couple cases. We may have done things slightly different on a couple of them. Doesn't mean one's right, one's wrong. It's based on our training and our experience. So you need to keep that in mind, and finally, use that evaluate on a case-by-case basis to see if they meet the physical standards. Gonna start with the handbook. The handbook has that introductory section first. What it explains, it provides guidance to the examiners. Real important. Their advisory criteria, we'll talk about those. There's bulletins, there's interpretations, and there's portions of the medical examiner handbook. They are all guidance. They are not requirements. They are not things you must follow. Even the medical advisory criteria, which for many years seemed to creep up into the regulation. Advisory criteria are advisory criteria. Guidance does not have force of law. It is not binding on the medical examiner, and you can look at it and should look at it, in my opinion, but you should never say to the driver, I need to follow it because. An ejection fraction of 40% may not be all that significantly different than an ejection fraction of 39%. Doesn't mean at 39% you just qualify and 40 you qualify. Old handbook, examiners got stuck on that one little point. Driver had a heart attack 60 days ago. Well, maybe it was 57 days ago. He wants to go back to work, the company really needs him. There was nothing magical about those waiting times. Even in the very, very, very few situations where there is guidance, it is guidance, and you've gotta look at it as such. FMCSA gives you one website for guidance to look at and say, yep, this is the guidance we're telling you about, and we'll look at that in a minute, but it is very, very long, and it includes guidance on any FMCSA regulation. There's no secret to searching it. There are other guidance sources that are available that FMCSA does not mention in the handbook, but I urge you to be aware of it. FMCSA mentions in the handbook that any expert panel mentioned in the handbook is not official, but what's really interesting, they don't mention any medical expert panel reports in the handbook at all. So it's kind of like they've written some parts from prior editions, prior drafts of the handbook, where they were mentioning those expert panels, and they left the phrase in, but it's kind of irrelevant because there aren't any. This is what that guideline document that they're talking about. It's 133 pages long. It affects all FMCSA regulations. It has regulations, interpretations, guidance, frequently asked questions. Not always useful, not always current, especially when it comes to the medical. Easiest thing to do is just enter a search term, and I usually just start with medic, M-E-D-I-C, or M-E-D-I. I'm gonna get things that are related to medical ambulances and such forth, but if I wanna get medications, if I wanna get medical conditions, if I wanna get medical certification, I can look at it that way. You can also search by sleep. You can also search by hearing, and you'll pull up those different questions. Try to include as many of those that are relevant to the medical conditions in the module for that medical condition. Not mentioned in the medical examiner handbook, but it was mentioned in the five-year periodic training, is the medical regulations and guidance resource links. This is where you can find the medical review board recommendations. This is where you find the medical expert panel. This is where you find the links to the evidence-based reviews. This is where you find the regulations. So this is one of those bookmarks. Again, this is guidance not mentioned in the handbook, but definitely something that is worth reading. And you either have or should already have copies of all of these slides. So I don't know where Nikki and Michelle got to. Do you have copies of the slides? Okay, I just wanna make sure, because I know we made sure we got them out early enough that you would all have them. I don't, you'll have to check with the staff, because I think that was sent as a link. So again, a lot of links, the expert panels, the medical review board reports. I think the medical review board reports, if you're interested in one document to look at, that goes over and includes the presentations. It includes the discussion. One of the nice things about MRB meetings, they're open to the public. So you had the medical review board, five experts, and they all really were, who would deliberate and discuss, and the public that was coming with many different perspectives. I attended most of the meetings, and I said, yo, the examiners are a little confused on this. Or, that works, but. And what was interesting on the expert panels, just to think about them, some of them had individuals who were very knowledgeable about the medical examination process. Some of them did not. If you read through some of them, you may pick up, this doesn't make any sense. This isn't workable in the process. In others, it's really clear that members of the panel understood, and were trying to work within the parameters of the certification process. The FAQs, they're in your, that's on the medical webpage from FMCSA. They're in your syllabus. Also a link to the source document, because a lot of them are really out of date. A lot of them are in conflict with some alternative standards, like vision and diabetes, and we'll talk about those with the applicable module. Medical examiners has to be licensed to healthcare professional, licensed to perform physical examinations in their state. This will vary from state to state. Includes MDs, DOs, nurse practitioners, PAs, and chiropractors. If you do a really detailed search, which I would not urge it, because it will take forever to download that spreadsheet, you will find physical therapists. You will find chiropractors. You will find dentists. You will find naturopaths. You will find RNs. Because many people took the statement on their medical licensure, which says, licensed to perform physical examinations, and stopped there, rather than proceeding to, to perform dental procedures, to provide physical therapy, to provide dot, dot, dot. Some states have gone after those individuals, and said, nope, you shouldn't be on this registry, because you can't perform a physical examination, evaluate the conditions, and then prescribe and treat. So, but FMCSA has not been able to, as aggressively as they might want to, really go through examiner by examiner by examiner, and pull those that really have very limited scope of practice. And yeah, you can do an exam, but not much more. So this is one of the key things. The commercial practice license, and drug testing, the key weight is 26,000 pounds or more. When we're looking at the commercial driver medical exam, it's 10,000 pounds or more. So there are a lot of individuals who are operating vehicles between 10,000 and 26,000, or 25,999 pounds, that need an examination, but do not need a commercial driver's license. So this is not a CDL exam. This is a commercial motor vehicle operator exam. Commercial driver medical examination. Two different parts of the regulations. This is 391 or 390. The other is in the 380s. So you've gotta keep that in mind. Second is how many, whether it's designed to transport passengers for compensation. So it transports eight or more for compensation. Which means, I pay you to take me. This is not, hey, I work for this company, we have a driver for this company, he shuttles people around the plant. That individual is not covered. The one who says, oh, I, you know, you pay me to take you to the airport, you pay me to take you to something else, directly as a driver, they are covered and require the examination. For others, it's 15 or more passengers, including the driver. And then if they have hazardous material, material required placarding, that also needs a commercial driver medical exam. The biggest difference is that weight. 15, I'm sorry, 10 to 26,000 pounds. That bucket needs the exam, does not need a CDL. Who else needs to be examined? Somebody who has not been medically qualified in the past 24 months. Someone who has not been examined, who does not have a current medical certificate, that kind of makes sense. If they've been operating in an exempt intracity zone, there are a few exempt intracity zones that do not qualify as interstate. So for example, New York, New Jersey, in that certain region, is considered an intracity zone, and drivers whose material, remember it's not the driver, it's the driver's material that they're hauling, stays within that zone, they can be considered intracity. There's not a lot of regions, there's not a lot of companies that that's really applicable to. That's a 12-month certification. We'll talk more about the diabetes alternative standard and the vision alternative standards. If they're qualified under those, it's 12 months. And then the next one, which is the most important one, causes the most problem. It's not if their certificate hasn't expired, but if their ability to perform his or her normal duties has been impaired by a physical or mental injury or disease. Now one of the things I've included a lot of exact words, because the exact words are very important. There's nothing that says how does an employer determine that. There's nothing that requires to have an examiner determine that, whether they need a new exam or not. I urge you to talk to your clients, talk to the company you're working for. Make certain that the companies understand what that means. They have the flu, they don't need a new exam. They had a stroke, they absolutely need a new exam. They've been out for two days because they had a syncopal episode, they need a new exam. They went to the ER because they sprained their wrist, they don't need a new exam. So it's really that understanding of is the condition likely to interfere with safe operation of that commercial motor vehicle. There is a process of regulation 391-47. Not a lot that you need to know on the regulations. We'll go through some of those. If the examiner disagrees, there's a couple of processes. Number one, the examiner can say, you don't know what you're talking about. I'm going for a second opinion. And guess what? The examiner can go for a second opinion. Now as an employer, you don't necessarily have to accept that. You may or may not have some liability if the other examiner qualifies, but it depends on a couple of things. The driver is required to give the same information to the second examiner. And those that have been examiners before probably have dealt with situations where, oh, you need a sleep study. You know, because you checked off the box, I snore. And you go to the next examiner, oh, I weigh 120 pounds and I'm six foot five. Okay, fine, just mark it down. Do you snore? No, okay, you don't need a sleep study. So FMCSA will go back and audit those when you get a disqualify and then a qualify afterwards to make sure the examiner gave the same information to both. But if they did, because there is no right answer to every single driver with the same condition, you may find that examiner A, who may be a board certified occupational medicine physician says one thing and they go to the physical therapist down the block and they give that physical therapist the same information, and that person feels that they're okay to be qualified. FMCSA will look at the medical conditions. But the problem is there is no right answer. It's an individualized assessment. Talking about how do you define inter versus intra. If it's between a state to outside a state, that's interstate. If they go through two paces in the same state but pass through a third state. So if you're going from Philadelphia to Pittsburgh and decide to have the material goes through Ohio to get there for some bizarre reason, that becomes interstate commerce. It's within two areas in the same state. If that commerce began somewhere else, so you have gasoline that began in Texas, and somebody from Texas drives it to the Oklahoma border and then somebody else picks it up and takes it into the other states, they're both involved in interstate commerce. So they both fall under the FMCSA medical standards. The examination forms we use, we'll talk about each of them as we go on. We have the medical examination reporting form. This is where you document your exam. That's the old long form. The medical examiner certificate, that's the certificate that you give to the driver. You have the 5850, which is the reporting form. It's an online form that you enter the driver's information, whether they've passed for how long with the expiration date, and it already has your information because you go through your examiner portal. That's the 5850. We then have some other fun forms. The 5871, which is for the alternative vision standard. 5870, which is for the insulin alternative vision standard. The 5872, which is for the non-insulin dependent, non-insulin treated diabetes. And the 5855, which is the optional medication form. And we'll talk, 5895, I'm sorry. And we'll talk about each of those forms in the appropriate place. Privacy. You should not be providing that long form to anyone without a consent, except for FMCSA officials or other government agencies. You can provide it to an employer with consent. So you've gotta keep that in mind, especially if you're in a big organization that's using Epic or one of the other medical records where everybody has access to everything. It cannot be released to the employee and commuter carrier without the signature. However, but it's important to also remember, that driver has the right to have his medical information. So if he says, I want a copy of that long form from the examiner, he's entitled to get. Doesn't matter who pays for it. That's his medical information. He's entitled to get a copy of it. If you're normal processes to have a record release signed when you give somebody their own records, you do it that way. Let me just check one thing. My count my own time. I am, okay, good, that's what I thought. Exemptions. There are a couple of exemptions that are now available. There are a couple of things that drivers apply for exemptions, but examiners do not issue exemptions. They can say you are eligible for, you may meet criteria for, you may want to apply for an exemption. But it's important that both the driver and the carrier know that just because you wrote qualified with exemption does not mean that the examiner has granted that exemption. Exemptions are only granted by FMCSA. And what else? I think that on that slide. Now we're going to some more meat of the handbook. Let's look at the regulations and the certification process. This is kind of all introductory. This is before we even get to the, what do I do with a driver who's in my office with blank condition? State regulations. Another really confusing for a lot of people. If the driver only drives within the same state, if the driver only moves material that's in that same state, and they truly are an intrastate driver. So this is somebody who works for a bread company that delivers bread only within Pennsylvania, never across the state line. The bread doesn't go outside of state lines. We don't worry about the flour and the sugar and the yeast and where that came from, because that's a different product. It's the end product we worry about. They may be eligible to be intrastate only. Now, a couple of caveats on that. When a driver shows up in your office, you examine them under interstate to start with. It's only if they don't meet the interstate criteria that you then step and say, okay, do they meet state requirement? The reason being is once they have that medical certificate for interstate, they can work for anybody they want to. You can't use the state only as a restriction. Most states have already adopted the federal medical standards for their intrastate standards. If you want to figure that one out, then go figure that out and keep track of it. If you have a driver who you know was not eligible for an interstate certificate, then you need to know what the criteria in that particular state are. Will some states qualify somebody who had a seizure four years ago? And the answer is yes, there are that will qualify them for intrastate only. So you need to know that, even if it's not the state where you're licensed. Maybe Maine, it may be whatever. California, if they don't meet interstate criteria, they want them disqualified. And then the driver will go to California independently to see if they can meet the California state driving rules to see if they actually are intrastate only. So your starting point should always be interstate only. Maximum duration certification is 24 months. As an examiner, you can issue a shorter than 24 month certification if you believe the driver needs more frequent monitoring. Maximum is 12 months. Exempt intercity zone. Received an exemption for seizures under the alternative vision, alternative diabetes standards. And we'll cover those in a lot more detail when we get to them. And again, repeat that same thing on how long can you certify them for. There's a lot of repetition throughout the handbook because they're trying to reinforce the important factors. You can certify that one of the crazy things is hearing. If you're getting a hearing exemption, that can be for 24 months. So it's the timing and how long you can certify. Requirement for driver to do both driving and non-driving tasks. It is not limited to a single company. So they work for mom and pop bread company. You send that medical certificate, you send that medical certificate, you don't look at the job task for mom and pop bread company. They can take that medical certificate you signed and they can go any company they wanna go to. Some companies require a new medical certificate because they want to know who was the examiner who examined this driver. Many companies don't. That was the idea behind the National Registry, that all examiners are trained theoretically the same. I can tell you right off, examiners are not trained all the same. For the first set, most of the training programs went page by page by page by page through the medical examiner handbook. And that was it. Didn't even mention any of the expert panels. Didn't even mention any of the medical review board discussions. And in fact, a number of the organizations were very angry at groups such as Acom. They said, no, we're gonna teach about sleep apnea and what the medical review board said about sleep apnea. And FMCSA said, that's okay. As long as you differentiate. This is official FMCSA guidance. And this is from other sources. Not endorsed by FMCSA. So that was the idea behind the National Registry is if the driver's listed on as certified by an examiner on the National Registry, they're good to go. Not every company accepts that. So for that reason, the driver's not limited. How far he drives, how much he lifts, where he goes, what kind of vehicle he operates. When you drive that medical certificate, that's good for anybody, anywhere. Physical examination. Now, I included the exact wording because it drove me crazy. For the longest time, FMCSA said, these examinations are a fitness for duty examination. No, they are to detect the presence of a physical, mental, or organic condition of such nature and extent as to render the individual's physical condition inadequate to operate the commercial motor vehicle safely. The fundamental task is, can they operate that commercial motor vehicle? Remember, it's any commercial motor vehicle they may be driving. Some of the definitions. It's really nice when they put regulations down and they use almost the same word, but they mean five different things. So treating provider, whoever's treating the patient. I know there's some people who don't like the term provider anymore. But FMCSA uses the term treating provider. Diagnosis, treats, follows, orders, tests, that's the treating provider. The treating clinician is the healthcare provider who manages the diabetic who's being treated with insulin. And your licensed healthcare professional, licensed medical practitioner, is any licensed medical practitioner, as defined, able to do physical examinations and prescribe medications and control substances and other drugs. So those are the different treating license wording that's used throughout the handbook. The medical examiner handbook, the medical driver, commercial driver's duties are all listed here. They consider it heavy labor. There are other job tasks. This talks about loading and unloading, working with load securement devices. It's talking about inspecting the vehicle, which requires them to be able to kneel, squat, reach, and pull. They have to be able to load and unload. If you have an unbalanced load, that vehicle can jackknife, causing all kinds of problems on the highway. So it is not just A, they get in the car and drive, and I think this is fantastic. I think it's overdone because in the introduction, when it describes the driver's tasks, it's also in the musculoskeletal section. The responsibility is to determine whether or not the driver meets the physical qualification standards. And there are 13 standards. Everything else is guidance. Our role is not to diagnose and treat. However, an examiner should notify an individual if a condition is identified that may need further treatment, further follow-up. If it impacts their certification, the examiner should review that and say, this is the condition that's causing you to be unable to be certified. This is the condition that's causing you to have a shortened certification. This is the condition, dot, dot, dot, dot. This is what you need to do. And it is not get A, B, C tests in most cases, as most cases it's gonna be follow-up your treating provider to make certain that this condition is stable and controlled and not likely to interfere with your ability to operate a commercial motor vehicle safely, including both driving and non-driving tasks. If you're unsure, consult with the treating provider. If you're unsure, consult with another OCDOC who's on the National Registry. If you're unsure, consult with a specialist. Our role is to promote public safety. We're supposed to talk about medications, including over-the-counter, and we read the labels and the warnings on those labels to understand what the med says. Do not drive and operate heavy machinery. Until you know how this medication affects you, then, hey, driver, you shouldn't be doing that until you know how it affects you. And then how to read and then seek medical care for a condition. So it's kind of very high-level medical counseling. And I do mean very high-level. We do not want to necessarily establish that doctor-patient relationship. Now we come to the meat of the handbook. This is what the rest of the day is going to be talking about. This is the physical qualification standards and guidelines. Some of them are incredibly useless. I hate to put it that way, but it basically says, this is the regulation, this is the condition. Consider these couple of things. Next section. A person is physically qualified to drive a commercial motor vehicle if they meet the physical qualification standards or if they've met the alternative standards or both. That's about what it is. Reminder, guidance is advisory. It is not mandatory. Olden process, and I still think it makes sense, is if you're not going to follow the guidance where it exists, and that's going to mostly be in the medical advisory criteria, document why you're not following it. There is some incredible medical advisory criteria on blood pressure. Those of you that have done these exams before know what I'm talking about. 140 over 90, 180 over 110 have very specific recommended triggers. It doesn't mean you have to follow the medical advisory criteria. I urge you, and again, this is Hartenbaum saying, if you're not going to follow where there is specific guidance in the handbook, document why you're not following it. Because if this guy ends up having a stroke and you qualify him with a blood pressure of 184 over 120, you're going to be brought into court. So document, and there may be a reason why you did that. But, document that importantly. Terms used in the FMCSA, and again, very careful in their words, recommend, consider, may, should, or could. Those are all advisory words. They are not requirement words. Shall. Must. Those are the things you must do. These are the most current regulations. I have them in the syllabus material. However, they have not changed too recently. But keep an eye up. One of the best ways of watching when things change, A, subscribe to the NRCMA mailing list, which you're going to automatically be subscribed to once you're on the NRCMA. And there's also a group out of UNC right now. It's an OCC-ENV-MED listserv. It really covers everything occupational medicine. Keep in mind, some of the posts make a lot of sense, and are very accurate, and I'd probably go by them. And there were a lot where it's like, and I think Dr. Berneking will agree with me. There are times I look at it, and I'm like, I'm going to bite my tongue and not say anything. And there's others where it's like, no, this is wrong. I'm going to put my two cents in for whatever that's worth. So, other thing that's important, not every condition is covered in the 13 medical standards. There is nothing in the medical standards specifically covering kidney disease, including end-stage kidney disease. So we're supposed to evaluate that under other conditions. And for whatever reason, because the most common cause of kidney disease is diabetes, it's covered in the diabetes section. When you're talking about, what was the other one? Non-insulin treated diabetes. There's not a regulation that covers that. The old regulation was requiring insulin for control. It was a disqualifier. And then it became requiring insulin for control was required an exemption. It doesn't even talk about that at all. It's being treated with insulin. So we're now supposed to evaluate diabetes not being treated with insulin, not requiring, but not being treated with insulin, even if their A1C is 15, under either maybe cardiac, maybe loss of conscience, maybe neurologic, maybe vision, but it really depends on that condition. So it's a lot more, you've got to understand the medical condition to understand, what am I looking for, what am I thinking about? The medical advisory criteria, basically this is information provided to the medical examiner to help them interpret the regulations. Two of the medical advisory criteria had been removed. Some of them had really great specific guidance. And some of them were kind of nebulous and didn't say a whole lot like cardiac. And we'll get to each and every one of those. But these are the, you really should look at that advisory. If nothing else, that is the highest should and document if you're not going to follow where it exists. It does not carry force of law. And I try to go ahead and highlight those words that are really important. And again, these are just information, so read that through, keep it in the back of your mind. Important information, but don't tell a driver or an employer, I have to. The guidance says, and I agree with the guidance. As I mentioned, we'll be reviewing it with each section. Some of the medical advisory criteria have been removed. So there are no medical advisory criteria for insulin-treated diabetes. It's real interesting that everything that would have been guidance is now part of the regulation. So the insulin-treated diabetes regulation is, like, yea long. And we'll go over that. Some of them have kind of moved around and they've taken what was guidance and moved into the advisory criteria. So those who have done this before and may have known that old Appendix A medical advisory criteria, it's all shook up in the handbook. And what's in the handbook is the current medical advisory criteria. So now other items that are not in the handbook. And again, we're going to go through very carefully of saying, this is not in the handbook, but we think it's important for you to know. For those of you listening to this on tape, I've walked from one side of the room to the other side of the room. Because it is not something you're going to have on the test, most likely. Not something that's endorsed by FMCSA. I hate to use this slide, but I keep using it. Things will get worse before they get better. I think we had a decent but certainly flawed product in the original handbook. I think we had some improvement as we got more guidance and expert panel reports and medical review board. But then we kind of got worse because everybody was using different pieces of information and different sources. And then we were really hopeful that we were going to get a more current handbook, maybe 2021 draft. And now we're back to the use your best clinical judgment, which makes sense, except that there's no starting point. And the old handbook had what should have been a starting point. So things will get worse before they get better. For those who have taken any of my training programs before, you've probably seen iterations of the middle picture. Those are my two daughters, which my whole word was, how would you feel having this individual driving a heavy oil tanker truck next to your family or transporting your family? So those are my girls. That's when they were babies. And the outside pictures of them now both married. And yes, that happened within a 10-week span this summer. So that's where all the new gray hair came from. So everybody likes to have their role. And my role is heart and mom's role. Conversial driver medical certification is, with the exception of the absolute criteria, there is often no absolute answer for a given diagnosis applicable to all drivers with that diagnosis. So I've been using that slide for a couple of decades now. I think FMCSA is saying pretty much the same thing. You've got to do a case-by-case, individualized assessment, utilizing all the information, so forth and so on. Driving tasks. We need to understand what the driving task is, not even thinking about those physical requirements. You get information about the vehicle. Okay, where is it? What do I got to do? How do I get it there? You have some sensory functions, because you're still dealing with that steering wheel. You're still dealing with one, two, or three pedals. You're often dealing with multiple, if you've ever been inside a large truck, there's, like, little things you push and pull and snip and snap all over the place. There's often three mirrors on each side, because you don't have that great view, as we have in a little car. You've then got to have the cognitive function to import all that information and say, okay, what do I do now? Do I turn right? Do I turn left? Do I speed up, slow down, and so forth? So it really is a very cognitive-heavy practice. So if they're taking cognitively impairing medications, they have a medical condition that may make them less cognitively aware, because they have sleep apnea, and they're having microsleeps constantly. But if they're on medication, it will cause sedation. That they're on, they have, you know, absent seizures, and suddenly they're doing fine, and they're like, stop. Okay, you've got to be aware and alert the entire time you're operating one of those large vehicles, even when you're operating it in traffic. This, I like. This is on the medication form. You have a copy of the optional medication form. We'll talk about the optional medication form. And I keep saying optional, because I'm trying to stress the regulation, guidance, required, optional. There are several required forms, and there are two optional forms. But we strongly encourage you to use the optional forms. And FMCSA has said that multiple times. The medication form, it's a great resource to get additional information on what medications are they taking. Have they revealed everything? Do they have other medical conditions? And then the optional diabetes form. But this is the optional medication form, and it really summarizes in a very long, wordy paragraph that this is what a commercial driver may have to do. It kind of takes those two pages that I told you were reported twice, and distills it down to the number of hours, uncoupling, working with low-securement devices, 50,000 pounds in a day, transporting material, cognitively alert and awake at all times. So what I will often do if I have a provider who doesn't want to give an opinion or I'm uncomfortable with they may return to work, may drive a truck, is I'll just copy this and say, hey, this is what he has to do. If I really have a problem, I'll copy this, and I'll give the two pages now that they're officially in the handbook before there's part of the skill performance evaluation certificate. We'll talk about what that is. But those are part of the skill performance evaluation certificate and not applicable to everybody, or that's the way some people interpreted it. What are we doing? Okay. Come on. Okay. This is how I like to think of it. And again, this is how I like to think of it. This is how one of the chief medical officers of FMCSA used to also say. What is the risk of sudden or gradual impairment or incapacitation over the duration of the certification? You as a medical examiner get to determine how long that certification is good for. Gradual incapacitation is just as bad. A person's hypoglycemic, they're trucking along, they're doing fine. Yeah, sugar's a little low, feeling a little lightheaded, feeling a little more lightheaded. Oops. It's too late now. And then, of course, you have the sudden incapacitation from the individual who has hypertrophic cardiomyopathy with a narrowed outflow, and he has a high risk of having ventricular fibrillation, and he does have an implantable defibrillator, but boom, he goes out, and that defibrillator tries to shock him. Once, twice, maybe three times it works. That's sudden, and that's at a defined time where he's not operating that vehicle safely. So I like to think of it as both sudden and gradual. FMCSA focuses on the sudden impairment or incapacitation. I know kind of what I'm doing, but I'm not fully alert and aware. That's just as dangerous, during the period of the certification period. Some of the points that I pulled from various older communications, which I think are still important from examiners. Again, this is not in the handbook. It's important to clearly communicate with the driver what is going on. Why are you making the determination that you're making? And I'll mention a couple of times that you don't want to tell the driver, oh, I'm going to need a sleep study, or oh, I'm going to disqualify you when you're only one-third of the way through, because what are they going to do? Bye, doc, I'm out of here. That becomes an incomplete exam. Go through everything. Maybe you'll find something you didn't expect to find. Maybe he really can be qualified. Maybe you really don't need that sleep study. Do the entire exam, but once you reach that, explain what you're doing and why. Make sure that as an examiner, you distinguish between this is a requirement versus best practice, and maybe even this is what I base my best practice on, and there is a book floating out there which is out of date, and that is not your resource to say, I based my decision on the book that has right now, I think it's an orange and black cover. So, yes, base it on the medical examiner handbook, but you've got to distinguish what you're basing it on. Avoid conflict of interest. One of the big problems is that you have a large examiner company, and everybody gets referred for physical therapy, and everybody gets referred for a sleep study, and everybody gets referred for a non-DOT drug test. But they have a test lab, and they charge for collections, and they have a sleep lab, There's that appearance of a conflict of interest, which is, the examiner is only sending me for this because I don't really need it, but they want to get paid for it. So you've got to avoid that conflict of interest. Who's responsible for making the certification requirements? Interesting. The medical examiner makes the decision. The motor carrier makes certain that only the drivers that meet those criteria are on the road, which right now is done by having an examiner on the national registry. That kind of comes into place from a legal situation is, oh, I know they had X, Y, Z, and this is why they've been out. You've got to send them for a new exam so that medical examiner can make that determination. As the employer, you're responsible for making certain that only medically qualified drivers are on the road, not to second-guess the examiner. And that's mentioned later in the handbook. It's a medical examiner's decision whether the driver is qualified or not. You should not be swayed by the company that says, I don't think he should be. Now, a little bit of a different story. If you have a company that has a knowledgeable, ideally on the national registry system, who can say, hey, examiner, are you aware of, and I'll be honest, I do it all the time, are you aware of this guidance? Have you reviewed it? Not saying it has to be followed, but have you reviewed this? Are you aware of this statement? I mean, I got somebody who was disqualified because he was 19 years old. It's like, no. If the driver's under 21, you can still do an examination. It doesn't mean you can't, so I'll go back and do that. But you shouldn't have an employer say, you know what? I want to make this certified for just a year because I want to have him back in a year. No. You make the decision. Must the driver returning from illness or injury have a new examination? And again, it really depends on whether or not their medical condition may make them unable to operate that vehicle safely. It's because the same thing, a condition developed after I had my last certificate, yes, if you developed a heart attack, if you had diabetes, if you had a stroke, if you had a syncopal episode, and you have a valid medical certificate, that medical certificate became invalid the day you had that event. And you do need to have it. And a lot of companies I've seen have gotten into trouble because they get a return to work note from a cardiologist, may return to work and they put him back in the truck. I think one education piece, if it's from a cardiologist, a neurologist, an endocrinologist, a specialist, you may want to have him re-examined. If it's from the family doc, maybe you do, maybe you don't. But more likely than not, if they've gotten to a specialist, there's something more significant going on. Again, family doc internist, maybe. How long have they been out? But that's not always the best factor because they may have gone to the ER for, again, another case I had recently, for an episode of encephalopathy on a Friday. And the doctor released him on Saturday night to come back to work. I want to know why he had that episode of encephalopathy. So you kind of need to look at the bigger picture, and that's something that the employer is responsible for identifying who needs that new exam. Am I required to have a medical certificate if I only operate in my own state? It depends. And again, it doesn't depend on the state, it depends on 10,000 or more pounds. If you're operating in trust state and your vehicle is between 10,000 and 26,000 pounds, it depends on the state. Pennsylvania until recently had 18,000 pounds. Other states don't require an exam for intrastate only until 26,000 pounds, until the CDL is required. So that's kind of a tricky question. You need to know what's in that state which is why I always say look at interstate first and then if it's intra only, then you've got to get all that additional information. And can I use medical marijuana? The answer is no. Medical marijuana as we define by the leaf, the oil, the other products, the edibles. Marinol is not the same. So if they're using Marinol, or they're using one of the other cannabinoids that's FDA approved, that are a scheduled medication other than schedule 1, the answer is it is not prohibited. Which is where we get into the whole medication assessment and evaluation of is it a safety concern? Should the person be permitted to be using it? Qualified on it? And there's a little bit of CBD we'll talk about with the medication module. Remembering medical certification granted to any job, not just the current job. They can't grant waivers. They cannot address how much is paid by the employer. The driver doesn't say who has to pay. And if the certificate is lost or damaged, the driver may request a new certificate. Medical Review Board advisory only listens to the medical expert panel reports that have gotten their guidance from the evidence based reviews. It's composed of physicians who are knowledgeable generally in a broad range of topics. Basically, MRB isn't mentioned anywhere in the handbook. What is important here is that one of the links, one of the pages in your syllabus is MRB meetings. There is really not a good reference that says the MRB discussed this at this meeting, schizophrenia. They discussed medications here, sleep apnea here, cardiac here, and dot dot dot. In your syllabus is a table that I've been putting together and maintaining which says on this date the MRB discussed this. So you can then go to the MRB website, pull up the meeting from that date for the topic you're interested in. Again, not for the test. This is one of those additional resources you may want to look at and say okay, what's there. Now for the more recent ones, you'll have presentation slides. For some of them you'll just have reports. For all of them you'll have MRB discussion. So that's why I think the MRB not for the test, but for additional knowledge of where do I go from here. That's module one. That's our background. That's the very beginning of how do we do a test. Then, Mike, if you want to pop up because I think you're doing two. If you want to switch off and get the next one up, we can do that. Any questions on module one? Yes? If somebody that you disqualified goes to another provider who qualifies, what's the process then? Or if somebody has an incomplete exam, how many can they see? The question is somebody disqualified at one and goes to the next one. FMCSA will look at that when there's two examinations by different examiners in a short period of time. One disqualify, one qualify. Same thing with incomplete and then redone. Same thing with determination pending. We'll talk about determination pending in module 10 and then they can go get qualified by a different examiner. If a person qualifies then after you're disqualified, they're still disqualified until it goes to... No. The most recent certification is the valid one. The problem that is more common is that somebody works for Schneider National. They want to leave and go work for Swift. They're qualified on Schneider but they go to the Swift examiner who disqualifies them. Now that information is being transmitted or will be next year to the state driver licensing agencies, that individual's commercial driver's license will have a disqualifying exam on the record. We're not seeing that right now but I think we will start seeing it when next year they start having that information sent directly to the states. The most recent examination takes precedent. If it's different than the earlier one, incomplete, qualified, then you often will have those that have FMCSA going in and seeing what's the difference. They'll look to make sure the same information was provided on both. How many opinions can they get? As many as they want. As long as they get... Whether or not the employer's going to accept it or not is another situation but of course you do have a lot of driver independent owner operators so there are... They will shop around. The question was about when you have these kinds of high profile accidents, does NTSB investigate them? Absolutely. NTSB does investigate them. NTSB will then issue recommendations. For example, sleep apnea, NTSB has issued recommendations to all four modal agencies saying you need to have something on sleep apnea. FTA, FMCSA, FRA, FAA has done things differently in how they're addressing it. Same thing with medications. They have put in place saying we recommend that you have a list of approved medications. That wasn't going to happen in any transportation mode. So NTSB puts recommendations to the agency for what to do. Do they follow them? There are a lot of ones that are closed unacceptable.

medical examiner handbook

commercial drivers

FMCSA guidelines

driver certification

regulatory framework

state versus federal jurisdiction

physical qualification standards

clinical judgment

examination process

2024 Medical Examiner Handbook