My name is Mike Bernikein, and I do not have the fame that Natalie does, but I'm currently serving as the medical director for Bronson Pro Health, which is a hospital system in southwest Michigan. And in terms of disclosure, I am a military flight physician as well, so I am not speaking, of course, on behalf of the United States Army or any other government agency. These are my opinions, and mine alone. How many of you all here are physicians? Everybody, okay. And you are? NP. Okay, good. I will give you a couple of little pearls that are not going to be tested on. They're not official anything. They're just the voice of experience, before I get into the meat of it. I've looked at a lot of these exams, and I can tell you that probably the biggest fault is the lack of documentation. Document, document, document. Okay, if you didn't write it down, it didn't happen. Natalie alluded to, if you do something that's outside of the guidance, you'll end up in court. It's not a bad thing, unless you didn't write down why you did it. Then it can be very bad. Okay? There's a tendency of examiners to pencil whip these things, because you can do a physical in a couple minutes, right? And they forget that this is a medical document, with all the medical legal implications that go with it. Okay. Pearl number two, Natalie's touched on this, I'm going to continue to harp on it. Independent medical judgment, okay? Somebody walks into your office with a wrist injury, you're not going to automatically give everybody the same treatment. Wrist injury automatically gets x-ray, PT, MRI, blah, blah, blah. No. You individually assess them, some people, here's some Motrin, go home, go back to work tomorrow. Oh, you need an x-ray. Oh, no, you need a splint and therapy. Same thing with the driver. Treat them as individuals, look at them as individuals, make a decision based on your experience, your training, and whatever resources you need to bring them to get them to be, for you to feel comfortable making the decision. And my final litmus is, would I feel comfortable with that person operating a tractor trailer next to my kid? And if I can't answer that question, yeah, I'd be good with that. Then I maybe need to do a little more thinking. And finally, do the whole exam first, then talk about, you know, do your self-note, subjective, objective assessment plan. Don't go into the room knowing that this guy's going to be disqualified because he's got a seizure disorder, and you tell him that, and the guy gets up and walks out before you did anything else. Now you've got a guy that you have to mark that exam incomplete, right? You didn't do it. You didn't finish it, okay? So number one, now you've got a guy that will go skipping down the street to somebody else and not mark that question yes, because he knows. And you know, a disqualification carries a little bit more weight than an incomplete. There are a lot of valid reasons why an exam can be incomplete. And number two, it's really your job to be able to provide this person that is going to be disqualified with the path to recertification, how they get to where they want to be, and also to make sure there's nothing else going on, because you want to tell them about everything. There's nothing worse than a guy that walks out the door being disqualified for something and then comes back, and because you didn't address it the first time, now he's got another issue. So anyway, we'll move on. Those are just my pearls. You can take them or leave them. This is the meat of it. All right. Vision and hearing, we're going to follow a very similar format through all these modules. We start with the form, okay? This is the history. Do you have eye problems? Pretty straightforward. If I were to take a test, I would probably be very familiar with this. This is a non-discretionary regulation. You have to follow this. Have to do it. If they do not meet this standard, you must disqualify them. So they have to be 20-40 in both eyes and together. They have to have a visual field of 70 degrees and horizontal, both sides. Yes, I know that's not normal, but that's what it is. And you've got to be able to recognize red, green, and yellow traffic signals. You don't have to perceive them that way. You've just got to be able to tell the difference. They move on. So that's the regulation. So we started with the form. Now we went to the regulation, 391.41. 391.41 goes on to introduce another separate regulation. It says if they don't meet the requirements of 391.41, then 391.44 might be relevant. That is that they can't see with both eyes 20-40 and together. One of them doesn't work or both of them. And again, this is with or without corrective lenses. Doesn't matter whether you have glasses or not. So now we're going to talk about the alternative vision standard. And again, this is a fairly scripted process, which is fairly easily testable. I'm not saying that this will be on the test a lot. I don't know what the test is going to be like. But again, this is pretty easy material to ask examiners about, because you do need to know this. This happens a lot. So basically, to be eligible for certification of the alternative standard, 391.44, number one, you've got to fail 391.41. Then you have to be, in all other respects, qualified. You can't have monocular vision and then a seizure disorder. And then you have to have an evaluation by an eye doc, optometrist, ophthalmologist, doesn't matter. And that person has to complete the MCSA 5871 form. Prior to your medical examination, 45 days prior to their commercial driver's license exam, they must have that exam done by an ophthalmologist or an optometrist. Then once that form is completed, then they come see you. And you, as the medical examiner, review that form. And if it's favorable, you may, and they're in all other respects qualified, then you may issue them a medical certificate under the alternative vision standard, with or without corrective lenses. You need to keep that. So this bold here, retain as part of the form, you don't submit that unless the FMCSA asks for it. But you keep it as part of the medical record. Three years is the requirement for FMCSA, but it may be longer depending on your state. So what's whole bolded here, the medical examiner must determine, not the ophthalmologist. The ophthalmologist is rendering you an opinion. You're asking their expert opinion, but you in the end are the guy that signs this card. And again, you'll see this often, independent medical judgment. The buck stops with you. Again, this is basically the old monocular vision. So for those of you who are familiar with the monocular vision waiver, an exemption process that's gone, states may still have individual waivers, but there's nothing federal. This is the alternative standard. You still got to be able to see red, green, and yellow, and if you can't, there's really no recourse for that. This is not something that's addressed under the alternative vision standard, nor is it addressed anywhere else. There's no exemption program for colorblind people. True colorblind, right? That you really can't perceive red, yellow, green, and I think I've seen one person in my career that has really truly just can't see diddly squat with colors. So we'll talk here also about stability. This does reference stability. That's your judgment. The form does, we'll see this in the form in a minute, does ask the ophthalmologist's opinion. You can use that, but not stable or sufficient time has not passed to allow the person to adapt. That would be to be not stable, but they're separate. You know, if the guy got his eye poked out two days ago, you're probably not going to certify him. If you got it poked out 10 years ago, maybe, right? This is a judgment call. This is where you're expected to use your independent medical judgment. The medical advisory criteria, so we've gone for the regulation now, and now we're moving to the next level, the MAC. Again, those are codified. They're in the code of federal regulations, though they're non-binding as a regulatory material. As Natalie said, though, if you deviate from them, tread lightly, and document, document, document. There is no, there is, the medical advisory criteria is silent, okay? This is important as well. So let's say the person shows up to your office, and they have, you'd, you know, this is the first time. They discover, you know, they have monocular vision. They don't meet the standard, right? And you're going to say, well, you know, I don't want to disqualify the guy, because then you'll have to do the whole exam over again. So you put them in pending. Wrong answer. You have to put them in, you cannot use determination pending. Remember, go back to 391.41. If they don't meet the standard, you have to disqualify them. It's non-discretionary, okay? There's four non-discretionary standards. This is one of them. You have to fail them. You can, you can, you can if they give you the MCSA 5871 that's completed, but you still are like, eh, I still think I want some more info. But you can't, you can't qualify them without that. So again, there is no more vision waiver program, which is a very old program, and then the exemption program. They're gone. And then they do mention that you can't use those funky telescopic lenses. Sir? Does everyone that wears glasses, are they required to have this 45-day exam? Corrective lenses, it's silent. You can meet the standard with or without corrective lenses. Just make sure you mark the form right, and then you make sure you mark the certificate correctly, too, that they've got to match. I see that all the time. Somebody marks it on the form, they don't mark it on the certificate, vice versa. There's the report, and I'm not going to belabor it. Right here, though, in your medical opinion, is this vision, because ultimately it's an opinion, stable? And they want a rough idea of how long? And so they do ask the ophthalmologist, so you can, you know, but ultimately, again, you're the one that makes the call, so don't pass the buck, you can't. Key points. So for people who are new to this, review the medical records. You know, this is from the FMCSA when we, you know, talked to them. You should look at the medical records if you need to get the records. You don't have to just get the form. And also, the question has arisen, well, what if the person just says they're okay? And again, with the ophthalmologist or optometrist, they're experts, right? They're not going to just, hopefully, seeing a patient say, oh, yeah, I believe you. Okay. All right. Medical examiner key points, again, okay. So when you certify them, you have to see them once a year. I don't care if they've got a glass eye, they've had it since they were 15, and it's never going to change. You still see them once a year, okay? They still have to have their MCSA 5871 filled out. I always tell my drivers, as well, that 5871 is only good for 45 days. So if you, three months from now, decide to go work for another trucking company, and they say, you need to go down to Bronson right now and have Dr. Bernikin do your physical right now, you should tell them, I need to go to my doctor first to get some paperwork because they're going to flunk me if I go down there right now. I'll be fine, but I've got to get the paperwork first. So he's not paying for two physicals, right? So again, 45 days before the commercial driver medical exam. And then, of course, you have to make sure they're in all other respects qualified. All right, road test. So if you read the regulation, there is a road test under 391.44 that's required. Not your problem. It's a requirement. You should know that it exists. That's the motor carrier's problem. Now, I might, as a very high-quality medical examiner, make a note on my reporting to the company that the individual was qualified under the alternative vision standard, but it is not a requirement, okay? And it really is the individual and the company that are required to do it, okay? The other issue that's come up in the frequent question, okay, so I don't meet the standard because I've got a cataract in one of my eyes, and I really can't afford to go get that fixed. You can't do that. If you have a fixable problem, you need to get it fixed. If you need to go get new glasses or new contacts because you wear your contacts all day long and you haven't had them updated in two years, too bad. Go get them fixed. Then come back and meet the requirements under 391.41, not the alternative vision standard. From FMCSA, they assume that individuals will make rational decisions, so I don't know who they're referring to, that they will take necessary steps to fix their eye problem, okay? So again, this is intended for people who have a fixed permanent defect. It's never going to get better, all right? But if it's a fixable problem, and where I see this usually is they need updated glasses or they need cataract surgery or whatever, then they have to have it fixed. This was another clarification, so I don't like to have my reading glasses because I'm just that kind of guy, so I got one eye corrected to see far away, and I got one corrected to see up close. Nope, you don't meet the standard because you've got to have it in both eyes, nor can you use the alternative vision standard, so that's not allowed. You have to either, usually I tell people, you know, pick one and test, you know, make sure they meet the distance requirement, and then they're going to just have to wear their cheaters, all right? Some people get LASIK, and they get one corrected for an instant and one to near, well, they're going to have to get corrective lenses to make that near vision eye be able to meet the standard, and they'll have to wear their corrective lenses when they drive. You should never be marking this federal vision waiver exemption, okay, because that doesn't exist anymore. Bye-bye. And, again, keep the report we touched on that. These are some other frequently asked questions. Can you give them less than 12 months, less than, less than, not more than, less than, yes, you can give them less than. So if they have another issue, and you don't feel like that they're, if you don't wanna wait a year to see them back, go ahead and just qualify them for less time. If you don't agree with the ophthalmologist, what happens then? Well, you're the one signing the form, it's your license number, it's you're the one signing. I would personally reach out, and this is the advice from FMCSA, talk to the doc, talk to the eye doc, come on, pick up the phone, it's not hard, and then ask some questions. But ultimately, at the end of the day, your clinical judgment has to prevail. And again, document, document, document, why did you deviate from the ophthalmologist? Maybe you know something the ophthalmologist doesn't. What do you do with the form? You keep it with the medical records, you don't submit it with 5876, you just keep it three years, of course, for FMCSA, longer if your state requires retention of medical records longer. You can't just accept a little note from the card, from the eye doc that says he looks good to me, you gotta use the actual form, that's what this question's about. Road test, again, we talked about this, it's the individual's responsibility to notify the motor carrier about the road test, ha ha ha. Yeah, I'll leave it there. Okay, again, so now we've gone from the regulation to the MAC, we've talked about the regulation, there is no MAC, now the handbook. The handbook, it's reminding you of things that you should consider when you're evaluating a driver with vision issues, right? So, has your vision changed? Night vision, cataracts, can you see okay? What medicines do you use for your glaucoma? Does it bother you for a while after you put your glaucoma medicines in? Do you have blurry vision, do you have LASIK? Do you have the starburst, the halos at night? That kind of thing, okay? But again, ultimately, y'all should know this anyway. I shouldn't, you shouldn't have to do this, but it's nice to have a little reminder. Tells you how to do the test, Snellen or Titmus is fine, must be recorded in Snellen compatible values, so 20, 30, 20, 40, with or without corrective lenses, but if they need corrective lenses to meet the standard, you gotta check the appropriate box on the 5875, the long form, and also on the 5876, the DOT card, and so on. Peripheral vision, you can do the Titmus, some, you know, the Titmus has lights off to the side, you can use confrontation, you can send it to an ophthalmologist and get a formal visual field evaluation, whatever you wanna do. So, basically say if they don't, if they can't see the, you know, 70 degrees horizontal, in each eye, then send them for an evaluation. So, that is part of the standard. Red, green, and yellow, again, they're stressing that you don't have to look at red and say, that's red, it may look brown to them, but as long as they can tell the difference between brown and off green, no problem. Don't use a traffic light in your office to test their color vision, everybody knows red, yellow, green, okay? Use something else. You can use a Shihara plate book if you want, it's not a requirement, you can use markers. My old company had a poster with just basically big squares of red, yellow, green, and they were all in random order, and we would just point to them in random order. But you can do what you want. So, let's move on to hearing. Here's the form, so this is on the 5875, the driver questionnaire, do you have ear hearing problems? Only one question. Here's the regulation, so we move from the form to the regulation. Forced whisper in the better ear, okay? So recall, for vision, you gotta have two good eyes, for ear, you only have to have one. So, they have to be able to perceive a forced whisper or pass an audio test. The audio test is in the speech range, so those of you who do hearing conservation, it's different, we're talking 500, 1000, 2000. This is in the regulation, what the calibration is. If you need to, we'll see this in a bit, you can correct this if you need to. Okay, basically, add them together, divide by three. I would know this, I would know this, because you will probably be asked to calculate an average, make sure somebody meets the standard. So, two eyes, one ear certifies, or one ear, two eyes certifies. There is a hearing exemption, and in fact, I just had a driver this week that I was the first one I've ever seen. He read lips, he couldn't hear at all, and I gave him a certificate that said he needed to have a hearing exemption. There it is, they will consider it. So, now we move on to the medical advisory criteria. Remember, there's the regulation, then there's the MAC. What they talk about in the MAC is the conversion. Now, you're not gonna get tested on this, so don't wrap your head around them memorizing what you gotta do. They might ask you if you need to convert it or something like that, but you're not going to have to actually convert, because, and this just basically tells you how to make the conversion from the ISO standard to the ANSI standard, because the ANSI standard is what's in the reg. If your audio booth is calibrated to ISO, do the subtraction. You all know you can't use your audio booth for somebody with hearing aids, right? Unless you're set up with that specific equipment. So, they also tell you in the MAC how to do the forced whisper. Five feet away, you're being tested toward the medical examiner, cover the other ear, whisper words. I mean, they're telling you exactly how to do it here. So, a forced whisper is 33, 29, not 33, 29, okay? I use numbers because people that have limited, you know, that are non-native, for example, that have limited English skills can do numbers generally, okay, and don't ask to do all S words. If people flunk the hearing test, the whisper test with me, I'll sometimes grab somebody else in the office and have them do it too, because sometimes it's just a voice thing, and I can generally tell when I walk in the room whether they're gonna pass the test or not. Hi, how you doing? What? Hey, how you doing today? We're probably gonna have an issue. All right, again, you only have to pass with one ear. If they need hearing aids to pass, that's fine. Then check the box, just like corrective lenses wearing hearing aids. But if they're going for the exemption, this is, again, in the medical advisory criteria, so this is codified to some degree, don't pick the hearing aid box. They're going to be exempted from the regulation, right? They're petitioning the Federal Motor Carrier Administration to say, I feel that I am safe enough to operate a commercial vehicle despite being deaf. I'm petitioning you to be exempted from this regulation, and here's why. So there's not gonna be, they won't have a hearing requirement. They're basically being exempted from it, so don't check the box. Just say they need an exemption, okay? And again, if they need hearing aids to pass, to meet the standard, check both forms. I see that all the time, get missed on paper, when you're doing it on paper. There's the website, it's for your reference only. How am I doing on time back there? Plenty of time, okay. This is a repeat of the last one. Now, this one, if they're getting an exemption, that you can qualify them for two years, okay? This is an exemption, not an alternative standard. A common question I get is, and I hear reluctance from examiners to certify people because of this. Well, I don't wanna give him a DOT card because what if he doesn't have the exemption, he drives? I'm liable. No, you're not. You are telling the Federal Motor, and they won't give him the exemption without that certificate, right? You're basically telling the Federal Motor Carrier Safety Administration that this person is, in all other respects, qualified to operate a commercial vehicle. They just don't pass this regulation. They need that because they're not gonna certify somebody to give somebody a hearing exemption when they have a seizure disorder, or you can't certify them for more than three months because they got other stuff going on. So you have to do that. You have to provide them with that certificate for them to be able to apply for the exemption. It's not your problem. And I tell them, I said, this isn't good without this exemption. You don't have it in your possession, and you get pulled over driving a commercial vehicle. It's on you, man. And I bet your company's gonna walk away from you, too. So don't do it. All right, and so here's the hearing aid. That's if they need hearing aids to pass. If they don't, then you get the, then they do the waiver exemption. Again, this is really rare. I had one person, I just had it this week, that. So let me, I'm having a senior moment here. Exemption. I think that was. So we're good on, so we can do questions and answers here on hearing and vision or anything else you like. Yes, sir. So if somebody comes in and they need new glasses, do you disqualify them if they don't need, and then you say, go, see, and then come back, and we'll do a whole new exam? That is correct. Remember, there are four regulations that are not up to you. You have no choice. One is vision. They have to either pass their vision or meet the requirements in the alternative vision standard. So for vision, if they don't meet the standard, you have to disqualify them. You can't have them drive in a vehicle that they don't meet that. And then they, yep, go get glasses. Then come back. You can't put them in pending. They don't meet the standard. Then they'll come back, and you have to do it all over again, whole thing. And a question that comes up frequently, and well, do I have to charge them for that? That's up to you. That's your discretion. Yeah, I do. That's my work. I'm getting paid for it. These regulations are not secret. Truck drivers can look these up. It's not like some code that we're not telling them. If you're in a profession, you should know the rules and regulations that affect your profession. So I tell them that. I'm like, I'm sorry, this is the rules. I don't have a choice on this one. This one, I don't. The other non-discretionary ones are hearing. They have to pass the hearing standard. They can't use insulin and drive unless they meet the alternative insulin standard, which we'll talk about later. And they can't have a seizure disorder. And again, there's an exemption for that, but those are, we'll talk about those later, but those are the four non-discretionary standards. The others, you have some wiggle room, and you can use things like pending. You have to do a whole exam again. You should not do a shortcut. Yep. I've had people that leave and they come back the next day. I run into this sometimes where somebody comes in the office and they left their glasses at home. So sometimes I'll say, well, how long is it gonna take you to go home and get your glasses? And it's like 15 minutes. I'm like, okay, you have 35 minutes to get to your house and back here. Do not stop at Burger King. Do not stop at the grocery store. If you are not back here by 9.35, I'm going to disqualify you and you will have to do it all over again. That's about all the leeway I would give somebody that left their glasses at home. If they're from another state, they're not gonna be able to get them too bad, you're disqualified. And I've had people come back the next day and I've had them repeat the exam, and it is what it is. Other questions? Natalie. Yeah, so we're doing, I'm making things like dessert, is I have to admit that's like, so there's a business following that. So sometimes I can hold that a little bit. Yeah. So I may give them first thing tomorrow morning. Right. I could say, I mean, day after day. Right. So Natalie has a different approach for the tape. She will hold, since she has to report the next day, next business day, she might hold on to that a little longer than I do with the glasses issue. I tend not to, because I'm, you know, it's just me. But again, there's no wrong answer on that, other than you cannot put them in pending and have somebody, because when they're in pending, if they have another certificate, they're, that certificate is valid until that certificate is done, okay? So if their medical certificate that they have doesn't expire for another two months, because they're switching jobs or whatever, that certificate is valid. Pending means that you're not done yet. You're waiting for more information. And I'm sure you're gonna talk more about that process, but that means you're not done yet. So that certificate is still valid. So now you've got somebody that doesn't meet a standard, and they're driving around not meeting the standard. So I'm pretty strict about these. If you don't meet the standard, I'm done, because then they can't drive until they get their problem addressed. Again, if it's something that's non-discretionary, or that's discretionary, non-vision or whatever, you can have some wiggle room. So keep in mind, a pending does not affect any current certificate that they may be holding. Don't rely on the driver to necessarily know whether or not they have a certificate, or they tell you, well, do you already have a DOT card? Well, they don't have a DOT card, so I'm gonna go ahead and put them in pending, because I feel bad for them. Okay, well, sometimes the driver interprets that, do you have a DOT card from this company? They didn't tell you that they got a card from another company, because in their mind, and they're not lying, they're not being deceitful, they don't understand that, right? They're just saying, no, I don't have a card. I just, I haven't worked for these guys yet. He didn't tell you he's got a card from another company that's perfectly valid, and he's gonna keep driving for them while he's waiting to get this job. So don't assume that they know what you're talking about. Okay, they come from very different backgrounds. For those of you who have never sat inside a tractor trailer, I would really encourage you to do it. Great opportunity to do it. If you can, even better, if you can go to one of the schools and they'll let you drive it around the parking lot, that's great, because you, I cannot even tell you, you know, it's a different world from what we live in, okay? For those of you who have served in the military, you might have an idea. Crappy food, crappy living conditions, you're away from home, you're away from your family. Other questions? I don't know where we are in time. I think we're actually gonna break. Again, as you've talked about, I know we will be here. Chances are, if he's 25th, or 26th, or 2100 today, he's probably driving away in the past couple of days. So we also are missing one eye or both eyes. If both eyes are gone, yeah, that's the end of it. But I wouldn't put him in determination pending, that would be in no way. That would be, oh, I'm just not gonna do the paperwork until tomorrow morning, because I have that option, so I'm like, by midnight the following day. Yeah, and what Natalie is referring to, and what I've been referring to are nuances, okay? For purposes of the testing, 2040 is the standard, okay? And if they ask you about a guy that's got a 2050 vision, or 2200 in one eye, 2040 in the other, 2040, both eyes, one ear, two eyes, certifies. And for the test, if they walk in and they don't meet the 2040, you disqualify. Correct. That's the bottom line. Bottom line.

medical evaluations

commercial drivers

independent judgment

vision standards

hearing standards

documentation

medical exemptions