Urgent message: The Department of Transportation’s responsibility to ensure that commercial drivers are physically qualified to operate in interstate commerce can mean new business for urgent care providers who qualify to perform certification exams.

Ellison H. Wittels, MD, FACP
The Federal Motor Carrier Safety Administration (FMCSA) – one of nine operating administrations within the United States Department of Transportation (DOT; Table 1) – is tasked with regulating commercial trucks and buses in interstate commerce. That means any trade, traffic, or transportation involving the vehicle and its contents crossing or driven with the intent to cross a state boundary.

More to the point, it is the mission of the FMCSA to reduce crashes, injuries, and fatalities involving large trucks and buses. Although recent data illustrate the success of this mission, a large number of individuals are still killed or injured in crashes involving large trucks and buses (Figure 1 and Figure 2).

In addition to causing fatalities and injuries, crashes involving interstate trucks and buses also have a significant financial impact. Based on the latest data available, the estimated cost of police-reported crashes involving trucks weighing more than 10,000 pounds averaged $91,112 (in 2005 dollars).2

Overall, the costs per non-fatal injury crash averaged $195,258, and fatal crashes cost $3,604,518 per crash.2

Table 1. DOT Operating Administrations

·         National Highway Traffic Safety Administration (NHTSA)
·         Federal Highway Administration (FHWA)
·         Research and Innovative Technology Administration (RITA)
·         Pipeline and Hazardous Materials Safety Administration (PHSMA)
·         Maritime Administration (MARAD)
·         Federal Transit Administration (FTA)
·         Federal Railroad Administration (FRA)
·         Federal Aviation Administration (FAA)
·         Federal Motor Carrier Safety Administration (FMCSA)
·         United States Coast Guard (USCG; moved from DOT to Homeland Security)

 

Federal Medical Certification

A major tool the FMCSA employs to this end is Federal Medical Certification, which is required for all drivers of a self-propelled or towed vehicle that transports passengers or property in interstate commerce that is:

  • ≥ 10,001 pounds
  • designed or used to transport eight or more passengers (including the driver) for compensation
  • designed or used to transport 15 or more passengers (including the driver) and is not used for compensation
  • any size and used to transport placarded hazardous materials.

It is here that the DOT’s public safety mandate intersects with the urgent care practitioner’s expertise, opening the door to providing additional services for patients who are commercial motor vehicle (CMV) drivers – and to companies who may be looking for new occupational medicine providers.

It should be noted that the DOT does not set fees. Fees are negotiated between the examiner and the payor; this may be the carrier who sends their drivers for examination, or even the driver.

The National Registry of Certified Medical Examiners

The Safe, Accountable Flexible and Efficient Transportation Equity Act – A Legacy for Users (SAFETEA-LU) became law in 2005. One part of this bill requires that the Federal Motor Carrier Safety Administration implement a National Registry of Certified Medical Examiners (NRCME). Examiners must be on the Registry to certify commercial truck and bus drivers.

Currently, medical doctors, osteopathic physicians, physician assistants, nurse practitioners, and doctors of chiropractic are able to certify commercial drivers if their state licenses allow. NRCME does not change the groups that are eligible. To qualify for the registry, the individual must complete and educational course and pass an examination. (Information on the registry is available on the NRCME homepage, http://nrcme.fmcsa.dot.gov/.)

Each of the approximately 8 million commercial drivers in interstate commerce must be medically examined and certified at least every 24 months. Many drivers will need to be certified more frequently because of an employer change, having a condition that requires more frequent re-certification, or having a medical exemption; some may need to be certified at least every 12 months if their ability to perform normal duties has been impaired by a physical or mental injury or disease.3 It is estimated, anecdotally, that as many as 5 million certification examinations are done annually.

Demographic data support that the need for trained, knowledgeable examiners will increase. The U.S. workforce is aging, and the average age of commercial drivers is increasing. The largest growth in the labor pool is expected to be from new employees over 55 years of age.4

An aging population is more at risk for chronic disease or sudden incapacitation than a younger population.
The vast majority of commercial drivers are male and over 40 years of age. The average driver is sedentary. Drivers are more overweight and as a group have a higher prevalence of smokers than the general population.
Overall, the CMV drivers are less healthy than the general population, are more likely to have more than two medical conditions, and have a higher-than-average prevalence of cardiovascular disease.

The aging driver population and the health of drivers should make certification decisions challenging. At the same time, the increased risk of injuries and fatalities from commercial vehicle crashes and the demands of their work require that commercial drivers be held to higher physical and psychological standards than drivers of passenger cars.

The Certification Examination

The examiner must consider several guiding principles in the context of the driver examination:

  • The certification examination determines the presence of medical or mental conditions that could affect the driver’s ability to safely operate a motor vehicle. It is not intended to substitute for ongoing medical care.
  • The DOT standards and guidelines are the same for all drivers; they are not job-specific.
  • Driver certification decisions cannot be based on specific job accommodations or requirements.
  • The same form is used for initial certification, re-certification, and return to work. This is a standard form provided by the DOT, available at http://www.fmcsa.dot.gov/documents/safetyprograms/Medical_Report.pdf.
  • Finally, and importantly, the examiner must remember that the certification examination is not done for the driver or the carrier. The examination is done to protect the other motorists on the road and their passengers.

History
The driver completes the history part of the form. He or she should list al medical diagnoses, the date of onset, treatment, and the treating doctor’s name and address. The driver must sign the form to certify that the information is correct.

The medical examiner should review all “YES” answers with the driver, document this on the form, and note any likely effect on safe driving.

The examiner should review all medications, including over-the-counter medications, that the driver has used regularly or recently and discuss with the driver their effectiveness, side effects, and potential hazards. This discussion should also be documented on the examiner’s form.

Specific testing required
Several categories of testing are required as part of the certification examination.3

  1. Vision requirements are regulatory. Requirements include distant acuity, color vision, and peripheral vision. The driver is required to have a t least 20/40 distant vision acuity with or without correction in each eye and in both eyes together. The Snellen chart is the preferred vision test. An optometrist or ophthalmologist may provide the eye exam.

The use of corrective lenses to pass the vision test requires that the driver wear corrective lenses while operating a commercial vehicle; this must be noted on the Medical Examiner’s Certificate. If the driver wears contact lenses or intends to do so while driving, sufficient evidence of tolerance and adaptation to their use should be documented.

In addition, the driver should have peripheral vision of at least 70 degrees in the horizontal meridian in each eye.
The applicant must also be able to distinguish traffic control signals and devices showing standard red, green, and amber colors.

  1. Hearing. The hearing standard requires that the driver first perceives a forced whispered voice at 5 feet with or without a hearing aid in at least one ear, or has an average hearing loss in the better eat at 4o dB at 500Hz, 1000Hz, and 2000Hz with or without a hearing aid.

If the driver needs a hearing aid to pass the hearing test, then he or she is required to wear a hearing aid while operating a commercial vehicle. This mist be noted on the Medical Examiner’s Certificate. However, a driver with a hearing aid cannot be tested on an office audiometer because of noise interference, and needs to be referred to an audiologist or hearing aid store for testing.

  1. Urine dipstick for protein, specific gravity, blood, and glucose.

The physical examination
The examination requires measuring the driver’s blood pressure and pulse, as well as the driver’s height and weight. The guidelines for blood pressure are based on the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure VI. The DOT form lists specific physical assessments. The examiner comments on whether the abnormal findings would affect the driver’s ability to operate a commercial motor vehicle safely.

It is helpful to use the hypertension guidelines printed on the form when determining certification for drivers with hypertension.

At the end of the exam, the examiner must sign the form and indicate whether the driver qualifies for two-year certification, does not meet the standards, or meets the standards but requires more frequent monitoring (making the certification for less than two years).

The examiner must also indicate any corrective device – glasses, contact lenses, or hearing aids – that the driver must use while driving and/or exemptions that the driver must have to legally drive.
After the Medical Examination Report is completed, the examiner may complete and issue a Medical Examiner’s Certificate which is given to the driver to show medical clearance, any corrective devices, waivers, or exemptions and the expiration date of the certification.

Standards, Guidelines, and Certification
The DOT Standards and Guidelines are the basis for determining certification of commercial drivers and also are the basis for the NRCME educational course and test.

For our purposes, the guidelines (medical expert reports) and Medical Advisory Criteria provide recommendations for the examiner.

The document goes on to state that “the medical examiner may, but is not required to, accept the recommendations.”

Note: The guidelines are recommendations and are no0t legally binding. However, the guidelines are based on expert review and are considered standards of practice. The guidelines are intended to minimize variations among examiners. The examiner should document why a guideline is not followed where applicable. There is, potentially, more liability when a standard of care is not followed.

It should also be noted that “current guidelines” do not necessarily reflect current treatment practices or technology (Table 3). Many of the guidelines are outdated, contradictory, or do not address major medical problems.

The DOT Standards are under 391.41. They are regulatory and must be followed. Nine standards are general, and the medical examiner has the latitude to use his or her clinical judgment to determine if the driver meets the standards. The examiner has no latitude regarding the standards for hearing, vision, epilepsy, or insulin-treated diabetes.

In addition, the first time a driver who has had an amputation from the ankle up or wrist up is certified, the driver must undergo a Skill Performance Examination with an FMCSA examiner before being certified.
Currently, the FMCSA is updating its Standards and Guidelines. When faced with deciding certification based on the current guidelines, examiners must use their medical judgment and are free to use other, more current medical recommendations.

Table 3. Publication of Guidelines That Inform DOT Recommendations

GuidelineYear published
Neurology1988
Pulmonary1991
Psychiatry1991
Vision1991/1998
Hearing1993
Anticoagulation1996
Cardiovascular2002
Medical guidelines not in agreement: Sleep disorders, dementia
Medical conditions not addressed: Renal disease, musculoskeletal disease, transplants

 
Considerations
In deciding Standards and Guidelines, the DOT must consider both the rights of the individual and public safety. Focusing on the driver’s right to earn a living in an occupation of their choice makes licensing less restrictive. Alternatively, if the focus is on society’s concerns and risk avoidance, licensing is more restrictive.

Central to each decision is risk – the probability that an adverse event will occur and the consequence of that adverse event. Tightening regulations beyond what is necessary has the potential to increase illegal driving and impose unnecessary negative economic and sociological impacts.

Most basically, the examiner determines if the applicant is medically suitable to drive a commercial vehicle. The examiner does this by evaluating the CMV driver for any condition that may cause sudden death or incapacitation or a fixed deficit that interferes with safe driving. For the certification examination, the examiner does not determine treatment, act as the driver’s physician, or provide specific medical advice.
 
Federal regulations require more than driving. The driver is responsible for:

  • pre- and post-trip vehicle safety inspections
  • making sure the load is secure
  • checking the load before beginning and periodically during a trip.

A bus driver should be able to assist passengers in case of an emergency.
Information from the history, testing, or physical examination may be cause for disqualification, limited certification, certification with restrictions, further evaluation, or consultation.
The presence of a medical condition does not necessarily disqualify a driver if the condition does not affect safe driving or is adequately treated and controlled and is not likely to worsen suddenly.

Findings and conditions that are not disqualifying should also be discussed with the driver. The driver should be referred for appropriate follow-up, particularly if the condition, if neglected, might affect the driver’s ability to drive safely in the future. This referral must be documented.

Section 390.3(d) of the FMCSAs allows employers to have more stringent medical requirements. Often, the employer requires not only DOT certification, but also that the driver meet essential job requirements. Additional carrier requirements that do not fall under the DOT should be assessed separately.

Say, for example, a driver is required by the employer’s essential job functions to lift 75 pounds. DOT certification does not require 75 pounds to be able to drive safely; therefore, the examiner can certify the driver regardless of his or her ability to lift 75 pounds. However, the inability to lift 75 pounds would disqualify the driver in terms of the employer’s requirements.
In deciding certification, the examiner may:

  • certify the driver
  • certify the restrictions
  • disqualify the driver.

The examiner can certify the driver for a maximum of 24 months. The examiner may also give a shorter certification, such as three months, six months, a year, or some other appropriate time. The examiner may also give a shorter certification while additional testing or consultation is obtained.

Currently, DOT recommends that drivers with cardiovascular disease, diabetes mellitus, or other potentially progressive conditions that can impair safe driving be seen at least annually.

While the examiner may require testing or consultation with a specialist, it is important to note that the final decision on whether to certify the driver remains with the examiner (i.e., the party who signs the certification card is one with the authority to make the final decision regarding certification).

The specialist may be the authority regarding a specific condition and treatment, but the examiner knows what the DOT medical requirements are for the driver with a specific condition.

Certifying with restrictions
The only two restrictions that the examiner may give on his or her own accord are printed on the certification card; the examiner can restrict the driver to driving only if wearing corrective lenses or a hearing aid. The other restrictions on the card require FMCSA approval.

Current exemption programs
Only the FMCSA can grant exemptions. States may grant waivers, but they are valid only within the state of issuance.

As of this writing, the only active federal exemption programs are the Vision Exemption Program, for drivers with insulin dependent diabetes mellitus, that began in 2003.

FMCSA now recommends that the driver seeking an exemption see the medical examiner first. The examiner identifies or requires the driver to correct any other disqualifying conditions. If the CMV driver passes the examination except for the exemption requirement, then the certifying medical examiner must write the needed exemption on the certification card and long form. The examiner gives the long form and card to the applicant to submit with other required forms to FMCSA.

Qualifies under 49 CFR 391.64
This program began in the early 1990s as a research program to determine if drivers on insulin or drivers with monocular vision could drive safely.

There were 2,300 drivers with a vision wavier and 113 drivers with an insulin waiver accepted into the program.5 In 1994, the court ruled these waiver programs contrary to the law as it was then written. The drivers in the programs were grandfathered in and could continue driving if they remained in good standing with the program, had no progression of the disease, developed no other disqualifying medical problems, and had no disqualifying driving infractions.

To be recertified by the examiner, each driver must have a letter showing their continued participation in the program.
Driving within an exempt intracity zone
In 1988, the states adopted DOT medical requirements. Active drivers whose physical condition was disqualifying under the newly adopted DOT requirements on July 1, 1988 or their first exam thereafter were allowed to drive only in specific zones if their condition did not substantially worsen and they did not transport hazardous materials. They are re-certified annually.

Skill Performance Evaluation (SPE)
Also known as the “alternative standard” this was established in 1999. It allows CMV drivers with fixed musculoskeletal problems or amputation the opportunity for certification if the rest of their certifications meet the requirements.

Disqualified
The driver who does not meet a standard must be disqualified. A driver who does not meet the current guidelines may be disqualified.

Conclusion
Although the DOT form has specific requirements for the history, testing, and examination, the examiner must still understand the duties of the CMV driver. In addition, the examiner must still use clinical judgment to decide certification. Often, because the guidelines do not cover all situations, the examiner should use more current information.

References

  1. U.S. Department of Transportation Federal Motor Carrier Safety Administration. Motor Carrier Safety Progress Report (as of 3/31/10).
  2. Zaloshnja E, Miller T. Unit costs of medium and heavy truck crashes. Final report for Federal Motor Carrier Safety Administration. Pacific Institute for Research and Evaluation. 2006.
  3. U.S. Department of Transportation Federal Motor Carrier Safety Administration. Medical Advisory Criteria for Evaluation Under 49CFRPart391.41.
  4. Purcell PJ. Monthly Labor Review Online. 2000; 123(10).
  5. Qualifications for drivers; vision and diabetes; limited exemptions; final rule. Federal Register. 1996; 61(59): 1333B.
Providing DOT Medical Certification Exams for Commercial Drivers
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