ACOEM Comments on DOT Guidance Documents

May 8, 2019
Docket Management Facility
U.S. Department of Transportation
1200 New Jersey Avenue, S.E.
West Building Ground Floor, Room W12–140
Washington, DC 20590–0001.
Re: Docket No. DOT–OST–2017–0069
To Whom It May Concern:
The American College of Occupational and Environmental Medicine (ACOEM) appreciates the opportunity to respond to the Department of Transportation’s (DOT) request for comment on all existing guidance documents.
ACOEM is a national medical society representing more than 4,000 occupational medicine physicians and other health care professionals devoted to preventing and managing occupational injuries. Our members are active in the many transportation modes and rely on medical guidance provided by the agency.
We understand that the guidance, while not regulatory, is meant to aid the health care professional in evaluating the issue at hand. The most significant issues we see are the lack of guidance in many areas and the need for existing guidance to be updated in a timely manner. Additionally, ACOEM believes there is a need for the DOT to take a more active role in distributing guidance to its intended audiences. Interested parties, such as medical examiners, may be unaware that such guidance exists or overlook its importance given that it is not regulatory.
A significant number of our members act as medical examiners for medical certification of commercial drivers. Unfortunately, some of the guidance they rely on has been removed or not regularly updated.
A primary source of guidance from the Federal Motor Carrier Safety Administration (FMCSA) is the Medical Examiner Handbook. While this was removed from the National Registry of Certified Medical Examiner (NRCME) website several years ago for update, many examiners still utilize it, as it as the main resource used by many of the NRMCE training programs. The only update to the Handbook since it was initially posted, was the removal of any reference to Obstructive Sleep Apnea. The FMCSA’s Medical Review Board (MRB), a panel of physicians whose purpose was to “provide information, advice, and recommendations to the Secretary of Transportation and the FMCSA Administrator on the development and implementation of science-based physical qualification standards” was tasked with updating this Handbook. MRB has been at  work on this project for over three years but has yet to make an updated Handbook available for medical examiners.
Additional sources of guidance for the commercial driver medical examiner are the FMSCA’s Frequently Asked Questions and Interpretations to the Regulations and the Medical Advisory Criteria (MAC). Both key resources need to be updated consistently with current, evidence-based best practices. MRB provided recommendations to the FMCSA in their Task Statement 16-2 (2006) to update the MAC, but the only minor changes have been made since these recommendations were made.
Many of the resources needed for these updates are already available. Since 2007, the MRB has analyzed numerous Evidence-Based Reviews, Expert Panel Recommendations and has made over a decade of recommendations to FMCSA. The Motor Carrier Safety Advisory Committee has also offered recommendations on several topics based on extensive reviews, including requests from stakeholders.
Unfortunately, not all examiners are aware of the work of the MRB and the evidence- based reports. While the examiner training programs are required to cover the FMCSA Core Curriculum, some limit the training to only what was in the Medical Examiner Handbook or on the FMCSA website (not the content from the MRB). Other training programs include additional guidance from the FMCSA, such as Evidence Reports, Medical Expert Panels, and the MRB Task Reports. Many examiners do utilize these reviews and reports as FMCSA guidance. However, the FMCSA’s has indicated in the past that they are not “official” FMCSA guidance and that their existence and content “may” but is not required to be taught in NRCME training. The FMCSA’s reluctance to endorse this content has led to many examiners either being unaware of its existence or unaware that the content should be used in reaching a certification determination. These guidance documents are based on current evidence-based medical knowledge, and it should be required that examiners be aware of and utilize their content when applicable to the driver they are evaluating.
Since full implementation of the NRCME, the number and types of health care providers have increased. Many providers are only able to perform a physical examination to recommend a specific type of treatment. Some of these providers have never evaluated, diagnosed nor treated patients with many of the conditions for which they are asked to perform a risk assessment, a determination of whether that individual is at risk of sudden or gradual impairment or incapacitation. It is impossible for a health care provider who has not been trained in the side effects or interactions of medications to appropriately determine whether the medication will impair the performance of safety sensitive-duties; and will often rely on the driver’s report or a statement obtained from the treating provider. Relying solely on the statement of the personal physician without basic guidance on the risks specific to commercial drivers is also inadequate. Treating providers are focused on treatment and mitigation of complications from the medical conditions and are often not trained in the assessment of the risk of sudden or gradual impairment or incapacitation from medical condition(s) or treatment(s)
Lacking current, consistent, evidence-based guidance to assist in an individualized assessment, some examiners may rely on the “seems good enough” evaluation to certify an individual. They may also at times issue a certificate for two years when the majority of highly qualified examiners would have at most issued a one-year certificate. In addition, there are websites and blogs that direct drivers to those examiners that rely on the “minimal medical standards” for certification determination rather than current medical literature to determine the risk of sudden or gradual impairment or incapacitation. It is possible that this widening variance in the performance of these examinations has led to the increased number of crashes identified in the 2018 Large Truck Crash Causation Study, which led to the recently initiated audit by OIG of the FMCSA Medical Program. If the FMCSA were to ensure that all examiners have access and are aware that guidance consistent with current best practice exists, those examiners would have sufficient information to at least ask the right questions.
There is also a need for more detailed medical guidance for those who are evaluating fitness for duty of mariners. The current NVIC 04-08 gives very little guidance to medical examiners on criteria for evaluating mariner medical conditions in determining actual fitness for duty. The Draft Medical Guidelines as published have even less guidance. It also places full responsibility on the owner/operator of a vessel to ensure each mariner’s fitness for duty. If the United States Coast Guard (USCG) is only determining “Fitness for Credential” as a checkbox in the mariner credentialing process, it would be more practical to reference best practices in mariner medical guidelines. The USCG should also make it very clear that the 719-K Medical Examination form is not a Fitness for Duty determination from the USCG. Currently there is a conflict between the USCG Fitness for Credential and the owner/operator Fitness for Duty which causes unnecessary EEOC claims.
Many of our members are also Medical Review Officers (MRO) and rely on guidance issued through the Office of Drug and Alcohol Policy and Compliance (ODAPC). While there is a new MRO Handbook available through the Substance Abuse and Mental Health Services Administration (SAMHSA) for non-DOT federal drug testing, a current document is not available for MROs reviewing DOT drug test results. One of the key areas of concern which is addressed in the SAMHSA document is whether a prescription is “too old”, and whether it is being used or was used “during the time period for which it was legitimately prescribed.”
Thank you for your consideration of this request. Please do not hesitate to contact Patrick O’Connor, ACOEM’s Director of Government Affairs, at 703-351-6222 with any questions.
Stephen A. Frangos, MD, MPH, FACOEM
ACOEM President