Q: You have a special interest in sleep medicine, particularly as it pertains to transportation. If you look at the physical stressors on drivers today – like long, sedentary hours, diet, and sleep apnea – compared to thirty years ago, what has shifted or changed the most?
A: In my opinion, the biggest shift has been the recognition that sleep plays a large part in an individual's health and wellness. Sleep medicine was not even recognized as a specialty until 1996. In the field of medicine, that is a very short amount of time.
However, I can’t say that has been translated into action when it comes to the commercial driver. Hours of service increased in 2004 — from ten hours to 11 hours — and including up to a 14-hour workday. It requires ten hours off duty, but that ten hours does not require the driver to sleep. Much of that time may be taken in commuting, normal activities of daily living, and interacting with friends, family, and social media. Published data shows that most drivers get about four to six hours of sleep on average compared to the national average of about seven hours. The national economy absolutely relies on commercial vehicles to move most goods in this country, and the current regulatory environment does not seem to be looking at improving driver quality of life unfortunately.
Sleep and fatigue are very under-reported or under-investigated as causes of large truck crashes; therefore the real-world impact is hard to gauge but the NTSB estimates it to be around one-third of heavy truck accidents.
Q: While the FMCSA provides guidelines, clinical judgment is still a big part of the job. The regulations give clear guidance on many things, but where do you find examiners struggling the most with "gray areas" or subjective calls?
A: The most common issue that I see is that they really struggle with deviating from recommendations or information found in the "old" Medical Examiner Handbook. For example, stress testing after a heart attack was recommended every two years, or that anyone with an ejection fraction under 40% should be disqualified, anyone with a blood pressure greater that 140/90 can’t get a two-year medical certificate, etc. Sleep apnea is another area – anyone with an AHI over a certain number requires treatment for example. Medications are huge – considerable ink and sweat have been spilled over whether drivers on certain medications should be medically qualified.
There is a lot of fixation on absolutes – if this, do that, but medicine is not and never has been an absolute. Every person is different and should be approached as an individual. Medical guidelines and standards of care have changed significantly over the years since that document was available and examiners really should be considering how various conditions are managed today.
Examiners must understand not only what conditions affect drivers, but also be familiar with the clinical course, treatment, co-morbidities, and side effects of treatment so they can make an informed risk assessment and medical certification decision. That is a lot to keep up with, but at the end of the day, the expectation is that we consider each driver on a case-by-case basis and use our independent clinical judgement to make the risk assessment.
Q: Medical examiners often must play "detective" because drivers might downplay their symptoms to protect their livelihood. What is your top advice to providers on how to build trust while ensuring public safety?
A: My approach is treating drivers with respect and honesty. Explain the why. I have a lot of success in reassuring them that most conditions can result in medical certification once adequately treated and controlled.
I also have a lot of success when I discuss with the driver that the medical certification exam is almost more about protecting them than the public. Right now, we live in a very litigious society. When something bad happens, often the first reaction is looking for someone to blame. If a driver is less than forthcoming with their examiner, and that comes up during a crash investigation, it can really expose the driver to more liability and a loss of credibility than they might have otherwise had.
Finally, don’t blame the government for a disqualification decision. Examiners need to own up to their decisions and explain them in terms the driver can understand. Today, drivers are quite familiar with the regulations and are very adept at looking up what they don’t know. If an examiner blames a non-existent regulation for a decision, the driver will know and the examiner will have lost all credibility and trust.
Q: You have a significant military background as an Army Flight Surgeon and Lieutenant Colonel in the Michigan Army National Guard. Is there a lesson you have learned from your time in the military – either in your training or your deployment – that you share in your commercial driver medical examiner certification training?
A: A saying one of my instructors at Fort Rucker was fond of was "Keep them flying, safely." I have applied that lesson to drivers as well – "Keep them driving, safely." There is sometimes a tendency to treat the medical exam as a "gotcha" moment; look for the bad, assume the worst, and find reasons to disqualify someone. Certainly, everyone has a tendency to downplay medical issues when your livelihood is on the line, but rather than guilty until proven innocent, I tend to take the approach another famous person did – "trust but verify."
Like pilots, drivers are a critical part of the "mission" to keep our supply chains moving. Without them, logistics grinds to a halt. No more groceries, no more mail, no more same day packages, no more gasoline — you get the idea. Do the due diligence but remember the "mission." Remember that drivers have bills to pay, families to feed, and sometimes not working is more harmful than staying gainfully employed. These are things that I think an examiner should consider as part of the decision-making process. Sometimes I can keep a driver working rather than simply disqualifying them by using a shorter certification window. That way I can keep an eye on them and make sure they are doing the right thing medically. Keep them driving, safely.