Am Fam Physician. 2010 Apr 15;81(8):975-980.
The commercial motor vehicle driver medical examination aims to ensure that commercial drivers can safely perform all driving and nondriving work-related tasks. In conducting the examination and completing the related certification, the medical examiner must follow mandated medical standards and consider medical advisory criteria. Examiners should consider the substantial expert guidance provided in making certification determinations. For several common conditions, regulations and guidance are currently under review by medical review boards and expert panels, and major updates are likely in the near future. In addition, legislative changes are likely to require specific training and certification for medical examiners. These changes aim to increase the effectiveness of the commercial motor vehicle driver medical examination as a public health safeguard by reducing commercial motor vehicle crashes.
Most commercial motor vehicle drivers are required to meet the medical standards of the Federal Motor Carrier Safety Administration (FMCSA); nevertheless, medical conditions of drivers continue to be implicated in crashes involving commercial motor vehicles.1,2 One strategy to improve safety is better training of the commercial motor vehicle driver medical examiner.2,3 Recent rulemaking may restrict medical examiner eligibility in the future to those who complete specified training and certification.4 This article focuses on major changes in assessment of commercial motor vehicle drivers since the 1998 review published in American Family Physician(http://www.aafp.org/afp/980800ap/pommer.html).5
When performing a commercial motor vehicle driver medical examination, commonly referred to as the Department of Transportation (DOT) examination, the examiner must follow the 13 federal medical standards Table 16); is expected to comply with the advisory criteria6; and should consider all other available guidance, including conference and advisory panel reports.6–9 Frequently asked questions (FAQs) are provided to aid the examiner in making the certification determination (Table 2),8 and the FMSCA is developing a medical examiner handbook.9 A driver's roles and responsibilities, which are outlined on the Medical Examination Report for Commercial Driver Fitness Determination (the form the examiner must use to document the examination), also must be considered. The examiner should remember that the medical certificate is not limited to the current employer and should only sign the medical certificate if the driver is able to perform all driving and nondriving work-related tasks.
Medical examiners are advised to refer the driver to a specialist, if necessary. For many conditions, including some types of heart disease and hypertension controlled by medication, medical certification should be for less than 24 months. Limited certification is also appropriate for a medical condition that does not disqualify the driver, but does require monitoring or reassessment.
In 2005, several changes in the examination process were mandated by the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users.10 One of the major requirements is the establishment of a National Registry of Certified Medical Examiners. Once implemented, only examiners who complete the required training and testing will be registered and permitted to perform commercial motor vehicle driver medical examinations.4 Rulemaking on this change is anticipated sometime in 2010, with about four years until full implementation.
A medical review board—a panel of experts that evaluates evidence on how medical conditions may affect commercial motor vehicle driver safety—was also created to provide medical advice to the FMCSA.11 The medical review board has heard recommendations from medical expert panels on several medical conditions 12 and has made recommendations to the FMCSA,13 but no formal updates on medical standards and guidelines have been issued. Medical examiners should be aware of the various recommendations and key issues, especially in areas where current FMCSA guidance is insufficient or updates are under active consideration. Physicians can remain informed through the eSubscribe services of the Medical Programs of the FMCSA (http://www.fmcsa.dot.gov/rules-regulations/topics/medical/medical.htm)14 or National Registry of Certified Medical Examiners,15 or through the Commercial Driver Medical Examiner Center of the American College of Occupational and Environmental Medicine.16
The following cases illustrate common medical conditions in which information has changed since this topic was last reviewed.5
A driver who has chronic back pain treated with a fentanyl patch (Duragesic) and oxycodone (Roxicodone) is anxious to return to work driving a truck.
Only a few medications are specifically disqualifying (i.e., insulin [unless an exemption is granted], antiseizure medications, and methadone), and the FMCSA has issued official guidance for a few others. For example, in a recent statement, the FMCSA Administrator advised examiners against certifying drivers taking varenicline (Chantix).17 An FAQ addressing modafinil (Provigil) indicates that drivers taking this medication should not be certified until they have been monitored closely for at least six weeks.8 Treating physicians and examiners must agree that daytime somnolence has resolved and no concerning adverse effects are present. Annual recertification is recommended for commercial motor vehicle drivers taking modafinil.
Even a legally prescribed medication may cause the medical examiner to determine that the driver should not be medically certified.8 Examiners should review and document a discussion on the potential hazards of prescription and nonprescription medications while driving. The medical expert panel on Schedule II drugs made several recommendations on the use of these medications.18 The medical review board recommended modifying medications that are disqualifying to include Schedule II drugs and benzodiazepines, except under specific circumstances.19 They also recommended that patients using any medication parenterally (e.g., intravenously, transdermally, intrathecally) not be permitted to operate a commercial motor vehicle. Several resources are available to assist examiners in evaluating the risk of impairment with specific medications in commercial motor vehicle drivers.20–23
The driver in this case should not be medically certified based on the use of medications, and possibly because of concerns about his chronic back pain.
A 60-year-old interstate driver recently started dialysis. His nephrologist has written a note that he may return to work, but may not work on dialysis days (Monday, Wednesday, and Friday).
The only current guidance for drivers with chronic kidney disease on dialysis is an FAQ that instructs the examiner to, at a minimum, obtain a letter from the nephrologist; however, the FAQ notes that the examiner is not obligated to accept the nephrologist's work recommendations.8 Examiners are also reminded that restrictions, aside from those listed on the examination form, are disqualifying. The medical expert panel on chronic kidney disease24 recommended that all drivers, or at least those at highest risk of chronic kidney disease, be screened for kidney disease through the use of the Modification of Diet in Renal Disease glomerular filtration rate calculation.25 They recommended that drivers in stages 3 and 4 chronic kidney disease undergo more frequent certification and that those in stage 5 or on dialysis be disqualified. Although the medical review board concurred with those recommendations, guidance from the FMCSA is still pending.26 It is most likely that the driver in this case should not be medically certified.
A driver's blood pressure is measured twice and the lower reading is 158/98 mm Hg. He is taking two antihypertensive agents and has no other medical conditions or risk factors.
Although the medical standard does not indicate a specific acceptable blood pressure, the guidance is detailed. Drivers who take antihypertensive agents should be medically recertified annually, even if blood pressure readings are in the range acceptable to the FMCSA (Table 3).6
The driver in this case should be medically certified for up to one year to bring the blood pressure into the range of 140 mm Hg or less systolic and 90 mm Hg or less diastolic. If the blood pressure remains above that level, but below 160/100 mm Hg, the driver may be given one additional three-month period to achieve control. Once the blood pressure is 140/90 mm Hg or less, he should be issued only annual medical certificates.
A driver whose diabetes has been managed with oral agents for the past 15 years began insulin therapy three months ago and has been cleared by his endocrinologist to return to commercial motor vehicle driving.
Currently, drivers requiring insulin for control of diabetes need a federal diabetes exemption; however, they no longer have to wait three years to be eligible for this exemption. The examiner should evaluate these drivers, especially for complications of diabetes. If the examiner determines that the driver meets all criteria except the insulin requirement, the driver could be certified for no longer than one year. The medical examination report and the medical examiner's certificate must note that the driver requires a federal diabetes exemption. The driver should be informed that the certificate is not valid until the exemption is granted by the FMCSA. This can take up to 180 days from the time the FMCSA has the completed application and all required documentation.27
A driver who requires two medications to control hypertension denies any other medical conditions, but admits to severe snoring. Aside from a body mass index (BMI) of 45 kg per m2 and a blood pressure of 138/88 mm Hg, his examination is normal.
The current guidance from the FMCSA does not provide screening criteria for obstructive sleep apnea (OSA). A 2006 task force suggested that drivers be screened for OSA if they met at least two of three criteria (i.e., BMI of 35 kg per m2 or greater; neck circumference greater than 16 inches in women or 17 inches in men; or hypertension that is new, uncontrolled, or requires at least two medications to control).28 Further evaluation is also recommended if any of the following criteria are met: sleep history suggestive of OSA; Epworth Sleepiness Scale score greater than 10; a previously diagnosed sleep disorder; or an apnea-hypopnea index greater than five, but less than 30 in a previous sleep study or polysomnography. More recently, a medical expert panel recommended that the only criterion for testing should be a BMI of 33 kg per m2 or greater.29 The medical review board has recommended that the FMCSA select a BMI of greater than 30 kg per m2 as the screening criterion.30
The driver in this case could be medically certified for a temporary period while undergoing evaluation for OSA. If OSA is confirmed, he should be monitored more often to assess compliance with treatment. His hypertension would also be grounds for a shortened certification.
A driver has experienced several seizures since a closed head injury 18 months ago. He has been seizure-free for six months with levetiracetam (Keppra) therapy. He has no neurologic deficits and is otherwise healthy.
Although a medical expert panel on seizure disorders and commercial motor vehicle driver safety recommended permitting some drivers to operate commercial motor vehicles if their seizures are well controlled by antiseizure medications (a recommendation with which the medical review board did not agree), drivers taking antiseizure medication currently do not meet the medical standards.31 Current guidance is that a driver with a single seizure may be medically certified if he or she has been seizure-free without antiseizure medication at least five years. For those with a history of more than one seizure, the waiting period is 10 years seizure-free without medication. The driver in this case may not be certified.
The examples above highlight some areas that have recently been reviewed by the FMCSA, the medical review board, or medical expert panels. It is important that all physicians who examine commercial motor vehicle drivers be aware of the regulations and all related information. Table 4provides key resources, and the recently redesigned FMCSA medical Web site is a good source to remain current in this rapidly changing area of medical practice.14
NATALIE P. HARTENBAUM, MD, MPH, FACOEM, is chief medical officer and president of OccuMedix, Inc., Dresher, Pa.