To help occupational health providers transition to the new system, VISIONS tracked down Natalie Hartenbaum, M.D, M.P.H., a nationally recognized expert in occupational fitness for duty, to ask her a few questions. We also include an excerpt of the white paper, “Gearing up for new Medical Examination Requirements,” written by former VISIONS Editor Karen O’Hara and originally published by UL Workplace Health & Safety (ulworkplace.com)––a member of the NAOHP Vendor Program.
Q: With the effective start date for the new medical examiner regulations a little over a month away, how is it going? Is there information you can provide on how many health professionals have received training or have registered with the National Registry? Are there any snafus in the process that you are aware of? Dr. Hartenbaum: According to FMCSA, they will have a sufficient number of examiners based on those that have registered. But the issue is that many who have registered have not sat for the examination. There have been issues with test locations and times but these are being addressed, and there is now a second testing organization with a third coming online in March. It is anticipated that additional [testing] times will be added to existing test organizations.
Q: To what extent will the new training and testing requirements improve the quality of commercial driver medical exams? Tangentially, do you think they will have the intended impact on highway safety? If indeed highway safety is improved, will the improvement be significant? Dr. Hartenbaum: Not certain how effective the NRCME will be [in] improving safety. [I am] concerned that some of the training programs are teaching the minimal medical standards and not current best practices on several conditions. The official guidance from FMCSA is very out of date – in some cases over two decades, and this is presenting a challenge for those examiners trying to utilize current best medical practice. My fear is that this will eliminate those examiners who have no idea from being able to sign off on a medical certificate but will also handcuff those trying to utilize best practice – in other words – will pull quality of the evaluations and determinations to the middle rather than optimal.
Q: How much latitude will individual medical examiners have within the confines of the medical exam requirements to pass or fail an individual driver? How much professional judgment will come into play? Dr. Hartenbaum: Nothing has changed with respect to the requirements. The requirements are the 13 medical standards; all but four leave a great deal of latitude to the examiners. Even for the four absolute standards – exemptions are now available through FMCSA. What has changed is that all examiners are expected to at least be aware of the basic information from FMCSA––the interpretations, guidance from the medical examiner handbook, frequently asked questions, and actual duties of the CMV operator.
Q: The government estimates that 40,000 certified medical examiners will be needed to meet the needs of our commercial driver population. Do you think we will ultimately be able to train and certify that many? What is the potential for a backlog? Dr. Hartenbaum: Not every driver needs to be examined [by] May 21, 2014, and FMCSA has indicated that they anticipate that [over the course of the next] two years, during which all drivers will need a certification examination, there will be a sufficient number of examiners.
Q: Is there a mental health component to the medical exam? Dr. Hartenbaum: Examiners are expected to evaluate the mental health status of drivers, both in terms of psychological conditions and medications that may impact cognitive function.
Q: What is the latest on the condition of sleep apnea as it relates to commercial motor vehicle drivers? Is it a disqualifying condition? Why has this part of the rule been controversial? Dr. Hartenbaum: Diagnosed obstructive sleep apnea (OSA) is not controversial nor is it disqualifying. The current status from FMCSA is that the driver who has been diagnosed with OSA must maintain compliance with recommended treatment and should have annual examinations with objective evidence to demonstrate effective treatment. What is controversial is identifying which drivers are at sufficient high risk to require testing to rule in or rule out OSA. The challenge is identifying reasonable criteria which can identify those drivers at the highest risk of having OSA and at the highest risk of having a crash due to that condition. This is essentially a statistics issue. If you test all drivers you would not miss any that have OSA; if you use different criteria, you would miss many.
Q: Do you foresee any changes to these rules in the coming year? Dr. Hartenbaum: FMCSA published a rulemaking earlier this year which would further integrate the medical examination and the CDL. This includes a new medical examination form. There is also a pending rulemaking that would take the FMCSA out of the process in determining which drivers on insulin should be granted an exemption and move that decision making to the examiner. While I would hope that some of the guidelines from FMCSA would be updated based on recommendations from the Medical Expert Panels and Medical Review Board, seeing the pushback on updating guidance on OSA, [I’m] not certain when other topics will be updated.
