Author: Dr. David Thorpe, DC, DACBOH
There is no doubt that many medical conditions can create issues that lead to impairment of a driver’s safe operation of a Commercial Motor Vehicle (CMV). Considering the catastrophic consequences associated with CMV crashes, is it a wonder that ensuring that the truck driver is healthy enough to safely operate a truck is considered important? I often use the analogy that if any one of us are flying to go on vacation, we certainly want to feel confident that the pilot flying the plane would be healthy and at little risk for any medical event that could impair his/her safely getting us to our destination.
The same concern holds true for the nation’s truck drivers. If you think about it, a truck driver, with all of the required training and responsibilities is quite similar as a professional to the pilot. The uniform may be different, but the need to ensure that they are medically fit for duty is the same.
A recent report released in April by the American Transportation Research Institute (ATRI) indicates that despite the good intentions of the FMCSA in implementing the National Registry of Certified Medical Examiners (NRCME), its impact on the trucking industry has apparently been more negative than positive, without accomplishing the desired results that were expected from additional training and certification for medical examiners.
THE HISTORY OF THE NRCME
Prior to May of 2014, there existed no requirements for training and certification of medical examiners despite the fact that there was the expectation that medical examiners conducting the exams should be familiar with the physical and mental demands associated driving a truck, coupled with the knowledge of many of the regulations and guidance that had been developed since the inception of the DOT physical exam.
Consequently, in 2005 Congress enacted the “Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users” also known as SAFETEA-LU. The Act mandated that FMCSA create and maintain a National Registry of Certified Medical Examiners (NRCME) among many other things. The purpose of this requirement was to guarantee that medical examiners who certified CMV drivers would be better qualified themselves by having a greater understanding of the demands of truck driving coupled with the knowledge of the regulations under 49 CFR 391.41 and 43.as well as guidance that exists for medical conditions as defined by numerous conference reports through FMCSA.
Prior to 2014, the vast majority of exams on truck drivers were performed by providers who had the ability to perform a physical examination based on state law. It was estimated that as many as 400,000 different providers were doing these exams, many of which were performed as a courtesy by the examiners family provider. The FMCSA identified a concern as a result of the exams performed that many drivers were certified incorrectly and that this lead to an increase in crashes.
As a consequence of the need for additional training and certification, currently only a little over 50,000 medical examiners are active through the NRCME. Most primary care providers due to the requirements of certification have decided to opt out. This met the original estimates from the FMCSA that this number would be needed by May of 2014. This figure being derived from the figures that existed for provider/pilot ratio’s established by the Federal Aviation Administration (FAA). Is this adequate enough? Will the added training improve the competence of medical examiners and the quality of the exams? It was the purpose of the ATRI research report to identify these things as well as the impact of the NRCME on the trucking industry.
THE ATRI REPORT
Released in April of this year, the ATRI in collaboration with the Mayo Clinic analyzed the impact of the NRCME. To assess this impact, they jointly developed surveys for commercial drivers, motor carriers, and medical examiners. The surveys for carriers and drives were distributed online through ATRI databases, industry publications and industry associations. The timing of distribution was set to analyze the results after 2 full years since the implementation of the NRCME.
Survey results included identifying driver and motor carrier demographics (type of driver, type of carrier, size of Fleet and more), and specifics concerning their observations about the use of examination forms, how they utilize medical examiners, their opinion relating to the quality of the medical exam.
Results of the surveys came from a sample of a little under a thousand drivers, and approximately 300 motor carriers. As a consequence the joint report resulted in identifying concerns about the NRCME. The results were compiled and conclusions were drawn. The results were compiled into a 42 page report entitled “National Registry of Certified Medical Examiners Impacts: Driver and Carrier Experiences.
In addition to this report, another survey was distributed to medical examiners that assessed their opinion of the NRCME and the FMCSA Medical Examination process. Greater than 1200 medical examiners participated in the survey from all 50 states. Conclusions were drawn from this survey relating the examiners exam experience, use of additional staff in performing the exam, use of electronic forms as well as satisfaction with the overall process and intent to continuing performing the exams.
TROUBLING FINDINGS ABOUT THE EXAM SEEN WITHIN THE REPORT
Although there was some positive findings identified within this report, there are a number of concerns that were identified that related to driver and motor carrier experiences with the NRCME and in particular the exam process. A synopsis of these findings are as follows:
- Despite not being viewed as being overly complicated, greater than a third of all driver respondents spent more than 15 minutes completing the form. The assumption related to the vagueness of the wording in the history section and the lack of fully understanding what these questions were asking.
- Drivers that reported that the form was difficult however, greater than 65% felt that it was too long and confusing, and almost 40% felt the language was confusing.
- Drivers were also asked about the thoroughness of the exam. Areas that were of concern included:
- Examiners frequently did not ask drivers to remove any clothing.
- Examiners frequently did not perform a hernia check.
- Examiners frequently did not use light to examine a driver’s eyes and ears.
- Although this did not occur in the vast majority of exams, a small percentage of drivers were not examined using a stethoscope on the chest wall.
- A small percentage of exams (6.5%) also related that less than 10 minutes were spent with the medical examiner, with the rest spending from 10 to greater than 30 minutes with the CME.
- An increasing number of drivers are experiencing delays or shortened certifications that are shorter than 2 years, with approximately 6% not receiving a card at the completion of their examination, and another 14 % receiving a certification of 6 months or less. The most common for this appear to be a need for more testing or treatment of medical conditions.
- A little less than 15% of medical examiners reported that they did not intend to recertify when their certification expires.
- Almost half of drivers were dissatisfied with the quality of their exam.
- Only 6.2% of drivers felt that the overall quality of the exam has improved since the NRCME was implemented, with almost 35% feeling that the quality has become worse.
- Examination cost have risen since the inception of the NRCME.
- There is a concern as to the number and reasoning for sleep apnea testing which appears to be increasingly being required for certification.
- There is concern over the inconsistency of certification between medical examiners (exam ambiguity).
- Carriers were requested to rank their top three concerns regarding medical certification. The highest ranking concerns were:
- Certification delays caused by requests for additional testing.
- Driver confusion on how regulatory changes affect their ability to hold a valid medical certificate.
- Unqualified or incompetent medical examiners performing DOT examinations.
- Medical unqualified drivers becoming certified.
- Changes in the medical exam process occurring too rapidly.
- Less than 1% of motor carriers reported that they had no significant issues related to driver certification.
- Approximately 7% of the medical long forms submitted have errors.
ADDITIONAL FINDINGS WITHIN THE REPORT
There are other conclusions that can be drawn from this report:
- The most common medical conditions that create concerns for drivers include:
- High blood pressure
- Sleep Apnea
- Drivers report behavioral changes since the NRCME was implemented such as quitting smoking and losing weight.
SUGGESTIONS TO IMPROVE THE MEDICAL CERTIFICATION PROCESS AND NRCME BY MOTOR CARRIERS INCLUDE:
- Allowing CME’s to access a driver’s prior medical certificate to prevent the practice of doctor shopping.
- Increasing the frequency of reporting by CMEs to daily submissions.
- Increased accountability for areas where subjectivity may occur to force CME’s to err on the side of caution rather than risk potential liability if the driver subsequently involved in a crash.
CONCLUSIONS THAT CAN BE DRAWN FROM THE ATRI REPORT
- Medical certification delays are a significant concern for both motor carriers and CMV drivers. Both drivers and motor carriers are impacted significantly in delays including lost wages, issues relating to driver shortages, moving freight, driver retention, recruitment and more. Also the time and money associated with testing a treatment can be significant.
- The NRCME accomplishment of stated goals – ensuring medical examiner knowledge of the relevant FMCSRs and guidelines – is not corroborated by the result of the carrier survey.
- CMV drivers did note that the impact of the NRCME was increased examination costs.
- The impact of the cost will be exacerbated when CMEs are required to renew their certification due to decreasing availability of medical examiners.
- Omitted and overlooked examination procedures suggest that examination quality still needs improvement.
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