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  • ACOEM Comments on Training Specifications Related to the National Registry Implementation

    Docket Management Facility (M-30)
    U.S. Department of Transportation
    West Building
    Room W12-140
    1200 New Jersey Avenue, SE
    Washington, DC 20590-0001

    Re: Docket Number FMCSA – 2008 – 0363

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to the request for comments on the draft guidance for the core curriculum specifications that could be used by training providers in implementing the National Registry of Certified Medical Examiners (National Registry) proposed rule.

    ACOEM has long been concerned about the process for determining the medical fitness of commercial motor vehicle operators. Many of our members are physicians or other licensed health care providers who are performing commercial driver medical examinations to ensure that drivers of Commercial Motor Vehicles (CMV) meet the medical qualifications set forth by the Federal Motor Carrier Safety Administration (FMCSA) The purpose of these evaluations is to protect not only the driver but the general public from motor vehicle crashes resulting from sudden incapacitation or impairment with either loss of life or significant morbidity. For many years ACOEM has offered courses and other continuing medical examination programs to provide information to Commercial Driver Medical Examiners (CDMEs) to ensure they understood the roles of the examiner and the driver, as well as the impact that medical conditions and treatments may have on driver safety.

    These comments relate to the Draft Core Curriculum. We also have concerns with the sample Medical Examiner training, some of which are mentioned below. However, we will hold extensive comment on the training module until comments are requested on that.  

    1. Medical Conditions: One of our major concerns is that the draft guidance is very process oriented, appearing to give equal weight to background information and to the actual guidance on specific medical conditions. It is imperative that any training program provide an understanding of not only the background of the examination and the examination process, but more importantly, the substantive information that should be included. This will ensure that the examiner understands not just the individual medical diagnosis, but how the diagnosis may impact driver’s operation of the commercial motor vehicle. Training should also include, in addition to the content of the Medical Examiner Handbook, any newer information, such as Medical Expert Panels or Medical Review Board recommendations or other recent medical literature (certainly clearly indicating that this is not “official guidance” from the FMCSA). In the draft guidance, it indicates the examiner should “Make sound determinations of the driver’s medical and physical qualifications for safely operating a commercial motor vehicle (CMV) in interstate commerce.” This should clearly indicate that the examiner should utilize all current information, not limited to the Medical Examiner Handbook, to reach his clinical opinion whether a medical condition or its treatment would interfere with safe operation of a CMV. If this training is geared towards the minimal standard, the result may be that examiners who attempt to consider best practices and most current medical knowledge (in conjunction with the guidance from the FMCSA) may be avoided in favor of those who do the minimum.
    2. Disqualifying Conditions: There are several places where conditions which “may” be disqualifying are listed. When these are listed, it should delineate those conditions that ARE disqualifying from those that MAY be disqualifying based on clinical information.
    3. Referral to Specialist: It should be clearly stated that, where referral to a specialist is suggested, the specialist must have knowledge of the “responsibilities and work environment of CMV operation.” Too often specialists have no awareness of the tasks and safety implications of the CMV operator, let alone that there are Federal Medical Standards and guidance which should be considered.
    4. Consistency: There is a great deal of inconsistency of detail in the draft guidance regarding various medical conditions. For example, there is significant detail about diabetes, whereas there is only an overview of other medical conditions, such as cardiovascular. If the intent is for consistency, then sufficient detail for all medical conditions and treatment should be included (including material not in the Medical Examiner Handbook).
    5. Reporting and Documentation: Topic 8, reporting and documentation, discusses the diabetes and vision exemptions but does not include that the examiner should indicate if the driver is qualified under 391.64. The date of the examination and the duration of certification are also not listed but should be included as a requirement. This section does not mention what the examiner should or may do with the results of the examination or the medical certificate. The examiner should be a) instructed on the minimum duration to maintain the results; b) that the certification should be provided to drivers for them to submit as required by their state; and c) how and when the examiner provides the results of the examination, (It appears that this will be included in the Final Rule for the NRCME, but there should at least be a place holder in the Core Curriculum); and d) that the employer may be provided a copy provided applicable state and federal laws are followed.
    6. Liability Issues: Not included in the Core Curriculum is any mention of liability issues for the examiner nor the carrier or driver. While there is an FAQ which covers dishonest responses of the examinee, training should ensure that the examiners are aware of their legal responsibilities in performing this type of examination and those of the carrier.
    7. Sample Training Module: In reviewing the Sample Training Module, the organization of the Module is very cumbersome with each of the 8 Core Curriculum topics repeated in each content or medical area. It would be more efficient to include much of that material in an overview section or module rather than repeating with each medical condition. For example, rather than requiring the training to describe the safety implications of the job of commercial driving, giving examples of how work environment impacts the ability of the driver to operate a commercial vehicle safely or recalling that the health history is completed by the driver are repeated with each medical condition, this could be adequately and more efficiently covered in an overview training module. Likewise vision testing could be discussed during a module on the physical examination allowing a more efficient “organ system” teaching approach.

      Another serious concern with the training module is that while it does note that the examiner may consider other sources of more recent guidance in their qualification determination (in the sleep apnea section), this sample training is totally based on outdated medical knowledge contained in the Medical Examiner Handbook and does not suggest that training should also incorporate current medical best practices as considerations for the examiner. The example given and scenarios presented are very simple and do not appropriately represent many of the complex cases that examiner will face. There are also several inconsistencies with other guidance within the training module. For example while the handbook indicates that a skill performance evaluation (SPE) is not for multiple sclerosis, the training module suggests pursuing an SPE

    Thank you for your consideration of these comments and we look forward to working with FMCSA as this important initiative moves forward.

    Sincerely,

    T. Warner Hudson MD, FACOEM, FAAFP
    President
    American College of Occupational and Environmental Medicine

    Natalie P. Hartenbaum, MD, MPH, FACOEM
    Past President
    American College of Occupational and Environmental Medicine