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  • ACOEM Comments on Merchant Mariner Medical Evaluation Program

    April 28, 2013

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

    Re: Docket No. USCG-2013-0089

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to the Notice and Request for Comments regarding the Merchant Mariner Medical Evaluation Program.

    ACOEM has long supported United States Coast Guard (USCG) initiatives to improve the quality of merchant mariner medical examinations. We participated in the MERPAC working groups in the mid-2000s on the revisions of the merchant mariner medical guidelines (NVIC-0408) and the medical examination form (719-K). We currently have several ACOEM members serving on the Merchant Mariner Medical Advisory Committee (MMMAC).

    ACOEM believes that perhaps a hybrid system utilizing parts of the Federal Aviation Administration (FAA) Aviation Medical Examiner (AME) and the Federal Motor Carrier Safety Administration (FMCSA) Certified Medical Examiner (CME) programs would provide a viable system of trained medical examiners for the Merchant Mariner Medical Evaluation program.

    The following is a discussion of the advantages and disadvantages of closed and open systems.

    Disadvantages of a closed system would include: Increased costs to the medical examiners which may be transferred to the mariner or employer; decreased availability of certified examiners which may pose logistical issues to the mariner or employer.

    Advantages of a closed system would include: Better qualified medical examiners and a decrease in processing time at the National Maritime Center (NMC) if all amplifying information was provided at the first submission.

    Disadvantages of an open system would include: Continued delays in processing medical evaluations by NMC due to untrained examiners not providing proper examinations and amplifying information. Improper evaluations when the examiner does not have the appropriate equipment necessary for the examination (i.e., vision/color vision screening devices, functional abilities testing).

    Advantages of an open system would include: Increased numbers of examiners available to mariners and employers.

    A hybrid system could include a tiered approach of examiners:

    Senior examiners would be physician based with MD/DO’s with Occupational Medicine/Maritime Medicine functioning as in the FAA model. These Senior Examiners would be able to issue a time-limited medical certification in the case of a mariner that met all qualifications. This time limited certificate could be revoked within a certain time period if the NMC review found cause for further evaluation. There would be a list of medical conditions, medications and physical findings that would cause the medical certification to be deferred to the NMC for further evaluation.

    Junior examiners would be MD/DO/NP/PAs that have had training in the proper process for performing mariner medical evaluations similar to the FMCSA model. They would also aid the mariner in providing amplifying information when indicated. The physicals performed by these examiners would still be forwarded to the NMC for evaluation and medical certification.

    The last level of providers would be the open system with any qualified MD/DO/NP/PA able to perform the examination. This is currently the system used for USGC Merchant Mariner Medical Examinations.

    The advantages of the top two levels of examiners would be more qualified examinations and expedited processing of medical information. Keeping the open system as the lower tier allows for more examiners but with some continued problems with processing the examinations.

    The Senior and Junior Examiners would require training/education and certification. The Senior Examiners could have a more extensive training. The Junior Examiners could have a shorter training. A list of Certified Senior and Junior Examiners would be maintained and available on line for mariners and employers.

    ACOEM strongly supports the educational component. We have been educating health care providers for over 15 years on medical standards for merchant mariners.

    ACOEM supports medical examiner training conducted by private sector providers accredited by a nationally recognized medical professional accrediting organization. This could either be conducted using a core curriculum designed by the USCG or by a medical professional organization approved by USCG such as the medical review officer (MRO) training. ACOEM would support maintaining a centralized database of all currently certified merchant mariner medical examiners. This would allow both employers and mariners to easily identify certified medical examiners in locations near where they live or work. Both training and certification should use current technology, with remote training and internet base testing available as alternatives to on-site courses and exams.

    ACOEM suggests that examiners be recertified every 6 years in order to remain listed on the registry, but would suggest that ongoing training requirements be similar to MRO training, i.e., 12 hours of advanced training every three years. With documentation of this type of training, the need for the medical examiner to repeat the entire training needed for the initial certification process every 12 years would be unnecessary.

    Several topics that we have recommended to the FMCSA are also addressed here:

    There should be clearly defined medical/medication issues that are disqualifying. This would enable all examiners and the NMC to be consistent. Currently there is great variation across examiners which can cause issues with public safety.

    We would suggest that there be an at least monthly submission of successfully completed examinations. To ensure that unqualified mariners are not operating, or that examiner shopping is not occurring when mariners are not satisfied with the outcome of their examination, there should be a mechanism for the examiner to transmit (e.g., within 48 hours), information on any mariner who is found to be unqualified by the USCG medical criteria.

    One area not addressed in this request for comments is incomplete examinations. There are many situations where mariners are required by medical examiners to either obtain additional medical information (e.g., hemoglobin A1c or glucose levels in a diabetic not on insulin) or to have additional testing (e.g., a stress test). Often, these mariners will not obtain the additional information, and might seek another examiner. There should be a requirement that incomplete examination results are also entered on the log with a notation of what documentation is missing. As for disqualified mariners, examiners should be required to submit information on incomplete examinations shortly after it appears the mariner will not be returning. A reasonable option would be to permit 10 business days to provide the required documentation or documentation that the required testing has been scheduled. If testing is needed, this should be completed with 10 business days as well but could be extended for an additional 10 business days if the medical examiner agrees this is reasonable. At the end of this period, the examination should be submitted as incomplete.

    In some situations, a mariner is initially found to be qualified but later becomes disqualified prior to the expiration of the medical certificate. This may occur if the mariner is begun on insulin, has a myocardial infarction or, upon review by a third party or corporate medical director, is found to be disqualified according to the medical criteria. There should be an option to submit information when an examiner is aware that a mariner is no longer medically qualified but may not yet have undergone a new examination.

    Information on disqualified mariners should be maintained in the Merchant Mariner's system. With the recent final rule, a mariner is required to provide certification status, but there is no requirement for the mariner to submit the results of a disqualifying examination.

    For many federally mandated occupational medical examinations, the retention duration is employment plus 30 years. Federal drug testing regulations generally require negative results to be maintained for at least one year and positive results for at least five years. Most states require a health care provider to keep medical records for at least seven years. ACOEM suggests that the Medical Examination (719K) Form should be maintained by the examiner for at least seven years (three two-year examination cycles if under Standards of Training, Certification & Watchkeeping [STCW], one cycle if USCG only). Mariners may leave and then re-enter the mariner pool. Having historical examinations to review will assist in ensuring that medical conditions which are present but controlled will not be overlooked. Almost every examiner can relate situations where a mariner with heart disease, hypertension or other conditions, will check the “no” box in the belief that, because their condition is controlled, it is no longer present.

    ACOEM is the pre-eminent medical organization committed to enhancing the health and productivity of workers and their families and would be willing to offer further assistance. Please contact Patrick O’Connor, ACOEM Director of Government Affairs, if you have additional questions or need additional information. He can be reached at 202-223-6222 or by email at patoconnor@kentoconnor.com.

    Sincerely,

    Karl Auerbach, MD
    President, ACOEM

    Tony Alleman, MD MPH
    Co-Chair, Transportation Section