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Transportation and Public Safety

While driving is considered a basic activity of daily living for most Americans, it has become apparent that not everyone drives safely. Certain individuals should not be operating vehicles, other moving equipment, or other heavy machinery because their medical conditions may impair their ability to safely operate their vehicle or equipment. Physical abilities, alertness, and decision-making abilities can all be affected by medical conditions or by the medications used in their treatment.

Medical fitness-for-duty programs in the transportation industry vary greatly. A pilot’s medical fitness is determined through the Federal Aviation Administration which has specific standards, detailed guidance, and only a limited number of trained and designated aviation medical examiners (AMEs). Many individuals who operate commercial motor vehicles (CMVs) as part of their occupational responsibilities are covered under Federal Motor Carrier Safety Administration (FMCSA) regulations, a system that has regulations and guidelines, but at the current time, no training requirements nor program oversight. Other CMV drivers are subject to state medical standards which – in most cases – are similar to the federal standards although waivers, grandfather programs, or exemptions are more common. The only railroad employees covered by the Federal Railroad Administration’s medical standards are locomotive engineers. They are only required to be examined every three years with just hearing, vision and color vision addressed in their standards. School bus drivers are required to meet specific medical criteria that are set by individual states. 

There are also a large number of workers who drive as a part of their jobs, but who are not required to meet any criteria other than that they must hold a valid driver’s license. Ensuring that employees do not place themselves or others at risk of harm due to an inability to perform their job tasks safely is a joint responsibility of the employer and the employee and is an integral component of most occupational and environmental medicine physician’s practice whether they be in the private, corporate or academic setting. 

When employees return to work from illness or injury, the majority of employers will accept a “return to work note” from the employee’s personal health care provider. However, in most cases, these providers do not fully appreciate the responsibilities and safety implications of the type of work their patient performs. For individuals covered under federal medical standards, this lack of knowledge and understanding is even greater. 

The National Transportation Safety Board (NTSB) has attributed several recent highway and rail accidents to medical conditions.¹ Insurance companies are reminding their clients that they may be liable for negligent entrustment if they permit an individual to operate a vehicle when they know or have reason to know that use of that vehicle by that individual may create a risk of harm to others. 

Another challenge in ensuring that only those who are medically fit to operate vehicles are permitted to do so is the lack of uniform reporting laws and protection from liability for reporting unsafe drivers. The American Medical Association has urged physicians to work with their state medical society to create statutes that will: 1) protect the patient and the public from unsafe drivers; and 2) maintain confidentiality while protecting from liability those health care providers who report in good faith. The NTSB has also recommended improved driver reporting laws which would include immunity for reporting in good faith. 

The American College of Occupational and Environmental Medicine (ACOEM) urges providers, employers, employees, and federal and state officials to take the following actions to ensure the medical fitness of all individuals who operate vehicles as part of their work responsibility. 

Providers 

1. Occupational physicians and other occupational health providers who are responsible for determining fitness for duty of employees who operate vehicles, or other similar equipment, must understand the safety risks and the role they, as health care providers, play in protecting public safety.
2. Personal health care providers must understand the public safety risks that exist in clearing an individual who has a medical condition that could potentially impair his or her ability to operate a vehicle. Health care providers should ask their patients whether they operate a vehicle or other similar equipment as part of their work. Where the personal physician is unsure of the ability of their patient to operate a particular vehicle(s) safely, or unsure of the regulations involved, he or she should consult with a physician knowledgeable in such matters.

Employers 

Employers must understand their responsibility in ensuring appropriate evaluation of those employees whose medical conditions may present a danger to others while operating a vehicle as part of their employment.

Employees 

1. Employees must understand the impact their health has on their ability to safety operate vehicles at work.
2. Employees must inform their treating and examining health care professional that they operate a vehicle requiring a commercial drivers license or operate machinery on the job.
3. Employees must accurately inform their treating and examining health care professional of pertinent medical history, medical conditions, medications, and symptoms in a timely manner. 

Federal and State Officials 

1. Federal and state officials need to be aware that guidelines, recommendations, and resources exist to aid providers and employers, and they are encouraged to utilize these resources.
2. Information on the effects of medical conditions and medication on safe operations of vehicles and equipment at work should be evaluated and communicated to appropriate parties.
3. State and federal legislatures should provide immunity from liability for physicians and other providers for good faith reporting of drivers and other transportation operators whose medical conditions may place them and others at risk of substantial harm.
4. A national registry of physicians and other health care providers qualified to perform related medical examinations for commercial motor vehicle drivers should be created.
5. A position of chief medical officer should be established within each transportation agency that is under the auspices of the U.S. Department of Transportation. This physician’s role should include identifying resources that health care providers should use in determining the medical fitness of individuals operating in transportation modes, reviewing and updating existing standards and guidelines, and serving as a resource for the transportation agency, health care providers, and legislators. 

ACOEM is the pre-eminent medical organization committed to enhancing the health, safety, and productivity of workers, retirees, and their families. In its established role as a leader in the area of fitness for duty, ACOEM has offered courses on medical fitness of commercial drivers and on serving as a medical review officer, and has published newsletters on both topics. The College has also participated in negotiated rulemaking at the Federal Highway Administration and presented comments on many transportation related fitness rulemaking.

^{1NTSB – School Bus and Dump Truck Collision – Central Bridge, New York, October 21, 1999; School Bus and Dump Truck Collision – Central Bridge, New York, October 21, 1999; Motorcoach Run-off-the-Road Accident, New Orleans, Louisiana, May 9, 1999; Collision of Two Canadian National/Illinois Central Railway Trains Near Clarkston, Michigan, November 15, 2001.}  

These guidelines were originally developed in February 2004, by Natalie Hartenbaum, MD. The guidelines were subsequently reviewed, revised, and reaffirmed by the ACOEM Board of Directors on October 22, 2007.

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