Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 59
59
Questions about Alertness Management actions adhered to published federal rules with respect
to methadone and Schedule II medications.
Q: Do you routinely advise drivers on how to main- · There also appeared to be variation in medical examiner
tain alertness and combat fatigue? anticipated actions regarding medications that had no
___ Yes ___No specific rules associated with their use. The examiners
were queried about a large number of medications. Other
Responses: than methadone, these medical advisors would permit
Only two of the medical examiners surveyed most of these medications for use by commercial drivers
(at Salt Lake City) reported giving alertness advice on the condition of receiving the prescribing physician's
to drivers at the time of their examination. One release notes, or by giving the driver advice to take med-
reported discussing sleep hygiene; the other dis- ication no sooner than 8 h before driving, or by comple-
cusses sleep apnea risk and referral. The remaining tion of a detailed evaluation at the clinic.
21 medical examiners reported that they do not give · The amount of education about medications provided to
drivers advice on "remaining alert and combating drivers by their CDME examiners was limited in this
fatigue." small group of surveyed examiners. The most common
advice was to avoid the of use of a medication within
Q: What do you tell them? (No responses) 8 h before work; advice most commonly given when the
medical examiner prescribes medications to the drivers
for medical conditions for which they are providing care.
Examiners' Comments and Suggestions · According to the group surveyed, the Medical Exami-
to Open-Ended Question
nation Report (Form 649-F-6045) is required by some
The end of the questionnaire/survey forms allowed the med- employers in addition to the Medical Certificate. This
ical providers (examiners) an open-ended opportunity to pro- appears to vary by region.
· Medical examiners' interactions with employers without
vide their comments and suggestions.
specific release of information were reported in about
half of the Salt Lake City group, and by none of the
Q: Your Comments and Suggestions here: Here we
Reno group. Information released was cited as primarily
solicit your comments, suggestions, recommen-
related to safety concerns, or why the driver did not "pass"
dations, etc., concerning the medical examining
the examination.
process and/or the Medical Qualification Standards
· The group of examiners surveyed reported that they
for CMV drivers. Remember these comments will
very seldom provided alertness education to drivers they
be held in confidence, so please be frank, but also
examined. Of the 2 of 23 examiners who indicated
be specific enough that we can determine precisely
they provide such education, one reported discussion of
what your comments mean in the context of this "sleep hygiene" and the other "sleep apnea."
synthesis study. · Medical examiners surveyed were not aware of any
"list" of prohibited medications.
Verbatim responses to open-ended question: Only · Open-ended responses by medical examiners were
a small number of open-ended responses were limited, and emphasized a need for a national medical
received, among them the following specific com- examiner standard of performance and the need to know
ments were proffered: underlying conditions (why the medication is being
"Indication for Rx [underlying condition being prescribed). One of the examiners indicated that he or
treated] plays a large role in how I handle she was not familiar with one of the more commonly
different cases." used privately developed sources of information on the
"Priority needs to be national standards/ CDME (Hartenbaum 2006).
certification for providers; need a national
database for drivers so they cannot MD shop." This initial study survey was limited by a number of factors:
"I am not familiar with the Hartenbaum book."
1. The size of the surveyed group (23 participants).
The U.S.DOT's FMCSA estimated that there are
DISCUSSION OF SURVEYS 317,000 medical providers who might perform driver
OF MEDICAL EXAMINERS
physical examinations on a regular basis in the United
This Survey States (FMCSA NPRM, 73FR-73129, 1 Dec. 2008);
however, in the synthesis survey work reported here,
This survey of a small number of medical examiners (n = 23) only 23 of these medical examiners in two western cities
of commercial drivers found the following: were questioned. Therefore, these survey data, on so
few medical professionals, cannot provide any infer-
· There was some variation in responses of the group of ences about the activities of so many other medical
medical examiners surveyed on whether their anticipated examiners. Nonetheless, this survey provides insight into
OCR for page 60
60
practices "in-the-field," and these data help underscore disease guidelines) are continuously being published, but pre-
the need to extend such survey work to other groups of sent a "moving target" for examiners' reference. The FMCSA
CDME examiners. Evidence Reports and Medical Expert Panel Recommen-
2. The list of medications queried was not a complete dations, as referenced earlier, and a new Medical Examiners
list of all medications used by drivers of CMVs. Handbook (NRCME-FMCSA) are available online. The
Medications were chosen by the synthesis co-author FMCSA Medical Review Board has also issued new recom-
(H. Leaman) based on his experience, review of NTSB mendations to the FMCSA regarding medications.
accident reports, and personal observations made dur-
ing a 25-year occupational medicine practice. This
survey study could be expanded and strengthened by Knowledge Base and Training
better methodology, including methods for choosing
Regarding knowledge base and training, the FMCSA Com-
medications.
mercial Driver Medical Qualification is evolving rapidly.
As this synthesis report was being prepared, the FMCSA
Observations Made from Survey Results announced the Notice of Proposed Rule Making to establish
a national registry of medical examiners (FMCSA NPRM
One of the more significant limitations on the process of Federal Register announcement No. 73FR-73129; Docket
medical examiners performing evaluations of commercial No. 2008-0363). The Role Delineation Study performed in
drivers (CDME) includes the completeness, or incompleteness, support of this initiative identified "Knowledge, skills and
of driver self-reporting of their medications to the medical abilities" that will guide CDME training and testing content,
examiner. Although drivers are required to complete their but did not directly identify the source of these attributes.
medical history form accurately and completely (or risk Because evaluating a driver's use of medication has been
invalidating their certificate) there is evidence this does not associated with at least five essential CDME tasks (see ear-
always happen; numerous medical examiners attest to this lier discussion) any training developed would be expected
from prior experiences with drivers who deliberately disguise to derive from some common understanding of effects of
the truth on their personal history forms and in interviews at specific medications on driving ability and performance,
the time of CDME exams. independent of the underlying medical condition. Resolving
the former issue (List) would likely be needed to complete
the latter (training and certification).
Estimate of Foreseeable Risk
One key issue that is implied but not explicit in this survey Alertness Education for Drivers
is that the certification actions of the medical providers rep-
resent their "estimation of foreseeable risk" of motor vehicle Commercial Driver Medical Examiners have not yet been
accidents in the commercial drivers they examine. In the asked to provide drivers with sleep and alertness education,
Medical Examiners Handbook (NCRME-FMCSA) the recom- or educational materials, which has already been provided to
mendation is given to certify the driver "if the examiner commercial drivers and their employers through the FMCSA-
believes that the nature and severity of the underlying condi- ATRI-sponsored train-the-trainer courses (O'Neill et al. 1996;
tion does not interfere with safe driving and the effects of Krueger and Brewster 2005). From having discussed this topic
medication use while operating a commercial motor vehicle with medical examiners in several round table discussions,
does not endanger the safety of the driver and the public." there appears to be a common opinion among the medical
examiners. The medical providers pointed out that it is the
Lack of Common Reference Guidance driver's responsibility to manage a suitable sleep/wake sched-
ule. Furthermore, they indicated that assigning this fatigue
Two possible sources of CDME certification decision vari- education responsibility to medical examiners would detract
ability regarding safe medication use that were encountered from the primary purpose of the examination, and may place
in this study are: (1) the absence of a commonly accepted, the medical examiner in the position of being responsible for
single source, up-to-date, medication-based (rather than dis- driver factors over which he or she has little to no control;
ease based) reference guideline ("List") for use by CDME they can't "write a prescription for sleep."
in the certification examination, and (2) absence of a uni-
form and specific training and knowledge base for examiner
Communication with Employers
qualification.
There are a few generalized findings from the questions asked
Need for a Medication List of the medical examiners about their interactions with the
drivers' employers. In brief, some employers seek too much
Regarding the topic of a "List," new guidelines for medication information from the examination process, and many ask for
use in commercial drivers (which are contained within specific too little.
