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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

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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.