What Employers Need to Know About DOT

Melissa Hay, Director of Product Development, Concentra

Good afternoon. I'm Melissa Hay. I'm the director of product development for Concentra. Welcome to our webinar, "What Employers Need to Know about DOT." I have a couple of housekeeping items before we get into the content. First, all lines are muted, but we encourage you to submit questions using the question feature in the webinar. If you aren't seeing a question feature, please go ahead and send questions by using the chat feature. We have a moderator who's going to be monitoring the questions, and we will cover those questions at the end of the presentation.

One other note before we begin. The webinar is being recorded. Within just a few days, we will send the link to the recording out to all of you by email. So please keep an eye out for that.

Let's begin. I'd like to welcome our guest speaker today, Dr. Anne-Marie Puricelli. Dr. Puricelli has her MD and JD from St. Louis University. She is board certified in internal medicine, and she joined Concentra in 1991. Dr. Puricelli is our clinical director of strategic onsite accounts, national medical director for transportation, and she also chairs Concentra's transportation medical expert panel. She definitely has a special and deep interest in all things related to DOT. Dr. Puricelli, thank you for joining us today.

Anne-Marie Puricelli, MD, JD, Clinical Director of Strategic Onsite Accounts, National Medical Director for Transportation, and Chair of Transportation Medical Expert Panel

Today we're going to talk about the Department of Transportation. I'm going to give you an overview of the department and a brief snapshot of the trucking industry. Then we will turn our attention to the DOT physical exam, briefly discuss drug testing and musculoskeletal injury, and then conclude with a discussion of DOT disqualifying medical conditions.

The Department of Transportation, or the DOT, regulates interstate commerce. The definition of that is trade traffic or transportation that involves crossing state lines or a vehicle and/or its contents have come from across the state boundary. So, basically, even if the driver stays within one state, if the contents have come from out of state, the driver is engaged in interstate commerce. We're going to focus on the Federal Motor Carrier Safety Administration, or FMCSA, during this talk.

So why does the FMCSA require medical certification to verify drivers are medically fit for duty? In 1999, a driver crashed a big motor coach in New Orleans. It was called the Mother's Day bus accident.

The accident was part of a systemic failure in the medical certification process to detect and remove medically unqualified drivers from service. Twenty-two individuals were killed and many were seriously injured. The National Transportation Safety Board noted that the driver should not have been medically qualified. He was actually very sick at the time of the accident. But he was driving.

The NTSB noted this was not an isolated case, but a systemic failure on the part of the certification process. At that point, the National Registry of Certified Medical Examiners (NRCME) was created.

Now, only certified medical examiners listed on the registry perform FMCSA (DOT) exams. In this presentation, we will be focusing on commercial motor vehicles (CMVs). So, even though we refer to DOT physical exams, we're really talking about FMCSA regulations for commercial motor vehicle drivers.

On the next slide, we see a snapshot of the trucking industry. The trucking industry represents $738 billion in annual revenue. There are roughly 3.5 million commercial drivers. Over the next ten years, it's expected that 890,000 new drivers will be needed and freight tonnage will increase by three billion tons from 10.5 billion tons currently.

From 1980 to 2017, fatal crashes involving large trucks actually declined by 69 percent. But in the last ten years, we've begun seeing a trend in the wrong direction. Over the last ten years, fatal crashes have increased. In 2017, large truck fatalities were nine percent higher than in 2016 and 41 percent higher than in 2009. In 2017, 4,761 people were killed and 148,000 were injured in crashes involving large trucks. That's equivalent to an average of 13 people killed and 400 injured each day.

The next slide shows how the trucking industry ranks compared to private industry. The trucking industry ranks among the industries having the highest occupational illness and injury rates in the United States. Workers' compensation costs for motor carriers are tremendous, according to Bureau of Labor Statistics data from 2017.

The non-fatal occupational injury rate for truck transportation was an average of 4.2 injuries for every 100 employees, compared to 2.8 for every 100 employees in private industry.

The Bureau of Labor Statistics also reported in 2018 that employees in truck transportation experience work-related musculoskeletal injuries at a rate of 62.3 for every 10,000 employees, compared to 28.6 for every 10,000 employees in private industry overall.

Over the next several minutes, as you see on the next slide, we will look at useful approaches for supporting transportation safety. We will also discuss medical conditions that can disqualify a driver.

Turning now to the DOT physical exam - Concentra will perform nearly one million DOT physical exams in 2019. We are the leading medical provider for DOT exams and driver certifications. We have more than 1,200 certified medical examiners listed on the National Registry of Certified Medical Examiners. In 2017, Concentra implemented electronic DOT exams. In 2019, we are implementing electronic pre-placement physicals.

Employers have experienced numerous benefits from electronic DOT exams. The entire physical exam process -- from authorization and clinic intake procedures to physical exam and results reporting -- is conducted in an electronic, paperless environment. The benefits include better and easier administration of physical exams and greater assurance of accuracy. That's a big one. 
Also, electronic exams allow employers to access reports more easily in Concentra's employer portal.

DOT exams must be performed by a medical examiner listed on the National Registry of Certified Medical Examiners. This slide shows a screenshot of the physical exam portion of the medical exam report long form. The components include general appearance. The medical examiner makes a note of a variety of factors, including obesity, whether there are any lumps or tremors, or any other conditions that might indicate an illness or cause for concern.

There are various charts to assess visual acuity. We use a Snellen chart. Drivers who normally wear corrective lenses may wear them during the exam. Drivers who wear contact lenses should carry an extra pair of glasses with them when they drive. The driver needs 20/40 vision or better in each eye and both eyes together.

Regarding the ears, the medical examiner notes any evidence of ear diseases or disorders that can affect balance, such as Meniere's disease or vertigo.

A hearing test that may be used is the forced whisper test. We typically start with this test. We may also administer an audiometric test. The medical examiner can reverse the order, but the driver must pass one of the tests to be certified, and the driver only needs to meet the standard in one ear. "One ear, two eyes, certify" is the phrase we use.

The medical examiner looks for any deformities likely to interfere with breathing or swallowing. Often we document what is called the Mallampati score, which is a predictor of obstructive sleep apnea. Basically, we score based on how much of the structures in the back of the throat are visible. The less visible the structures, the higher the score.  We can go up to four, and a score of three or four is associated with sleep apnea.

In the cardiovascular examination, the medical examiner inspects for any current irregularities in heart function or evidence of an enlarged heart, congestive heart failure, or other cardiovascular disease. If a medical examiner determines that an EKG, or electrocardiogram, is indicated, one may be performed.

Regarding blood pressure, the goal is lower than 140 over 90. If the driver has hypertension or is being medicated for hypertension, re-certification should occur more frequently than the standard once every 24 months; typically, it's annually. A driver in stage one hypertension can be certified for up to a year. Stage one hypertension means blood pressure is less than 160 over 100 and the driver is not on medications.

A driver with stage two hypertension (160 to 179 over 100 to 109) should receive only a three-month certification.

A driver with blood pressure of 180 over 110 or greater requires immediate medical attention and shouldn't be certified. When blood pressure does come down to 140 over 90, the driver can be certified but should have six-month intervals of certification.

In the lung examination, we look for any abnormalities in chest wall expansion, respiratory rate, and breath sounds. We may require pulmonary function testing or chest X-rays.

In examining the abdomen, we inspect for any weakness, tenderness, or enlargement of the liver or spleen, or the presence of any masses.

For the genitourinary exam, urinalysis is required for assessment of blood protein and sugar. Elevated levels may indicate an underlying medical problem that needs to be addressed. The medical examiner is also required to check for hernias.

In the spine/musculoskeletal exam, the medical examiner assesses for any previous surgery that may have occurred, examines the individual for deformities, limitation of motion, any tenderness, and we may require additional testing.

Moving on to the extremities, this part of the exam looks for any loss or impairment in function of legs, feet, toes, arms, hands, or fingers, as well as any deformity and loss of muscle tone.

In the neuro exam, the medical examiner assesses the function of the brain and nervous system. The focus really is on mental awareness, motor function, balance, sensory response, and reflexes.

Let's talk a little bit about drug testing.

Drug and alcohol screening may be done pre-employment, randomly, for cause or suspicion, post-accident, and upon returning for duty after a drug or alcohol violation. DOT testing is a five-panel drug test regimen. As of January 1, 2018, the opiates category was renamed opioids because now the test includes semi-synthetic opioids, which are listed on the slide.

We test for marijuana or THC, cocaine, amphetamines, opioids, and PCP. Only urine testing is permitted for regulated tests. Rapid drug tests and hair tests are not permitted for regulated testing. Concentra will be hosting a drug and alcohol testing webinar in November, where we will go into a lot more detail on this particular topic.

Okay, next let's talk about treatment of musculoskeletal injuries. Long-haul truck drivers are significantly affected by musculoskeletal injuries with incidence rates three-and-a-half times higher than the national average. Two leading musculoskeletal injuries are injuries to the arm at 26 percent and back injuries at 21 percent. The two leading causes of musculoskeletal injuries to long-haul truck drivers are falls at 38 percent and contact with an object or equipment at 33 percent. At Concentra, we practice a sports medicine approach in the treatment of musculoskeletal injuries. Our goal is to restore function. There is much less emphasis on pain. It's important that the patient is an active participant in their treatment and, as I mentioned, our focus is not on pain, but on function - what the injured worker can do, not what they can't do. It's a much more positive approach.

Now let's talk about DOT disqualifying medical conditions.

Disqualifying medical conditions may take truckers off the road near term but they may not always be a permanent roadblock for the driver or the employer. Understanding the FMCSA standards and guidelines, the role of the medical examiner, and when there is room for discretion in deciding whether to grant certification can keep your trucking business running at full throttle.

Ultimately the goal is to identify conditions that may cause gradual or sudden incapacitation. In some instances, the driver can return to driving after the condition is treated. In other cases, the condition is progressive or cannot be treated to a point where returning to driving would be safe.

Let's talk about DOT disqualifying medical conditions. There are 13 FMCSA standards that the driver must meet. Four of them are non-discretionary, so the medical examiner has no discretion in interpreting the standard. The standard is what it is. One of the first is epilepsy or any condition that can result in a loss of consciousness. To meet the standard, the driver must be seizure-free and off seizure medications for ten years. If they have a single seizure, they would have a five-year wait off seizure medications. There is an epilepsy exemption that may be available to these drivers. Exactly what the criteria is for that exemption is listed in one of the seizure MEP reports by the FMCSA medical expert panel.

Next in the non-discretionary DOT disqualifying medical conditions is vision and hearing loss.

Drivers unable to demonstrate at least 20/40 vision in each eye and both eyes together with or without corrective lenses are medically disqualified. For hearing, if the driver cannot pass the forced whisper test, passing an audiometry test may still allow for certification, but failing both would be disqualifying. Drivers with monocular vision - so vision in one eye - now they would have to meet the standard in the other eye. This isn't for drivers who have reversible vision in one eye. It's truly for the drivers who have lost vision permanently in one eye. They can be certified with a vision exemption.

Drivers who do not meet the hearing standard also may be certified with a hearing exemption. Both of these federal exemptions are issued by the FMCSA. Drivers with a hearing exemption are not allowed to drive buses.

Next is diabetes. In 2018, a new diabetes rule was finalized to allow drivers with well-controlled diabetes requiring insulin to obtain certification without an exemption. These drivers must have their treating clinician complete Form MCSA 5870, which is called the Insulin-treated Diabetes Mellitus Assessment form, and it must be completed no more than 45 days prior to the certification exam. You can find the form online. The form should be brought in when an employee is going for their DOT exam. They also must bring three months of electronic glucose log measurements. If they bring in those two items, they can be certified for up to one year. If they don't have the blood glucose log measurements, but do have the Form MCSA 5870, they can be certified for three months while they get their blood glucose logs.

Schedule I drugs include heroin, LSD, marijuana or cannabis, ecstasy, etc. Regarding the use of marijuana, even if a licensed medical practitioner has prescribed or recommended it, marijuana use is a disqualifying medical condition. This is true whether it is used alone or as CBD oil or in any other products or preparations derived from hemp or cannabis. CBD oil, to be legal from a federal perspective, marijuana use must meet the requirements of the farm bill. Right now, there's only one product on the market that meets the requirements, and it's a pharmaceutical grade CBD oil used to treat seizures, mainly in children. Methadone, while not specifically mentioned in the regulations, is mentioned as disqualifying in the medical advisory criteria.

Let's talk about the discretionary disqualifying medical conditions. These are conditions that fall under the nine discretionary standards. The medical examiner is able to use discretion regarding certification. However, the medical examiner is expected to follow FMCSA guidance or medical expert panel recommendations and advisory criteria when certifying a driver. Let's start with high blood pressure. There are no numbers listed in the standard. It reads: "…has no current, clinical diagnosis of high blood pressure likely to interfere with his or her ability to operate a commercial motor vehicle safely."

But medical examiners are provided guidelines but they must use discretion in deciding whether to grant certification.

So typically, we are going to follow the guidelines given to us by the FMCSA, and they actually base that guidance on old blood pressure criteria. There's newer criteria that lowers stage one blood pressure, but the FMCSA has not adopted those more recent guidelines.

Respiratory conditions: the medical examiner may seek further tests or send a driver to a pulmonary specialist to determine if the condition should be disqualifying. The most common condition that falls under the standard is sleep apnea. Obstructive sleep apnea, as I said, falls under the respiratory regulation, and that reads: "…has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his ability to control and drive a commercial motor vehicle safely."

The regulation is discretionary. The medical examiner uses the FMCSA guidance advisory criteria to decide if the driver meets the standard outlined in the regulation. This is unlike vision or hearing, which are non-discretionary and the driver must meet exactly what is outlined in the regulatory standard. None of the discretionary regulations go into any detail regarding specific medical conditions, and so sometimes it's not clear why we refer drivers for a sleep study. While there is no mention of sleep studies or obstructive sleep apnea in the regulation, it's our job as medical examiners to correctly interpret and follow the FMCSA guidance and recommendations. In 2015, the FMCSA sent a bulletin to all medical examiners reminding them that they cannot ignore sleep apnea. With other sleep disorders, when we might disqualify a driver, typically we're going to give them 90 days to get a sleep study unless we determine they are high-risk, they have fallen asleep at the wheel, or something like that.

We would disqualify them if they have a sleep study diagnostic for obstructive sleep apnea, and their sleep specialist has recommended treatment, but they have not started on treatment. We would disqualify somebody with untreated symptomatic obstructive sleep apnea, narcolepsy, or restless leg syndrome with excessive daytime sleepiness.

Regarding medications, there is no list is prohibited medications. Only Schedule I drugs and methadone are prohibited. However, there is a fair amount of guidance and recommendations from the FMCSA's medical expert panels regarding medications, including opioids and psychiatric medications. The FMCSA also has posted on their website a suggested form for medical examiners to use regarding medications. It's called MCSA-5895, the CMV Driver Medication Form.

Regarding certain heart conditions, a current clinical diagnosis of having a heart attack, chest pain, or heart failure would be disqualifying. Once the condition is resolved and the driver has finished the waiting period (it's two months after a heart attack), and a cardiologist has given clearance, they also need some additional testing, like an electrocardiogram and a stress test, a driver may again receive certification.

Regarding intracardiac defibrillators, drivers who have tried so far for exemptions have not been successful.