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Medical Examiner’s Handbook & Apnea

Newsletter Update

The Federal Motor Carrier Safety Administration (FMCSA) is currently reviewing comments about the proposed revisions to the Medical Examiner’s Handbook. The handbook was pulled from FMCSA’s website in 2015, depriving medical examiners (MEs) of a resource of information that went beyond the regulatory basics. Some medical qualification decisions are based on objective facts, such as blood pressure readings. However, diagnosing and treating sleep disorder has always been murky at best without any clear guidelines. Many of the comments received make this clear, and the industry wants a more structured process regarding sleep disorders.

One commenter, Pam B., thinks that “individuals caught up in the system need to be protected from financial entanglements between MEs and those who would profit from that diagnosis. There are simply too many instances where the ME works for the same corporate medical behemoth as the sleep study doctor, which corporation also conveniently sells the device and supplies. Even if they don’t actually work for the same company, often the alliances between these parties are far too cozy and mutually profitable to pass the ͑sniff test. ͗” cover of medical examiner's handbook

Another commenter, the Alliance of Sleep Apnea Partners, cited studies that demonstrate a link between apnea and a higher risk of a motor vehicle accident, and a much higher risk for drivers who have been diagnosed but are not adhering to treatment. Yet another commenter cautions against coming up with a “one size fits all” solution. For example, are neck size and body mass index reliable predictors of an underlying sleep issue?

The following comment from the National Association of Small Trucking Companies underscores some of the variables involved in making a definitive diagnosis: “No one, regardless of gender, age, neck size, body-mass index (BMI), small airway, snoring, or hypertension, scores a perfect 0 on an overnight sleep study. Therefore, no threat exists to the driving public up to a current AHI (apnea/hypopnea index) threshold of 30, unless there is a chronic and measurable sleep deficit in evidence. Thus, the medical examiner should look for extreme OSA, a sleep deficit, or evidence of narcolepsy. The addition here of this objective evidence would improve the certified medical examiner guidance, reduce subjective findings by MEs, and reduce expensive, time-consuming sleep study orders.”

OOIDA (Owner Operator Independent Drivers Association) feels that “The handbook should acknowledge that MEs (medical examiners) should not overrule personal medical physicians. The MEH (Medical Examiner’s Handbook) should stress the importance of MEs accepting the medical judgment of a driver’s personal physician. Too often, MEs ignore personal physician’s judgments and deny medical cards to drivers. The handbook should also specifically state that a driver is entitled to a second opinion and that the ME must acknowledge that fact if asked by the driver. From conversations with our members, we understand many MEs believe it’s against regulation for a driver to get a second opinion.”

Part of the comment from the ATA (American Trucking Associations) summarizes what many in the industry have been saying: “…moderate to severe OSA can be a serious safety concern if not effectively treated and we appreciate the effort to provide MEs with guidance when evaluating CMV drivers for OSA. ATA feels the current draft allows for too much discretion and will further facilitate inconsistent CMV medical examinations. Should FMCSA decide to further address OSA, it should be done through the rulemaking process as required by law.”

There is no timeline for FMCSA to sift through all of the comments and then formulate a plan on how to proceed. Overall, the industry is asking for a more definitive process less dependent on interpretations by individual Medical Examiners. On the other the other hand, a regulatory approach may result in a “one size fits all” type of solution which is also problematic. We just need to stay tuned and see how all of this plays out. The industry will have a chance to respond to the next publication in the Federal Register.