FMCSA published a Notice of Proposed Rule Making (NPRM) “Qualifications of Drivers; Diabetes Standard

What does FMCSA’s proposed rule on diabetes and Commercial Motor Vehicle (CMV) driving mean to you? You, the Medical Examiner? You, the driver? It’s important to be able to answer that question. From my perspective it is a mixed bag — Some good things, some not. 

Perspective

From my perspective:

A good thing: Elimination of the Diabetes Exemption Program is a benefit to CMV drivers. 

In the May 4th notice of proposed rule-making (NPRM) FMCSA proposes to allow drivers who have insulin-treated diabetes mellitus (ITDM) to operate a commercial motor vehicle without applying for a diabetes exemption.

Elimination of the bureaucratic, cumbersome Diabetes Exemption Program is a true benefit for the CMV driver. The Diabetes exemption program requires drivers to wait 6 months after starting insulin before applying for an exemption. It requires drivers to send in quarterly reports from an endocrinologist on the status of diabetes management, and to undergo an annual eye examination for retinopathy (a complication of diabetes). 

With those provisions eliminated, drivers with diabetes can keep their jobs without interruption if they move from oral medications to insulin management of their diabetes. Drivers without health insurance can save money. Drivers would no longer need to provide quarterly reports. Drivers no longer need to find an endocrinologist but can rely on the health care practitioner who is treating they driver’s diabetes. It means they don’t have to have additional expense that some might think are unnecessary.

Not a good thing: FMCSA is not only proposing to eliminate the diabetes exemption program but is also eliminating all the prevention and safety requirements that accompanied the exemption program.

The proposed rule has no requirement for the driver to keep blood glucose logs — no requirement for the driver to test his blood sugar prior to getting into the CMV driver’s seat — No requirements to carry rapidly absorbable glucose — No requirement for a special eye exam for retinopathy, a complication of diabetes that causes vision impairment. 

The proposed rule does not include any important measures to prevent unexpected hypoglycemic events. It includes no requirements to ensure safe driving — requirements included in Transport Canada’s rules for Canadian drivers and recommendation included in the American Diabetes Association’s Policy paper on diabetes and driving (these are recommendations for for People with ITDM who drive any type of vehicle). 

Drivers can get into the CMV without knowing their blood sugar level. It means they don’t have to mess with blood sugar logs. It means they don’t have to remember to carry a candy bar or other rapidly absorbable glucose. 

A good thing: FMCSA’s NPRM includes a required annual medical examination with verification from the driver’s treating clinician about the management of the driver’s management of his/her diabetes. 

It is important to have collaboration between the treating clinician and the Medical Examiner. It is invaluable to have reports form the health care practitioner who sees the driver regularly. 

Not a good thing: But, the proposed rule does not have any authority over the treating clinician. 

What if the treating clinician won’t respond to the Medical Examiner’s (ME) questions? What does the driver do? What does the ME do? What if the treating clinician only states that the driver’s “Diabetes managed well” but gives no data on which the ME can pin his/her decision-making? And, what about those drivers who get their insulin over the Internet without a doctor’s prescription? Those drivers who don’t have health insurance and can’t afford a treating clinician so they self-medicate? 

The proposed rule does not include medical examiner (ME) authority to request specific information such as the Hemoglobin A 1C results, the driver’s blood sugar logs or any other important information about the driver. Yet, the ME is held responsible for the driver’s physical qualification determination. 

In essence, the Agency is giving the driver’s treating clinician the authority to make the decision about whether a driver can operate a CMV in interstate commerce. Of course, this isn’t spelled out but is implicit in the rule’s language. If you read the proposal carefully you will see that the only requirement is a report from the treating clinician stating the driver is managing the diabetes well and hasn’t had any serious hypoglycemic events in the last year. This, despite the National Registry of Certified Medical Examiners that requires MEs to be trained, tested and certified on the National Registry before doing a driver’s medical examination. So the treating clinician is not given authority to qualify the driver. But the ME is not given the tools to make a well-informed driver qualification decision. Is this good for Medical Examiners? Is this good for drivers? Will drivers be caught in a limbo waiting for their treating clinician to respond to the MEs request? 
 
Is it good for driver’s in the long run? I don’t think so. Diabetes is a very complicated disease. Lots of people think of it as simply having high sugar in the blood. But, diabetes affects every body organ. It has serious life-threatening implications. It can cause blindness, legs amputations, heart disease and myriad of other medical conditions. 

FMCSA seems to think that driver’s will comply with their treating clinician’s recommendations because of the quality of life issues. But as most health care professionals know, one of the most challenging issue in health care today is patient compliance with the treating clinician’s directions. People just don’t seem to want to follow their doctor’s orders. 

I believe the proposal may have short term benefit for drivers — less expense and less lost time from work. But, in the long run, improperly managed ITDM causes havoc - lots of expense, hospitalization, limb amputation and possible complete loss of the job. And, what about the danger to the driver of an unexpected hypoglycemic event that causes confusion, unconsciousness or worse? With this rule, the driver loses the added incentive to manage his/her diabetes well, to know the status of any diabetes complications and receive treatment early. 

Drivers, will you go to the treating clinician regularly? will you follow the doctor’s orders? 

I suggest you read the proposed rule. Think about the long term consequences and submit comments to FMCSA. The proposed rule is found in the Federal Register at federalregister.gov.

Once the final rule is published, we will have to live with it for a long time. Thus, it is important for you to learn about the proposal, figure out its impact on you and submit comments to the Agency. Be a part of the rule-making process. Use your power to influence policy-making, while you have the chance!