Um, appreciate everybody's attendance and I'm going to just run through a few housekeeping slides. Uh, so welcome to our commercial driver medical examiner training course. I really want to pay honor and homage to grand who Bob all this that came up with the original content when the guidelines were first published in 2013 to be implemented in 2014. Dr Daniel J. Callen, who's now retired. And I'd really like to thank Dr Warren's for stepping in and carrying this course for the last five years. Uh, and for being our, uh, like, like Liz Clark, Swiss Army knife that's willing to lecture on anything at any time with very little notice. They like the special ops of CME lectures. So, uh, there's my beautiful, uh, nose. It does look like it's slightly deviated. And, uh, and that was my Tennessee license. We've since relocated to, uh, to Oklahoma to be near our family. So we're gonna credit the programs accredited. We're gonna give you minute for minute credit. So if we go nine hours instead of eight hours, don't fret. We'll, uh, we'll get you as much credit as it takes for, uh, Dr Warren's to, uh, make you an expert medical examiner. So our faculties here, they had nothing to disclose, except that they're all very good looking people and would enjoy conflict. So if you'd like to, uh, to sponsor them and put them on a payroll so that they have something to disclose next time, they would love that. Uh, they away wants us to read this to you. I'll summarize it by saying that the viewpoints are are not those of the away and are no substitute for independent medical judgment. Well, we'll have a course evaluation for you to complete. That's a serves two very important roles. Obviously, it lets us know how to improve our course, but most importantly, it attests that you attended so that we could file your CMA for you. All right. So that's the end of my remarks. I'll be around, though, if you need me. So, um, so we'll go to a one. So you have to end screen share. Thank you. That's fine. I can do this. That's because it's stopped and restarting. I forgot what it was. All right. You're good. Okay. Thank you. Good afternoon, I guess, everybody. We'll run logistics here in the room. Greetings to everybody who's both here and online. My name is Carl Wurz. I'm the course director for this class. I've been teaching in the curriculum pretty much since we started. My background is in academic medicine, although I'm now in private practice of occupational medicine in Morgantown, West Virginia. What we're going to do today is go through the curriculum. There are some difficulties, and I'll lay them out as best I can. One of the things that's happened is that, because I went back as recently as yesterday, to see if they changed the curriculum, and they have not. We're still using the 2012 curriculum as we're required to follow. But the curriculum is vague. It just says, you'll talk about this disease, and this body part, and this. We're okay. We're not going to get in trouble. I mean, there's nothing in the curriculum that's wrong, but it's just that they haven't updated the curriculum. Let's go through a little bit of the history of the program. Okay. So this course is run by AOC OPM. We were one of the first groups accredited to teach the class, and we continue to do that up through now, both live and in person. I mentioned also that we were going to thank the person who put this together originally, Dan Callen, who is now retired, and last I knew was, I'm not making this up, working as a groundskeeper at a local country club. He has finally escaped from medicine and found something productive to do with his life. Our instructors today, I'm Carl Wurz. I said, I'm from Warrington, West Virginia. Liz will be joining us, who is newly from Colorado. And Naomi is also going to be presenting, who is from Columbus, Ohio. And we all practice occupational medicine in various different ways. Just like the person earlier was interested in talking to you if you wanted to learn how to, if you wanted to do FECA exams, federal employers, if you want to do black law exams, which is a different part of the Department of Labor, I can tell you everything I know about those. So we're going to go through this. Hopefully you did the pre-test before. The working lunch, we've just finished. We'll do the post, we're going to review the pre-test at the quarter, kind of towards the end of today's session. We're officially booked today from 1230 to 530. That's the official booking today. So that we'll get between our goal, and there's a 15 minute break. So, and the way that the CME works now, it's minute for minute. So they will watch and go, well, this was, you know, so they're going to count minutes and say, okay, you get your eight hours or it's only seven hours. So we want to make sure that we take advantage of that. My goal tomorrow, because it's going to be, that's as it could be as much as four and four and a half hours today. And then tomorrow we'll have another three-ish hours to do. My goal tomorrow is that we're all done in time to go out back here to the modern art museum and go to brunch. That's my goal for tomorrow. It is worth, it is really cool. Anyway, I don't care if the art museum is okay, the brunch is amazing. So we've already done the check-in things. We've got everybody's IDs and in order to be certified, you need to be here today for however many hours we do and tomorrow for however many hours we do. So you get the whole class. We're going to go through all these competencies and I don't want to spend a whole lot of time on them. Let's just do them. So these are all the things we have to include in the course. I said, the outline has not changed. It's not very specific. It's just, so we've been able to update it to reflect that information. There are 13-ish modules that we'll go through today. So first question is, why are we here? Well, this is the picture of the safety failure that started this whole process. Now, keeping in mind that everything that we're involved with occurs at government speed. So that's a 2001. They had the review of the 1999 accident that was shown in that last picture. I'm not going to get super lost in the details of this, but they had a rack of a motor coach. It had a 55-passenger bus. They had 43 people on board on route to, and I'll probably pronounce this wrong, Laplace, Louisiana. I think that's right. And they were going to, there was all a bunch of senior citizens on their way to the casino. This was one of the casino buses. And they, as they were approaching a certain milepost, they bounced off the right side of the road. They found a grassy slope, got the bus onto its side. It slid for a while, struck the end of a guardrail, spun through a chain-link fence, over a paved golf path, golf cart path, and then ran into the dirt bank on the other side and bounced around. And 22 passengers were killed and 15 passengers were seriously injured and five passengers had minor injuries. So they looked into the 46-year-old driver who had a bunch of medical conditions, who had a current CDL and medical certificate and a bunch of medical conditions that probably should not have been certified. So happening with great federal speed, in 2012, 2010, they started this process and this became finally effective in 2014 when you had to complete training and then take a test to be certified to do commercial driver medical exams. They've gone through, they've done a bunch of looking and there's a lot, the problem before was everybody, if you were licensed to do an exam in your state, you could do CDLs. I don't have the picture here. This is where I would insert the picture if I'd taken one myself, but I've seen the sign and was amused when I was in occupational medicine but wasn't teaching this class, was driving west on Route 70 from Wheeling into Ohio. It was a big sign, big billboard that said you had to stop and get your CDL medical exams at this certain exit truck stop, guaranteed pass. Actually said it on the billboard. And when you, I've stopped at that, I know what rest area was. And when you stopped there, they had the chiropractor's office is still in that truck stop. He's still there, but he took down the sign about the guaranteed pass. So there was a problem because anybody, if you were licensed to do exams in your state, you too could do CDL medical exams. You didn't have to have any idea what was going on. So they put together a couple of different things. They put together the medical part that we're part of. That was the last slide. They put together, they're trying to tighten up on the drug testing because what would happen is because there was no central repository of drug test results. So if I went to Liz's trucking company and failed my drug test, I would go home for about two days. And then I go to his trucking company and apply for a job. They do a new drug test. I passed that one and I'm fine. And there was no way to know that. And then if Bridget's company fired me because of my drug use and failing a drug test there, I could go three days later to Liz's company and get a new job. Because there was no cross-checking and there was no requirement for that. That's the other thing they tightened up as part of this same effort. So they want us to be, and it's highlighted here, familiar with the physical qualification standards, hand certification test, and maintain competence through periodic retraining and retesting. And we'll go through that in just a few minutes, how that has manifested. Before they did this, this was in around 2008, 2009, they did study, they went to a couple of states and 66,000 medicals in California, they figured about 10% shouldn't have been issued due to lack of qualifications or given a shorter certificate. Indiana found about 28% error rate. Now, obviously the goal is these will all become zero. I know we're not perfect, but- That was really Ohio. Was, well, Ohio could have been like that too? Yeah, it could be. These two states looked at it and there's a lot of, there's a big number of not done well exams. So, we will- When have you ever seen someone who looks like that? They exist in the trucking industry, that guy exists. That's just, or it's not, I didn't say there's more than one of them. There's what? A couple of, we'll see, there's a lot of drivers, there's one of that. So this is, they looked at human impacts and these are for people that had, so total number of large trucks involved in crashes. And then they looked at causes, as best they could come up with. 68,000 were driver issues, 8,000 the vehicle failed, and 2,000 was the environment. Now, what they're, so, and the best way I can figure out that this would actually make sense is some of the weather stuff is probably up in here. Deciding to drive when it's icy is probably puts you in the decision part, not in the weather part. Every once in a while, a tree falls on your truck while you're driving down the road, those are hard to prevent. Okay? So a little bit about the history of the CDME guidance. So when they started with the medical part in 2010, they decided there were way too many providers because any licensed provider who's allowed to do a physical exam in their state was able to sign CDL medical cards. And they thought, try just making these crazy determinations and put endangering the public, like guaranteed pass is probably not the right policy. NTSB was also very concerned about sleeping drivers. And that was actually part of this whole thing when it started up. So they put a process together where we're gonna start to train people, we'll certify them, and we're gonna have this thing called the CDME handbook and medical review board recommendations. We'll follow all those and we'll all only certify people who are truly safe to drive. That's the plan. So starting in 2014, they started doing training. This is an estimate about 100,000 providers were trained. Not quite everybody took the test, but a lot of people were trained. And I have some data, I think later in this talk and later in this module, where we'll look at some numbers. And then we'll just all follow the CDME handbook. Data, recommendations, and only people who are fully certified will be qualified. Now, the problem was that once you started doing this, some drivers weren't getting certified or couldn't get certified, and they got cranky. And there were some very long recommended waiting periods. Some of them probably exceed medical or current best understanding of medical science. Medical review board recommendations started, some really getting a bit dated because some of them went back to like 2002. And so in 2015, that might not be the current recommendation. A lot of that has to do with the cardiac testing that we'll loop back around to. There was no appeal process other than a few specific waivers. So if you didn't like my determination, there was no, you couldn't do anything about that. The process to get an SPE was not available in many areas. I practice in West Virginia, and in West Virginia, we had no access to SPEs up until about three years ago, maybe four. Because the federal government said, you'll have one in the state of West Virginia, said, yeah, we don't have one of those. So people that needed an SPE had nowhere to go. And FMCSA could not for the life of them keep a medical director on staff. So there was no, huh? They have one now. Well, they have one now, and the person's been there for almost three years, which is, as long as he keeps breathing, that's okay. The comment was he's older than Dirk, but they've had one for about three years, but for the first five or six years of this process, it was like five people's worth of work they wanted one person to do, and they'd be there for three or four months and leave, and just say, this is way too much work for one human. And they were in this weird policy. They wanted to make medical decisions with policies that they can't influence, which may just drove them nuts. They're doing better right now. So in 2015, we went, by 2014, we were at full implementation. There were only a few non-negotiables at that time, and that was the vision, epilepsy, hearing, schizophrenia, Meniere's disease, insulin, and methadone. That was the list back then of the hard no-nevers, right? And then CDMEs were used their best clinical judgment for things other than that. And it was okay if you could deviate from the recommendations as long as you documented it, and you used your best medical judgment. And the recommendation came out in about 2015. They said, if you don't like the first doctor you go to, if you don't like their determination, just go to a different doctor. It was perfectly okay. So that's the recommendation. That was how they dealt with their appeal process was go find somebody else to sign your card. So moving forward a little bit, in 2017, during the government shutdown, when all the federal government people were all told to stay home, they found time somehow in Congress to pass a rule requiring that FMCSA can't do anything medically relating to sleep apnea without going through the formal rulemaking process. And over the next, I don't know, year and a half, because it was government speed, everything about sleep apnea slowly evaporated from the FMCSA website. It just kind of sublimated off into the ether. It no longer was a thing. They kept telling us we'd use our best clinical judgment about sleep apnea, so follow current recommendations, but we won't tell you what they are. And by this point, all the states had access to SPEs because they set up regional testing centers. I need to make a map. There's like six or eight places. Where I am in West Virginia, they can either drive into DC or to Chicago. They're their two choices. But they've got them in and around major cities where they can go get an SPE done. They came out with this form, which actually is not bad. This is a form and it's the optional medication form. And the first, it's a two-page form. The first page is just where they tell you, like they self-identify like who they are and all that kind of stuff and give their doctor permission to fill out the form. The right-hand page is where it's theoretically per medication or per disease. The treating doctor writes down what the medicine's for. Because if you start thinking about a calcium channel blocker, I mean, if we took a poll in this room, I bet we can come up with 10 different indications for calcium channel blocker. And many physicians, many patients have no idea why they're on it. Is it for migraine prophylaxis? Is it for blood pressure? Is it for rate control from the rate fib? Is it for, you know, and there's a bunch of other things to choose for, huh? Is it for the Raynaud's phenomenon? Yeah, there's a bunch of things. This form gives the treating physician a way to communicate to the CDME why that person's on that medicine. I use this occasionally and it's usually for, and this way what I've gotten is written documentation from the prescriber. So if I've got somebody, I'm not usually not terribly worried about the calcium channel blockers, but if I have somebody that's on like an anti-seizure medicine for behavioral things, gabapentin for, Ward knows what they're using it for, but especially if they're on an anti-epileptic, maybe it's for behavioral things, that may be compatible, that may be okay for driving, but I want to know that they're not using, they don't have them with valproic acid because of their seizure disorder. I want their doctor to tell me why they're doing. That's not that, so that came out about that time. 2019 to 2020, we got a process for certifying insulin using drivers. It has some flaws and we'll talk about those in a few minutes, but at least there's a process now. We got the 2020 edition of the Commercial Driver's Handbook. It went from 324 very dense pages in the original 2012 one, to 77 way less dense pages. The wording got way more vague. There was almost nothing listed as you may not certify. It doesn't say that. Just stand by. The old book had, in a disease family, would say you can't certify this, this, and this, but you can certify these, these, and this. It gave you choices. The words cannot certify was replaced with may not be eligible for certification, or wording like that. All the wording was really watered down. There are only a few hard stops. You don't meet the vision standard, any of the vision standards, no, you can't drive. Total blindness is actually a disqualification, but not very many, or perhaps should not be certified, or may not be qualified. It's gotten difficult. Best medical judgment was encouraged, and the hypertension table sort of evaporated, but then it returned. It came back. I mentioned that that kind of died, but then in the 2020, and I'm sorry, let me finish. 2019, we got a new form. It gave us a place to record a second blood pressure, and so we can do that in other testing if you wanted to, but the guidance from FMCSA degraded from, they must meet the numbers in this table. We went all the way to, you have to fill out this form. That's the requirement. You have to put numbers in the boxes on the form. That's all you have to do, and there was no other required thing relating to blood pressure, and I should add in here, 2021, they redid the CDME handbook. We got up to 114 pages, still almost no recommendations, but interestingly, the blood pressure table came back, and we'll go into this a little bit more, but in a weird way. So there's a process now in 2022 to certify people with monocular vision. That's an interesting, this is like everything old is new again. When I first learned how to do this exam as a resident, on the form, it said if they've had monocular vision for six months, you can certify them. That's what it said on the form, but then we couldn't certify monocular vision at all. Then you get a waiver, and now you can do it yourself following a set of rules, which is probably the right process. The five-year recertification modules, due in 2017, finally came out, and there's a plan for 10-year recertification. Yes, so this is all stuff quoted. This is directly from the periodic training module that we all, hopefully everybody did last year. Please, everybody go like this. I hope, yeah, there's about 39,000 of us doctors, or of us providers that are certified that haven't done the mid-cycle recertification, just saying, that are late. I don't mean somebody who just certified a year ago, but that are overdue and didn't do it. FMCSA is probably going to start removing those people from the registry. They said they were going to do. So we've gone to having guidance. We have no rules. We have guidance. And so there aren't regulations. They're not legally binding, and they'll keep telling you this. It's not legally binding. Whatever we say is not legally binding. It's up to your examiner to use their best medical judgment. They could have just taken that whole 114 pages thing and just said, use your best medical judgment on one piece of paper, a big text, and they would have covered almost everything in the guide. It's just advisory. It's not mandatory. And if you're mad at somebody, get mad at your provider, not us. So supposedly, on June 23rd, 2025, I will be... I had an old slide where I kept crossing off the date, and this is like the seventh date for this to actually happen. They will find a way for the database and registry to talk to the databases in the states. It's been promised. I said the original date I had on my oldest slide was a date in late 2015. Then I had a 2017 date, 2018 date, 2020 date, and now we have 2025. So we'll see if this really happens. The theory is when we get to this date, you will not need to issue a paper certificate to somebody who holds a CDL. If they don't hold a CDL, they'll still need to get a paper certificate. But if they actually have an... If they are actually a CDL or a CDL learner's permit driver, they won't need it because it's all in the state database. Again, we'll see if that holds. Interstate drivers and non-CDL drivers will still need paper certificates. Interstate, if you have that in your state, like I'm in West Virginia, we do not. If your state has intrastate drivers, you need to talk to them. I'd call them up in about May of 2025 and ask them if they're gonna be able to receive them from NRCME. They should know by that time. So rules and regulations. First thing is everybody calls these DOT exams. DOT has lots of parts. And so that just means part of transportation. Everything that allows things and stuff to move in the United States is under the DOT. Okay, so FMCSA is the motor vehicle people that we're working. The National Institute of Certified Medical Examiners is us. You, after you complete this class, take your test, and all that stuff will be a CDME. A CDL is a commercial driver's license. A commercial motor vehicle is a CMV. The Code of Federal Regulations, the National Transportation Safety Board looks into bad things that may have happened in transportation, and then they talk about, then DQ is disqualified, not eligible for certification. I don't, I think I've completely removed the disqualified DQ from anywhere in this presentation, but if I missed one, that's what that means. Okay, the Department of Transportation has seven and a half administrations in it. And all of these may, or they're all part of the Department of Transportation. Okay, so we're FMCSA, that's what we care about. Federal Railroad Administration has its own world, has nothing to do with these exams. FAA has their own exams parallel to this, and way better done. The Federal Transit Authority has to do with buses and trains and trolleys and things like that, and most in urban areas. Federal Highway Administration builds highways, they don't really run them. The U.S. Maritime Administration, I don't think they actually have an operational arm. The NTSB, the National Traffic Safety Administration and Pipeline People, there are sometimes jobs, and I should imagine the Coast Guard. Coast Guard is really good friends with the Department of Transportation, although they're no longer officially part of it, but they do a lot of, a lot, they used to be. I mean, before September, before about 2003, the Coast Guard was, during times of peace, part of the Department of Transportation, okay? And they've now moved into Homeland Security, so they'd have adult leadership. But they're still part of this whole regimen. There are jobs in almost all of these regimens that may use an FMCSA exam. Just as an example, deckhands in the Coast Guard system are allowed, if they pass their FMCSA medical, that is an adequate medical exam for them to be a deckhand, not the captains and the pilots, they need a special exam, but the deckhands, this is good enough. So if somebody comes in, I think this is one later on, somebody comes in, wants an exam, and you're, just do the exam. Don't fight with them, they don't need one, just do the exam. They probably actually know more about the regulations for their little thing they wanna do than you do. All this stuff comes out of the Code of Federal Regulations, 49 CFR 391.41 is our part. We will try to do this. So they have standards, and if I've done this correctly, the standards, the things that must be true or must be done will be in red during all the slides here. Guidelines will be in various shades of blue, and I couldn't always match that exact shade. And this is an ongoing process that theoretically we'll keep updating the process. It's been made more vanilla rather than made more difficult, but that's okay. We're all on Title 49, and that's where the medical standards are. So there's a bunch of things that are available to support our decisions. So sometimes the agency does their own analyses. They often do data stuff, because they have access to the data of how many crashes there were and how many were this and how many were that. There are sometimes national and international regulatory analyses. They're under whatever NAFTA is called now. The transportation safety people from Mexico, the US, and Canada get together every so often, talk about things of mutual interest, like accident rates and drug use and stuff like that, to try and harmonize them across the NAFTA space. They also, they do use evidence-based reports, of which there are very few. There are medical expert panels, which are groups of specialists in an area that will provide a report of advice to FMCSA. So there might be one on cardiovascular disease or one on seizures or something like that. So that's what a medical expert panel is all about. And there's also a medical review board, which is supposed to be the summary that takes in all this other data and makes the recommendations for people like us to follow. All of their reports are, such as they are, are available on the FMCSA website. And you can actually, you may have to drill down and keep trying stuff till you find the report you want, but a lot of this stuff is out there. Some of it's very well hidden, but it's actually there. So the other thing I've sometimes tried to put into RED is things that might be testable. We'll talk about tests in a few minutes. So there's five experts in the medical review board. I think one of them has to be an OCDOC, but like not more than two. And so there's other people from other areas, there'll be a cardiologist and maybe a neurologist. There's people from other areas on it as well. They provide advice to the secretary of transportation and the chief medical examiner, who's at the doc that they finally got to keep at FMCSA, and work on ways to make this safer. So as I said, it started in 2005. Safety loo is probably a test question. Because what's happening is, since there's less and less standards, I'm expecting that there will be more and more questions about process and more and more questions about things that are totally irrelevant to be able to do the exams well, like what legislation may enable us to do this kind of a thing. This could be a test question. One thing to keep in mind is the theory is that the creation of the National Registry did not change the physical qualification standards, but just makes them implemented more uniformly. So as I mentioned before, Safety Loo, it created the medical review boards to make recommendations and then the process that eventually led to us doing these classes and the exams. Their goal is to identify best medical evidence for doing these exams. That's their theoretical goal for the medical review board. The reviewing panels, that's the medical expert panels, will make recommendations, the medical review board that makes decisions that then tells us, right? That's the way this is supposed to work. The one thing that they did set up was that if your state has a state form, which is possible, I don't know if anybody does anymore, but if they do, you have to include the federal question, the federal information, the federal questions. Same way, if you wanna use a slightly different form in your practice, you're allowed to do that as long as the federal questions are exactly, are verbatim the way they are on the federal form. But if you wanted to reformat it, have it on a computer screen, or you wanted to add more questions, you're allowed to add more, you're just not allowed to take anything away. Okay? So key dates, I don't, we started with all this stuff in 2008, 2011, 2012. The national registry was finally published in 2012. Great guy, they're not gonna ask questions about that. But on 5-21-2014, everybody had to be, all the examiners had to be certified. Our big focus here is on safety. I'll just show you in this picture. You may notice that this is one of the tractor trailers that had a sleeper cab, except now the sleeper cab is on its back in the middle of the roadway. So that might've been quite a ride for the guy in the sleeper cab. So regulations are things that must be true. And there's a few of them in here and we'll talk about them. Guidelines are more advisory criteria and things you ought to think about. You can decide whether or not to choose, whether or not to follow the guidelines. You're required to follow the absolutes, the regulations. These are the actual regulations. If you wanna look something up, this is where you can find all that stuff. So the, how to fill out the medical certificate, the examination forms, drug and alcohol testing, that whole process that we'll talk, cover a little bit, but there's way more depth available on that website if you wanna get into that, have more questions. And the various things down towards the bottom, there's a little bit about intercity zones and vision waivers. And we'll talk about them when we come to those sections. So these are the original regulations. So you can't have a medical history or clinical diagnosis of diabetes mellitus, currently treated with insulin unless they meet the requirements of that center, which we'll talk about in a little bit. They can't have had a myocardial infarction, angiopectus, coronary disease, or any of those things. Now, these are actually from the regulation. This is not, this is what the regulations say. The question is, how do you implement this? So though, I mean, clearly if the, so a current clinical dose of myocardial infarction, they've got ST elevation right now, don't give them a medical card. You're solid on that. You know, they're, that's, but I don't know when does that, when are they better? This is where, this is why I need regulate. This is where the guidelines come in to play. If they have, and then you can fill in almost any other medical condition, and it'll read just like the blood pressure one here in the middle for number six, has no clinical diagnosis of fill-in disease condition here, likely to interfere with his or her ability to operate a commercial motor vehicle. That's what it says for almost all of the bodily systems. You can't have a musculoskeletal problem. You can't have epilepsy or anything else likely to cause loss of consciousness. And I do like the fact that they continue on or loss of ability to control motor vehicle. The assumption is if you've lost consciousness, you're having a seizure. You can't control your motor vehicle. Those are, I think, reasonable assumptions. So we have to have distant, this is again, this is the actual regulations, distant visual acuity of 2040 and the visual meridians of 70 degrees in each eye. And you can see red, green, and amber. Those are the things that are essential in the vision standard. And again, what's happened is they did change the, there's, they added extra stuff on for some of the waivers, like for insulin and for monocular vision. They added more stuff, but the core thing didn't, they didn't change the wording before, which is sort of interesting. You have to be able to hear. You can't be using a schedule one drug of any type. Let's see. And you can't have a current clinical diagnosis of alcoholism. It keeps going on. So it talks about things that are highly susceptible, emotional, highly susceptible to frequent states of emotional instability. And they specifically mentioned schizophrenia, active psychosis, paranoia, anxiety, or depressive neuroses. And they may warrant disqualification. Not that you have to, but you might want to. That is like the strongest statement you'll find anywhere in the current rules. We talked about drug use, and methadone is still, it's own special no-no. So these are the mandatory ones. You have to meet the vision standard. You have to meet the hearing standard. And the little star means there are limited exemptions available. Deaf people can be certified. They'll need a waiver. You can't do that yourself yet, but you get the process started and then they'll get the waiver. We'll talk about that in a little bit. Epilepsy, the waiver just takes you from 10 years off drugs and seizure-free to eight years off drugs and seizure-free. That's the waiver they'll give you. Schizophrenia, active psychosis, methadone use, any Schedule 1 drug, and yes, that does include marijuana, and current alcohol or drug use are the ones that are in the regulations as you should not qualify. And then with the schizophrenia, active psychosis, the active psychosis is still there. Schizophrenia is vaguer. Both you and the driver are required by law to be honest and truthful in your reports. So they have to be honest about the medical conditions and you have to be honest about your opinion. Concealing or disqualifying medical condition is specifically making a false statement to the government and could end up on a federal rock hockey team and you don't wanna do that. You need to keep records, be prepared to both keep the records and also share them with the government if they ask. And there are penalties if you don't do any of those things. Yes, sir. So, and I think it was the update, the interim training, it was pointed out that if you left a company, the records, you had to have access to them. Correct. But you're the one that's on the hook for them, not the company. Correct, the question was, if you work someplace and you leave and who's responsible for having the records available, their FMCSA's deal that you signed on to when you became a CDME is with you, not your employer. I think that the employer would have a hard, since they're, and almost always, if you read your physician employment agreement, it'll say something about them maintaining your medical records. I think they have a very hard time not sharing with you if you specifically, if you get contacted and specifically ask them. I don't know what the right, what the requirement, I mean, I don't know who would be found to be at fault if like you don't work there and they went out of business and like they just shredded all the records or something. I don't know how that works. They only have to keep them for three years, they don't have to keep them forever. But that is, the FMCSA was clear that their opinion is that their deal is with the CDME and they want you to produce the record, the CDME to produce the record if there's a question. I hope that's clear. Anybody who, if there's lying going on in the process, like if the driver doesn't tell you about something that they ought to have told you about, that will invalidate both the examination and the certificate that may have resulted from it. So they go to see Liz and tell them about her seizure disorder and they go, I can't certify you with your seizure disorder. Then they come to see me and kind of forget about their seizure disorder. That my, because they didn't tell me, I have no liability for that thing that Liz knew about. If we're all, if they had adequate personnel to pull this off, what's supposed to happen is they go to see Liz, Liz puts them in as a denied. I'll go into the database and put them in as a pass. Like two days later, what they're supposed to do if they had the personnel is they would get our reports and compare them. Now, if they told me about the same condition they told her about, we're all good. Like I'm making a different medical decision but I'm not allowed to have different facts to start with. And so, cause that would be on the driver. And I sometimes disagree. In my, when I was at the university, I would certify some people that other people would not certify and that's okay. You're allowed to be different as long as we all have the same facts. Yes, you have a question. Second, back to the alcohol or drug. You know, the driver drinks six pack a week. How do you know that? He said it. If he drinks a six pack a week, I don't know that you have a huge problem. What though? That's mandatory. No, so if somebody is currently, so if somebody is, the way they word it on like the state, you know, on your medical issue, you have the intemperate use of alcohol. If the person comes into your office and smells like a brewery and they're drinking, a fifth of vodka every day, you probably don't want them driving. If the person has a beer three times a year, it is the use of alcohol, but it's not while driving. And what I just remind people is that if I see somebody that says, oh, I do drink a little bit, I just remind them, you want to be, but I talk about the bottle of throttle time, just like with aircraft. You know, I said, at least eight hours, preferably 12 hours between when you have a beer and when you drive, and you're probably safe. Keep in mind that, and I remind them if they even look vaguely shocked, because just remember, your cutoffs for DUI are way lower in a commercial vehicle than they are when you're driving your personal vehicle. Just be aware of that. You know, it's 0.04, not 0.08 when you're driving a commercial vehicle. So that's what I'm saying. So, but current alcohol, if they're, and current use of marijuana, current is the key word there. So- Very recent, very recent. Super recent, yeah. As opposed to, you know, for anybody who's ever been in the AA world, once you're an alcoholic, you're always an alcoholic. And so there's people coming and say, you know, my name's George and I'm an alcoholic, and I've been dry for 12 years, and everybody claps, right? They still, so they're still an alcoholic because Bill W. said so, but they are not actively drinking and they've been dry for 12 years. They're fine. Prior diagnosis is not a problem, current use is a problem, that's for drugs and alcohol. So if you get, I mean, this is the least of your problems, but if you're inappropriate or fraudulently certified driver, they might delist you. You might go to jail. You may lose your house. You know, there's a lot of bad things that can happen. De-certification is the least of your worries. Yes, ma'am. So this happened to me once. If someone comes in and threatens you, I mean, like with a gun, because this happened, you either sign it or I'm going to shoot you. Sign it. Sign it and call them up. Yeah, so- They have a division, a security division that will say, don't be confrontational, but do report it. Yeah, so the comment was made, and we have, this is one of our slides later on, but if somebody comes in and threatens you, do what's necessary to make everything safe, sign the form, let the person leave with their medical form, and then you have two phone calls to make. You're going to call your local police, because that's not okay with them, and then you're going to call, there's a number that's on one of the slides later on, the security division of FMCSA, and they'll be super interested as well, okay? But you need to do both. You need to call local police, local law enforcement, and also call FMCSA. And the guy that threatened me had already threatened an examiner before, like two days ago. Oh, I'm sorry. Yeah. Two of the six- Chris, you're in Texas. The examiner may have drawn down on him, who knows? He may have just left it at a draw. Yeah, so anyway, so it's a big, don't falsify stuff. You'll be delisted. You'll, $250,000 fine, five years in the pokey. All those things would be bad. And that's both for you and for the driver. So, and there's hazards. We don't want to certify people that are not safe, because you probably, you have a little bit of protection from liability if you're following the recommendations from FMCSA. You have zero if you're making stuff up, and your malpractice insurance probably will not cover you if you're making stuff up, because that's fraud. I mean, most insurance doesn't cover fraud or a criminal act. This would be a criminal act at that point. Keep in mind that if you give them a certificate, not the one where the guy threatened you with a gun, that one's easy. But if you give them a certificate because you choose to certify them, even though they don't meet the standards, they can keep driving until FMCSA gets around to taking the certificate back, and that may take a while. Like probably more than the length of certificate. So if you're threatened, you call local law enforcement and then call these guys. I have a name down there. There's Alex Keenan. I don't know if he's still there, but the phone number is still good. And they will be super interested, and they will want to talk to you. There are lots of resources. Interestingly, when we did this course five years ago, I would spend like five minutes trying to explain how to find stuff on the FMCSA website. It is way better now. They must've gotten some high school kids to design a website that you can actually use. So you go in, and if you go under FMCSA, if you go to the NRCME main page, there's a thing that says resources. If you click on resources, it takes you to all these documents you can download. So they've got the forms there. They've got the handbook. They've got some of the other books that are available, direct download from that site, which is actually pretty useful. So I said we have, in 2015, they removed the handbook from the website for updating. Four years later, they put it back up, an abbreviated version. And in 2021, we got a slightly less abbreviated version. There's still some errors that are missing, like non-insulin dependent diabetes is just not there. There's stuff on insulin, but they kind of recapped the insulin rules, but there's nothing on the non-insulin diabetic. My personal favorite part is the blood pressure that we'll come back to. Well, I'll show you the details, but there's two different recommendations for blood pressure. And then they say, you could use this one, or you could use that one, or you can make up your own. It's a bizarre book. I still think it's a work in progress. The 2021 blood pressure was just gone. At least they got something back in the 2021 book. So at least acknowledge that it might be a health hazard. Who knows? So when we first started doing this, FMCSA estimated there were about 10,000 CDL holders. 10 million, sorry, 10 million. One of the things that happened back then was because at that point, the medical and the driver's license were completely separate. You couldn't do the thing without having both. But so you could have a CDL from some old job, hadn't had a medical for 15 years, but you still got a CDL license, right? Because the license didn't evaporate. I know my dad at one point in his career worked for the bus company around Philadelphia, and they got him his bus driver certificate for Pennsylvania, for the city of Philadelphia. And so when we went to these number of driver's licenses, he had a class six license, because he could drive a bus. Hadn't driven one in 40 years, but it was still on his license when he died in 50 years later. That's not true anymore. Now they're trying to link them. And in most states, you can't keep your CDL active without a medical. And there's usually like a little bit of a waiver period, but after a certain period of not having a medical, they'll take away your CDL. So there may be 9 million people might need CDLs. Their goal was to get over 100,000 providers. And if you kind of do the math, that's somebody's gonna do, some people may do 100 a year. I don't do anywhere near my fair share of these right now. So there's somebody else doing a lot more. These are real numbers from FMCSA. And I actually, this doesn't have the chart in it. Okay. I'll show you the chart in a little bit. I'll get it up on my laptop. And so what happened is, so these are the real numbers. The actual number certified is about 85,000 that actually got certified total ever. And then it breaks it. I'll share this with you later on so I don't do the tech part. May not be till tomorrow morning, but we have like, there's a thing about like, like what kind of a provider they are and how the certifications worked out and what the total numbers are. Keep in mind about 39,000 of us have not done our thing and may get kicked off the registry. Had not done last year's mid-cycle retraining and may very well get kicked off the registry. Yeah, I'm talking about not certifying every month or not going in and making a statement. I pray to God not, because I always forget that half the time. With the way my, where I am right now, I only end up doing CDL medicals right now. If the guy who's, because I rent space in an office, if you're in these and Lance's thing earlier this morning, he talked about, you know, using somebody else's office. That's what, that's my practice model. The only time I do CDL medicals is if he's on vacation. So I'll, and he's got a bunch of customers that he does CDLs for. And so if he's away, if he's like in Florida or goes to Italy or something for a week or two, I'll do all the CDLs from his customers. But I don't, so I may have one or two months a year when I'm, when I get 20 or 30 a month. And then the rest of the months, I forget half the time, but go click the box. They gave us a date now. It's like by the third or something. I wanted to put my phone, but I keep forgetting to do that. So I'll share those numbers with you in a little bit. Any questions about the, what we're here for part? And I'm going to do, oh, there's chat questions. Let me ask the chat questions. Okay, hold on. Let me do chat. Okay, so relation to current alcohol use, is there a recommendation for how long they need to be alcohol free? And then he said six months, a year, or is it just best clinical judgment? Well, the correct answer is best clinical judgment. My personal absolute minimum is three months, if I'm going to consider them to be dry at this point. And it's three months with support, with active support. That's my personal, that's Carl's personal cutoff. So, and long, I want a much longer period if they're not, if they're going to, I said, do you go to meetings? And they go, oh yeah, I go to like a meeting almost every day. And then I go, okay, fine. They're doing that thing. And three months to me is an okay time to let them go back to driving. But I might not want to give them a full, I might want to give them a full two year certificate. Maybe I'll give them a three month certificate and we'll reassess. So I don't, because one of my goals, and this is, I view this, my goal is, my first goal is we're always safe, right? I want to do what we can so that we're, so that no, I'm safe, you're safe, your family's safe when we're on the highways. The second goal is I want to figure out, if somebody has a medical condition that's a problem now, I want to work with them for how they can get back to work. There are all these reasons I don't want people off work. And so if they're a truck, truck drivers, what they is, how can we safely get them back to truck driving? And that's, to me, that's a big question. Certain number of exams to maintain certification. So the question was asked, do you need a certain number of exams to maintain certification? The answer is no. The only thing you have to do is you have to tell them if you went for an entire month, you're supposed to report them all within 48 hours. By the end of the next business day, you're supposed to put them into the database. And if you don't do any exams this month, you're supposed to go in, I think it's by the third of the next month and say, I didn't do any last month. So, but there's no requirements for minimums. It's not like the FAA where they want you to do so many to stay active. Okay, so let's see if I can, I'm gonna see if I can do this all myself. We'll see if this happens. So I'm gonna stop share.

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