DOT certification, Which class should I take?

[Guest Elpatodog]

I am thinking about becoming DOT certified. I haven't researched it much so I thought I would ask here what class you all would recommend taking to become certified?

 

Thanks

[Guest UVAPAC]

DOT exams are awful, very subjective and no real guidance.  FMCSA/MRB have been "updating guidelines" for years now.  

HOWEVER... I took an online course hosted by Nathalie Hartenbaum.  Simple/Quick/Easy.  I found the examination was pretty easy.  

[sas5814]

I too took an online course. You just need to learn enough of their arcane and ever changing rules to pass the certification exam. Personally I hated DOT exams because every time you disqualify someone they take it out on you. You give them a limited certification for 30 or 90 days and tell them to come back before it expires and they come back in 2 days because nobody will hire them without an unqualified certification. It was a major pain.

[Cideous]

I've told people for years, the two visits that scare me are desperate drug seekers and desperate DOT exams.  I have been threatened physically, called every name you can imagine and in one case the clinic had to hire private security for a month.  These guys will literally accuse you of starving their kids, breaking up their marriage, on and on.  All because you are following the guidelines and not passing them.  I am actually pretty liberal about the BP guidelines, but there comes a point where you can't give anymore.  I hate them, but sadly they are very much a part of Urgent Care.  Most UC's now require you to be DOT certified before you can work there.

[MCHAD]

I’m certified and wish I wasn’t.  We’re forced to be the “bad guys” when someone doesn’t pass requirements.  Doesn’t matter what I say, when I give someone less than a 2 year certificate 90% of the time I get my butt chewed.  

Not to mention the ridiculous website to log the drivers has been down for over a month with no indication for when it will be back up so I have a backlog of paperwork that I’ll have to put in when they get it working.  Oh...and if you aren’t going to do them at least once per month you have to log in to the website to report that you have no exams to report...or you can lose your certification.  

[Guest Elpatodog]

i appreciate everyone’s comments and I think I am going to hold off right now.

[rev ronin]

Also:  Hernia checks on all male (95%, in my practice) drivers, just in case you needed another reason to hesitate. :-)

[Cideous]

7 hours ago, rev ronin said:

Also:  Hernia checks on all male (95%, in my practice) drivers, just in case you needed another reason to hesitate. :-)

lol good point ;)

[Guest UVAPAC]

7 hours ago, rev ronin said:

Also:  Hernia checks on all male (95%, in my practice) drivers, just in case you needed another reason to hesitate. :-)

It has always baffled me that a hernia examination is a part of the examination.  How does having an inguinal hernia impact your ability to operate a commercial motor vehicle?  Even if someone has incarceration/strangulation it is not like the are immediately incapacitated.  

 

Scenario:  You find a small, non-tender inguinal hernia on a male driver...

Do you require he have surgery prior to clearing?

Do you get a note from a surgeon saying he is stable to driver?

Do you clear without further workup?

[sas5814]

7 minutes ago, UVAPAC said:

It has always baffled me that a hernia examination is a part of the examination.  How does having an inguinal hernia impact your ability to operate a commercial motor vehicle?  Even if someone has incarceration/strangulation it is not like the are immediately incapacitated.  

 

Scenario:  You find a small, non-tender inguinal hernia on a male driver...

Do you require he have surgery prior to clearing?

Do you get a note from a surgeon saying he is stable to driver?

Do you clear without further workup?

What does the DOT guidebook say? That is what you do. Common sense rarely figures into anything run by the government.

[Guest UVAPAC]

2 hours ago, sas5814 said:

What does the DOT guidebook say? That is what you do. Common sense rarely figures into anything run by the government.

There is no DOT guidebook.  The guidebook was pulled from the website in 2014 for "updating" and has remained that way since.    (See Link)

https://www.fmcsa.dot.gov/regulations/medical/fmcsa-medical-examiner-handbook

 

I basically go by Nathalie Hartenbaums book which is updated yearly for a "guidebook."  That being said there is no real standard...

 

[sas5814]

That makes me laugh. They give you a zillion odd and sometimes vague rules and guidelines, pull them for updating, and never update them. But don't screw up! :-)

[Guest UVAPAC]

2 minutes ago, sas5814 said:

That makes me laugh. They give you a zillion odd and sometimes vague rules and guidelines, pull them for updating, and never update them. But don't screw up! :-)

It is really pathetic.  There is no standard of care.  There is no uniformity in conducting these examinations.  It is 100% subjective. What is disqualifying at one clinic is not at another...

I have been to a conference or two where this subject is discussed.  Apparently FMCSA has had a job positing for an MD for several years and have been unable to hire anyone due to lowball salary.  They have no plans on updating the guidelines until one is hired.

[rev ronin]

5 hours ago, UVAPAC said:

It has always baffled me that a hernia examination is a part of the examination.  How does having an inguinal hernia impact your ability to operate a commercial motor vehicle?  Even if someone has incarceration/strangulation it is not like the are immediately incapacitated. 

I completely agree.  I would joke with patients, making fun of the requirement by saying "I've never heard of anyone going 'ow, my hernia!'" while pantomiming turning a steering wheel to the left, in order to lighten the mood a bit.

[Cideous]

I've had several guys look at me and say, "is this really necessary?  What does it have to do with driving my rig?".....The clear implication is that I just wanted a peek at the junk down low....Talk about awkward!

Oh the guidelines...how long did we go without sleep apnea guidance?  Mercy.  The only hard and fast rule I believe is...pray one of your DOT drivers is not the guy in the accident that kills people.  Every time I see on the news.... "18 wheeler driver hits school buss...film at 11..." I feel terrible for all involved, but my mind immediately goes to the provider who wrote that card and I pity him....and his malpractice carrier.

[CornellSPA]

I personally decided not to do DOT certification even though the UC were was was Per-diem really wanted me to.  I had nightmares of some CDL holder crashing into a schoolbus, and my name was on his health certificate.  

Plus, as mentioned above the regulations are pretty intense!

JERRY 

[Guest UVAPAC]

On 1/7/2018 at 11:03 PM, Cideous said:

I've had several guys look at me and say, "is this really necessary?  What does it have to do with driving my rig?".....The clear implication is that I just wanted a peek at the junk down low....Talk about awkward!

Oh the guidelines...how long did we go without sleep apnea guidance?  Mercy.  The only hard and fast rule I believe is...pray one of your DOT drivers is not the guy in the accident that kills people.  Every time I see on the news.... "18 wheeler driver hits school buss...film at 11..." I feel terrible for all involved, but my mind immediately goes to the provider who wrote that card and I pity him....and his malpractice carrier.

Guidelines on sleep apnea?  I would love to see them!

I know the medical review board has made recommendations, however if you went strictly by the recommendation likely 50% of drivers would be going for a sleep study.  

[rev ronin]

On 1/9/2018 at 0:43 PM, UVAPAC said:

[...] if you went strictly by the recommendation likely 50% of drivers would be going for a sleep study.  

You say that like it's a bad thing.  24% of adult men need OSA treatment; having truck drivers be double that doesn't seem unreasonable.

CPAPs are far more workable and humane than they used to be, and when initiated early in life are preventative medicine.

[Guest JMPA]

On 1/7/2018 at 4:46 PM, rev ronin said:

I completely agree.  I would joke with patients, making fun of the requirement by saying "I've never heard of anyone going 'ow, my hernia!'" while pantomiming turning a steering wheel to the left, in order to lighten the mood a bit.

hernia examination is to determine restrictions of movement, in order to do a proper truck inspection drivers must be able to crouch, stoop, bend, and climb. All these movements can be affected by a hernia, Hernias themselves should not be a contraindication unless it causes restrictions

[Guest UVAPAC]

6 hours ago, rev ronin said:

You say that like it's a bad thing.  24% of adult men need OSA treatment; having truck drivers be double that doesn't seem unreasonable.

CPAPs are far more workable and humane than they used to be, and when initiated early in life are preventative medicine.

It's not a bad thing but I have encountered several issues.

1.  Drivers without medical insurance who it is very expensive to have a sleep study done, and even more expensive if they require CPAP treatment.

2.  Difficult to get a patient scheduled for a sleep study in a timely manner.  Often times the sleep center calls and asks me for their diagnosis code warranting a sleep study.

3.  If a sleep study comes back as negative, drivers have often made comments such as "are you going to reimburse me for my sleep study" "I told you I don't have sleep apnea" "My family wont be able to go on vacation this year because of you"

4.  With the new regulation of not being able to issue temporary cards, drivers become irate if you tell them you will issue a 3 month card while they get a sleep study, and then they will require an entirely new physical at the end of the 3 month period.

 

More-so than anything as a Certified Medical Examiner our job is to determine pass or fail, but we are not their treating clinician. Their primary care physician, or cardiologist, or pulmonologist are the ones who should be saying "wow my patient has a BMI of 55 and a Mallampati score of IV, maybe this person should go for a sleep study."

 

There is a reason that very few primary care offices are performing DOT examinations... they don't want to deal with the above...

[Cideous]

3 hours ago, UVAPAC said:

It's not a bad thing but I have encountered several issues.

1.  Drivers without medical insurance who it is very expensive to have a sleep study done, and even more expensive if they require CPAP treatment.

2.  Difficult to get a patient scheduled for a sleep study in a timely manner.  Often times the sleep center calls and asks me for their diagnosis code warranting a sleep study.

3.  If a sleep study comes back as negative, drivers have often made comments such as "are you going to reimburse me for my sleep study" "I told you I don't have sleep apnea" "My family wont be able to go on vacation this year because of you"

4.  With the new regulation of not being able to issue temporary cards, drivers become irate if you tell them you will issue a 3 month card while they get a sleep study, and then they will require an entirely new physical at the end of the 3 month period.

 

More-so than anything as a Certified Medical Examiner our job is to determine pass or fail, but we are not their treating clinician. Their primary care physician, or cardiologist, or pulmonologist are the ones who should be saying "wow my patient has a BMI of 55 and a Mallampati score of IV, maybe this person should go for a sleep study."

 

There is a reason that very few primary care offices are performing DOT examinations... they don't want to deal with the above...

^^^ This this this....and THIS!

[pennpac]

As others have said, I wish I wasn't dot certified..I got my cert because I was given a raise once I got it but I hate doing them. They're the worse and the guidelines are incredibly vague

[Guest UVAPAC]

Figured i would share on my lunch break...

Did a DOT PE on a patient who I saw last year (and certified for 1 year) who was previously taking Ativan as a muscle relaxer for lower back and Percocet for "migraine headaches."  I explained I would not certify him on these medications.  

He got a note from his primary care physician stating he was unaware these were contraindications to a CDL license, and was permanently removing from medication list and would no longer prescribe the medications.

On today's form he put down his medications (blood pressure and cholesterol meds).  I decided to look him up in the PMP to verify he was indeed off all controlled substances.

Since last year he had filled FORTY FOUR prescriptions for Diazepam, vicodin, percocet.  Each prescription a 1 month supply, filled regularly every 30 days.

I asked him if he disclosed all of his medications, he replied YES.  I asked if he was taking any medications for the conditions addressed in his not last year, he said NO.  I then told him I could review these in a database and he had filled 44 prescriptions and asked if that sounded correct.  His response "NO WAY THAT IS ACCURATE."

Anyhow, I disqualified, and told him that we will no longer conduct DOT PE's on him in this office for lying on a federal form.

 

Oh so fun!

[Cideous]

11 hours ago, UVAPAC said:

Figured i would share on my lunch break...

Did a DOT PE on a patient who I saw last year (and certified for 1 year) who was previously taking Ativan as a muscle relaxer for lower back and Percocet for "migraine headaches."  I explained I would not certify him on these medications.  

He got a note from his primary care physician stating he was unaware these were contraindications to a CDL license, and was permanently removing from medication list and would no longer prescribe the medications.

On today's form he put down his medications (blood pressure and cholesterol meds).  I decided to look him up in the PMP to verify he was indeed off all controlled substances.

Since last year he had filled FORTY FOUR prescriptions for Diazepam, vicodin, percocet.  Each prescription a 1 month supply, filled regularly every 30 days.

I asked him if he disclosed all of his medications, he replied YES.  I asked if he was taking any medications for the conditions addressed in his not last year, he said NO.  I then told him I could review these in a database and he had filled 44 prescriptions and asked if that sounded correct.  His response "NO WAY THAT IS ACCURATE."

Anyhow, I disqualified, and told him that we will no longer conduct DOT PE's on him in this office for lying on a federal form.

 

Oh so fun!

Does your state and clinic office let you conceal carry?  Not joking.

[rev ronin]

On 1/11/2018 at 3:24 AM, UVAPAC said:

It's not a bad thing but I have encountered several issues.

1.  Drivers without medical insurance who it is very expensive to have a sleep study done, and even more expensive if they require CPAP treatment.

2.  Difficult to get a patient scheduled for a sleep study in a timely manner.  Often times the sleep center calls and asks me for their diagnosis code warranting a sleep study.

3.  If a sleep study comes back as negative, drivers have often made comments such as "are you going to reimburse me for my sleep study" "I told you I don't have sleep apnea" "My family wont be able to go on vacation this year because of you"

4.  With the new regulation of not being able to issue temporary cards, drivers become irate if you tell them you will issue a 3 month card while they get a sleep study, and then they will require an entirely new physical at the end of the 3 month period.

 

More-so than anything as a Certified Medical Examiner our job is to determine pass or fail, but we are not their treating clinician. Their primary care physician, or cardiologist, or pulmonologist are the ones who should be saying "wow my patient has a BMI of 55 and a Mallampati score of IV, maybe this person should go for a sleep study."

 

There is a reason that very few primary care offices are performing DOT examinations... they don't want to deal with the above...

Yep--none of those are new to me, and I have the luxury of not having to do DOTs anymore, but here's my feedback:

1. That is the patient's choice; the cost of a sleep evaluation and/or treatment are just a cost of doing business.  Many companies reimburse the costs for work-required stuff like apnea testing as a business expense.

2. Yes and no.  Sleep medicine around here is no more or less backed up than any other growing specialty.  I'd love to have more throughput, but right now I can get drivers in, tested, and qualified in about 2 months, start to finish, with 30 days of compliance data.  REALLY hard to bring it much down below that.  Now, if my own interps were good enough, I could cut another two weeks off of that, but right now we're still using insurance rules--board certified sleep medicine doc interps only--so I can't shortcut that further.

3. This is a failure to set expectations up front.  You can't run a DOT medical examiner's office like a family clinic: cash-in-hand up front before the provider enters the room, every time.  The driver pays, but he is not a patient, he is an examination subject--the patient is "society" and we examine the subjects (drivers) for the safety of society.  For this reason, I completely agree that PCPs are fundamentally compromised in their ability to do FMCSA exams on their own folks. No, I'm not reimbursing anyone for anything, unless I was somehow wrong to order the screening in the first place.

Rude or threatening behavior is inappropriate, and grounds for both dismissal (easier, since there's no ongoing relationship) and reporting to the authorities.  Also note that there's a nice little box on the form (https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/MedicalExaminationReportFormMCSA5875.pdf) that asks if a medical examiner's license has ever been denied.  They need to know that if they are denied, they will be reported truthfully to a national database.

4. See #3.

Yes, PCPs should screen for sleep apnea, but as you pointed out, a lot of truck drivers have made the choice to not have one.  STOP BANG is really dead simple to administer, and 3/8 is a "screen", so even if they lie to you about the first four, BMI >35 and neck >17" in any male, OR one of Neck >17" or BMI >35 in a male 50+ are objective grounds for screening. 

So... What do I do other than saying "My way or NOT the highway"? (I crack myself up sometimes)

First, I do a lot of patient education.  I take 1/2 hour for a new patient sleep apnea intake, and I cover pathophys, screening, and treatment modalities.  I'll talk about all the bad things OSA can do in addition to drowsy driving.  I believe in sleep medicine and the health benefits, since I'm an AutoPAP user myself, so authenticity and enthusiasm aren't faked.

Then, if they need treatment, I talk it up as a GOOD thing: we're going to put a stop to premature aging.  I work with them, as do the RPSGTs on staff, to make the experience enjoyable--listening to what doesn't work for them, finding alternatives that do, basic stuff like that.

Finally, once they're happy with the new therapy--which is well over 90%--I ask them to go out and evangelize all the CDL holders they know with a key message:

- Sleep apnea sucks
- CPAP is tons better than it used to be.
- Give us time, come in early.

The message IS getting out. I'm seeing more and more 30-50 year old blue collar workers, not just CDL holders, who heard from another guy that CPAP was a life changer.  I'm really not seeing too many truly adversarial people in sleep medicine, which is probably their choice to not follow up at all.

So... steel and silk: firm resolve as a CDL examiner to do the right thing, excellent patient care as a sleep medicine practitioner to get patients treated.