DOT exams-how strict are you?

[Wish1pa]

How strict are you with things like blood pressure for DOTs?  The guidelines say BP should be <140/90. We had a guy who's BP was like 148/82, was told he could have a 3 month card and must get referral form signed by pcp saying his blood pressure is controlled ( we have these special referral forms in our urgent care), 3 months later he comes in without signed form, BP no better. We said we're sorry but we can't give him anymore time until he gets that form signed by a physician and BP lower than 140/90. He is livid. He can't go to work tomorrow and his doctor is on vacation. I feel bad, but.. I am currently in the middle of a DOT/workers comp/fraud investigation in which I cleared a guy who ended up coming in later for workers comp and he is now being investigated by the school board and I don't like being in the middle of these things so I am pretty strict, but I do feel bad.

What do ya'll think? ...I HATE DOTs....

[sas5814]

Well first of all I agree and I'd rather have a testicle removed with a pair of needle nosed pliers than do DOTs again.

 

That said I followed the guidelines to the letter. If he has a wreck, crosses the median, hits and kills a bus load of nuns and orphans guess who his roomie will be in the pen?

In this case when he starts sniveling about how its his livelihood etc etc suggest he should be more diligent in doing the things that make sure he can earn a living.

it used to wear me out. I'd get these hugely overweight diabetic hypertensive guys and their excuse? "I'm a truck driver." What....you can't park where they sell salad?

[thinkertdm]

Before you go into the appointment, try practicing what you would say to a jury when you are on the stand trying to defend why your signature is on the form allowing Mr. Vasculopathy to drive.  You didn't make him morbidly obese.  Sooner or later the bill comes due.  Rules are rules.

[MCHAD]

I follow guidelines exactly.  If they complain I tell them to write their congressman.  Not worth me losing my job because someone is whining.  Especially in the situation above when the person had 3 months and didn’t correct the problem. 

[quietmedic]

Rules are rules. It was his responsibility to get to his PCP. 

I've heard anecdotally of doctors who will pass without referral for DOT, if a second resting blood pressure after a few minutes is under 140/90.   I forget if a second "relaxed" pressure is officially sanctioned in the DOT manual, but I can certainly understand someone might have a slightly high BP at first pass... I don't recall if those anecdotals were passed for the full two years or just for one year...but I could sort of understand that sort of laxity.

But in his case, look, he certainly had enough time to visit PCP. Nothing to feel guilty about.

[rev ronin]

I'll let them retry BP multiple times to get under 140/90, but that's about it.

I don't LIKE DOTs, but that's mostly because I think the hernia check is pretty pointlessly invasive.  I have heard of providers not doing them.  Sorry, but if the forms says I checked, I have to check.  Ultimately, I would rather I do them than folks who cannot say 'no'. 

[lemurcatta]

People “whine and snivel” because it is their job. Can you imagine being forced to undergo an invasive medical evaluation once yearly or biyearly, which is high stakes, where even having a bit of white coat hypertension can cause you to fail and then lose your income? And on top of that, the clinician treats your desire to keep working with contempt. 

Is there even a shred of evidence that hypertension or hernias cause truck drivers to plow through the median? I think a much more likely explanation is stress, low socioeconomic status, and the the pressure to get in more miles on less sleep. 

The forms don’t say that you can’t be nice, understanding, and use good clinical judgement generally. Like, maybe offer to recheck pressures after they relax a while. I was once getting a dot for ambulance driving license and the PA didn’t want to sign the forms because I had a childhood surgery she didn’t understand. I eventually got a letter from the surgeon explaining there was no reason not to approve the application, which didn’t help. She was rude and couldn’t even be bothered to learn about something she didn’t know. Eventually I just went somewhere else. 

[MCHAD]

 

3 hours ago, lemurcatta said:

People “whine and snivel” because it is their job. Can you imagine being forced to undergo an invasive medical evaluation once yearly or biyearly, which is high stakes, where even having a bit of white coat hypertension can cause you to fail and then lose your income? And on top of that, the clinician treats your desire to keep working with contempt. 

Is there even a shred of evidence that hypertension or hernias cause truck drivers to plow through the median? I think a much more likely explanation is stress, low socioeconomic status, and the the pressure to get in more miles on less sleep. 

The forms don’t say that you can’t be nice, understanding, and use good clinical judgement generally. Like, maybe offer to recheck pressures after they relax a while. I was once getting a dot for ambulance driving license and the PA didn’t want to sign the forms because I had a childhood surgery she didn’t understand. I eventually got a letter from the surgeon explaining there was no reason not to approve the application, which didn’t help. She was rude and couldn’t even be bothered to learn about something she didn’t know. Eventually I just went somewhere else. 

Have you done DOT physicals?  I have had to do them my whole career and they suck.  My problem is the majority of people who don’t qualify repeatedly fail to address problems they know they have and then they come in the day before their card expires and I’m the bad guy because I won’t give them a 2 year clearance when their blood pressure is 170/95.

[CAdamsPAC]

These are the same subset of patients who show up in the ED demanding that I refill their prescriptions. Having done DOT physicals years ago and experienced the customer satisfaction crap from "the suits" and the sad story of the patient, I'm glad to not do DOT exams as part of my job!! There's no need to be snooty to these patients, but they also need to accept that they are RESPONSIBLE for their health, not us.

[GetMeOuttaThisMess]

This is why I always told them that the exam is not being done for YOUR benefit, but rather for the benefit of the general population. Driving is a privilege, not a right. Now, if you want to take advantage of your employer and get a good general exam and take note of areas warranting attention, then please do so.

[Cideous]

Man what a bunch of hard-asses lol

148/82?

Come on..!

 

1.  This is their job and livelihood.

2.  A diastolic of 82?  Really?

3.  Everyone knows that stress pushes up systolic and 148 is not crazy high.

 

With this blood pressure I would do a manual and if they are close...very close, I give it to them.  The electric BP machines are wildly inaccurate at times so don't live by their reading.  Now if someone is 170's/100's then we are talking fail fail fail.  But within a few pts on something SOOOOO subject to stress?  Give me a break.

 

[MCHAD]

5 minutes ago, Cideous said:

Man what a bunch of hard-asses lol

148/82?

Come on..!

 

1.  This is their job and livelihood.

2.  A diastolic of 82?  Really?

3.  Everyone knows that stress pushes up systolic and 148 is not crazy high.

 

With this blood pressure I would do a manual and if they are close...very close, I give it to them.  The electric BP machines are wildly inaccurate at times so don't live by their reading.  Now if someone is 170's/100's then we are talking fail fail fail.  But within a few pts on something SOOOOO subject to stress?  Give me a break.

 

Because I don’t set the guidelines and they are clearly written in the examiner booklet.  I didn’t say I think it’s right.  I don’t agree with my 65 year old rancher patients that have blood pressure 145/80 needing blood pressure medication all the time either (new guidelines say keep this subset under 150/90) but that’s the rules the feds give us.  And I always double check blood pressures manually after letting them rest of the initial blood pressure is high. 

[thinkertdm]

1 minute ago, Cideous said:

Man what a bunch of hard-asses lol

148/82?

Come on..!

 

1.  This is their job and livelihood.

2.  A diastolic of 82?  Really?

3.  Everyone knows that stress pushes up systolic and 148 is not crazy high.

 

With this blood pressure I would do a manual and if they are close...very close, I give it to them.  The electric BP machines are wildly inaccurate at times so don't live by their reading.  Now if someone is 170's/100's then we are talking fail fail fail.  But within a few pts on something SOOOOO subject to stress?  Give me a break.

 

True.  I have to sign off on a number of other high stakes type of exams.  I don't care what the real world reason for these arbitrary cut offs lie; I do care that all the stupid little boxes are checked.  If the form says "140/90" and they are 140/92, personally, I'd let them rest, sit whatever, but if it doesn't come down, it's not going to pass. Sorry.  I know the chances of crashing, dying, whatever, but that's not my call.  I'm not fraudulently putting down "90"', but I will work with you during that visit.

 

[Reality Check 2]

DOT refs are there for a reason. Long haul truck drivers are well known to be a seriously unhealthy lot with long hours, poor diet, little exercise and smoking from boredom.

I have 25 yrs of DOTs in 2 states and don’t do them anymore. I have had my life threatened, been yelled at and cursed.

Again, I don’t set the rules but have to abide by them. The drivers know the rules, THEY KNOW THEM, but ignore them a lot.

One of my last DOTs sunk it for me. Guy is NONCOMPLIANT with CPAP using it only 40% of the required 70% with less than the required 4 hrs per session and still only the 4 of 10 nights. Sleep apneic drivers are found to be more dangerous than drunk drivers. I refused to sign any type of card. I read up, I called DOT. I followed the rules.

The private doc I worked for was not DOT certified and laid some sob story customer service BS on me openly and blatantly coercing me to sign the card.

NO NO NO NO NO

Patients have responsibility.  PERIOD.

Thankfully, I will never do another DOT ever. I can only hope those that do protect the public and remember it might be one of my kids or theirs on the road with that driver.

Done with soap box... for now

 

[rev ronin]

3 hours ago, Cideous said:

  But within a few pts on something SOOOOO subject to stress?  Give me a break.

Yep.  That's why I allow retries.  They still have to meet the letter of the law, because documenting that they met it when they didn't would be fraud.

[lemurcatta]

People here are so concerned with exact accuracy on DOT forms. For other (non-DOT) patient visits, I assume none of you have EVER documented respirations of 16 without carefully counting, or CNII-XII intact without testing each branch of the trigeminal? 

I’m definitely not advocating lying but you might want to examine any biases against people who drive for a living. 

[GetMeOuttaThisMess]

4 minutes ago, lemurcatta said:

People here are so concerned with exact accuracy on DOT forms. I assume none of you have EVER documented respirations of 16 without carefully counting, or CNII-XII intact without testing each branch of the trigeminal? 

I’m definitely not advocating lying but you might want to examine any biases against people who drive for a living. 

No.  If it's on the record then I checked it.  If not, I didn't.

[Cideous]

Let me be clear, I fail people all the time and I would never think about fudging a DOT with a non-compliant CPAP user, diabetic or the like. I was simply pointing out that if someone is a few pts high on their BP?  Well, that just seems over the top to me to fail someone because of that, but hey different strokes and all that.  p.s. I hate doing them as well for all the reasons stated.  I have been threatened, told I was killing his kids, sentencing him to be homeless...etc etc.  They are in a word....AWEFUL.  

[mgriffiths]

2 hours ago, lemurcatta said:

People here are so concerned with exact accuracy on DOT forms. For other (non-DOT) patient visits, I assume none of you have EVER documented respirations of 16 without carefully counting, or CNII-XII intact without testing each branch of the trigeminal? 

I’m definitely not advocating lying but you might want to examine any biases against people who drive for a living. 

What people do and what people should do are very different things...both are fraud (and as said above, for me if it is marked as done, it was done).  With that said, a DOT exam is a bit different - again they are both fraud, but the risk is different.  Patient comes in for a physical and has BP of 142/90 I am allowed to make a clinical decision on whether to treat their blood pressure with medication or give them the opportunity to make lifestyle changes - BUT much more importantly the patient has a choice.  I can recommend an ACE-I, ARB, CCB, etc. but it is their decision to actually take the medication.  For a DOT exam, the provider is purely examining and filling out a form there are no clinical decisions.  Either the patient meets the criteria or they don't.  Obviously there are decisions to make when actually trying to get the DOT patient's BP below the required level, but that is separate from the actual DOT exam.  Also for a DOT, the patient does not have a choice.  Either their BP is where it needs to be or it is not.  They either take the medication prescribed and do what they are required or they are not allowed to drive.

To "fudge" on the numbers to "help someone out" is no different than prescribing my wife, neighbor, father, mother-in-law, etc. a medication without actually examining them - and even then ethics state we should not be treating family unless there is no other option - THEY ARE BOTH FRAUD.

[rev ronin]

2 hours ago, lemurcatta said:

People here are so concerned with exact accuracy on DOT forms. For other (non-DOT) patient visits, I assume none of you have EVER documented respirations of 16 without carefully counting, or CNII-XII intact without testing each branch of the trigeminal?

"Grossly normal" and "no abnormalities noted" are wonderful terms.  E&M codes don't demand that you do a GOOD or THOROUGH exam, unless you want it to count as a 'detailed exam'.  As far as respirations go, those are done by my MAs, and if I retake any vitals, I will say e.g. "BP by provider" and give exactly the numbers I get when doing so.

[CAAdmission]

On 11/26/2018 at 3:52 PM, sas5814 said:

That said I followed the guidelines to the letter. If he has a wreck, crosses the median, hits and kills a bus load of nuns and orphans guess who his roomie will be in the pen?

If it is some of the nuns I had as teachers in grammar school, I might be ok with that.

[ventana]

How do you defend the lawsuit brought by the father,mother,son,daughter who was killed when your driver had a stroke and your note says 142/82?   Hint, you can’t

 

the standards are there for a reason. If you do not like them write a letter to the board. I would NEVER lie on a DOT.  

 

I would give the patient every pissibility to pass.  Ie resting no food or drink no r3cent smoking arm relaxed not talk8ng blah blah blah.  If this brings them under the 140/80 (or what ever guideline) I would carefully document I retook an appropriate bp and it was xxx/xx.   

 

If if you want to make someone rich with a malpractice claim,and make your own life a living hell then accept alternative facts.  

 

I prefer to follow the guidelines for for my own protection...

 

as for a doc pressuring me to sign.  Nope, I would politely hand my pen to him/her and let them sign it. (Oops your not DOT certified, well sinc you are asking me to lie what’s the problem?.)

 

[sas5814]

On 11/27/2018 at 8:24 AM, lemurcatta said:

People “whine and snivel” because it is their job. Can you imagine being forced to undergo an invasive medical evaluation once yearly or biyearly, which is high stakes, where even having a bit of white coat hypertension can cause you to fail and then lose your income? And on top of that, the clinician treats your desire to keep working with contempt. 

Is there even a shred of evidence that hypertension or hernias cause truck drivers to plow through the median? I think a much more likely explanation is stress, low socioeconomic status, and the the pressure to get in more miles on less sleep. 

The forms don’t say that you can’t be nice, understanding, and use good clinical judgement generally. Like, maybe offer to recheck pressures after they relax a while. I was once getting a dot for ambulance driving license and the PA didn’t want to sign the forms because I had a childhood surgery she didn’t understand. I eventually got a letter from the surgeon explaining there was no reason not to approve the application, which didn’t help. She was rude and couldn’t even be bothered to learn about something she didn’t know. Eventually I just went somewhere else. 

It is their job to meet the criteria. I don't make the guidelines but if I do DOTs I am obliged to follow them. If you have a CDL you are obliged to follow them. You don't get to participate in the system and then complain about how the system treats you. You knew the rules going in.

As for invasive physicals and meaningless criteria...same answer. Not my rules. being forced to undergo exams to keep your job? You mean like my annual physicals or twice annual PT tests during my military career? Or the polygraph tests or drug screens I had to take randomly when I had a security clearance or was working narcotics in law enforcement? Yes I can imagine. And I can imagine had I failed any of those tests I'd be out of a job so I made sure I didn't fail them.Whining and sniveling is what I call it when you don't take responsibility for your own actions and want to blame someone else or the system.

I was never mean or dismissive...until they got all horsey about how I was costing them their livelihood. Personal responsibility seems to have gone the way of the horse and buggy. See your doctor, take a pill, lose 10 pounds, eliminate salt, caffeine, and ETOH from your diet. Do something...anything except whine and snivel.

[MCHAD]

Another BIG problem is Physicians and pa’s that don’t follow guidelines and do pass people with hypertension or diabetes for a 2 year certificate for example.  Then I’m the bad guy in the future when I tell them they only qualify for 1 year.  

[Wish1pa]

22 hours ago, MCHAD said:

Another BIG problem is Physicians and pa’s that don’t follow guidelines and do pass people with hypertension or diabetes for a 2 year certificate for example.  Then I’m the bad guy in the future when I tell them they only qualify for 1 year.  

Yep. This has happened too, They get even more mad and say “but dr so and so gave me two years last time and I had hypertension then!”. Also I have been pressured by non medical corporates at my company to sign cards to appease an angry patient.  Not cool. I show them the dot handbook and say nope sorry.