Student Case

[rev ronin]

STUDENT case.  Pre-PAs are welcome, but practicing PAs please refrain from commenting until after August 1st.

You're working alone in a combined family/occupational medicine clinic.  Your last patient of the evening (scheduled; no walk-ins with Covid-19) is a ~40 year old male, new to your clinic, here for a DOT physical, which you just so happen to be certified to perform.  (If you have any questions on the standards, feel free to ask, but I trust you won't need to)

The patient has filled out his pre-screener, a single-page form your clinic uses, designed to highlight some common pitfalls. On it, patient states he takes no medications, and has signed the form.  Your MA has, at your direction, pulled a prescription drug monitoring program query on this patient.  It indicates that, for the past year, the patient has been getting 150 Hydrocodone/Acetaminophen 10/325 tablets every month for the past year (it's a one-year query by default) from a PA and MD who work together at the same address.  This prescription was most recently filled yesterday, per the query printout, at the same local pharmacy that had filled all of the year's prescriptions. Because you're familiar with the local area, you know that the MD in question does pain management for the largest local orthopedic group.  Any habitual use of narcotic medications, prescribed or not, is disqualifying by default, per https://www.fmcsa.dot.gov/faq/what-medications-disqualify-cmv-driver

Upon entering the room, the patient hands you his completed official DOT medical exam history form.  On it, like on the screener, he has written that he regularly takes no medications.

You've double checked the date of birth and name--which isn't particularly common.  The odds of this being a different person are nonexistent.

How do you begin the conversation?

What choices do you make before you do so?

What are your goals for this encounter, knowing what you know from the above case?

[rev ronin]

Really? Not a single PA student or pre-PA is willing to articulate any thoughts on this?

[DiggySRNA]

I'll take a shot...

I'd introduce myself and ask how the patient is doing today. Find out what they do for a living (sound interested in their personal life). Then...

Ask the patient have they ever been DOT certified before

Restate the question "are you on any prescription medications for (list common dz HTN, HLD, DM, COPD]

..any surgeries or injuries in the past (try to cross-match PMHx with the vicodin Rx query).

Restate the question AGAIN "are you on any pain medications"

Ask the patient if they are aware of any disqualifying reasons, just to see what knowledge they have regarding DOT exams and the certification process.

Then say, "per protocol, any individual seeking to become DOT certified must meet certain requirements (list a few) followed by listing a few disqualifying factors.

The goal is to not catch the patient off-guard or make it seem judgmental. Provide facts and the reasoning to which they do not qualify.

Proceed with (for this reason, I am unable to pass you for the DOT certification at this time). Provide a handout regarding what disqualifies a patient.

Then say "should you want a second opinion, you're more than welcome to do so"..."any questions?"

***Stand in the room with your back towards the door after initial physical assessment but before the questioning***

Edited July 25, 2020 by Diggy

[rev ronin]

Super!  Anyone else want to take a fundamentally different approach to this one?

[Aunt Val]

Can I play along?  I'm a newly graduated PA and don't have a job, so I'm not practicing yet.

My thoughts are pretty close to what Diggy said very well already.

"What are your goals for this encounter, knowing what you know from the above case?"

My goal would be to not give/renew the patient's certification.  Second goal, communicate that to the patient without getting my head ripped off.

"What choices do you make before you do so?"

I would have to make the choice to follow or not follow DOT regulations --> choose to follow, knowing that having a narcotic user behind the wheel of a truck or bus is not a good idea and could result in traffic fatalities and that it could come back on me.  Making that choice, though, means that I'm also likely choosing to deprive this man of his livelihood and ability to provide for his family if he has one.  I would want to be sensitive to that.

"How do you begin the conversation?"

See Diggy's example above.  Would not want to be accusatory in any way, but gentle and straightforward.

Is this a very common situation?

[WakadanPA]

Pre-PA here.

I would follow the same approaches listed above with a few differences:

What choices do you make before you do so?

After evaluating the DOT form from the patient and the PMP form from the MA, I would step out from the room and print the DOT cert guidelines from the nurses station to review with the patient back in the exam room.

How do you begin the conversation?

"Ok Mr. Joe we aren't going to be able to get you physical done today. Let's take a look at the requirements really quickly. (review requirements and explain any liability concerns.) The DOT requires any medical provider completing your physical to review your prescription records. The record on file under your name and DOB states you have xyz Rx which does not allow you to receive an approved DOT physical today. However, I see on your forms you state that you aren't on any medications. If you believe the PMP data to be an error I think it would be best if you call the doctor's office and the pharmacy to get it cleared up, and then return to us to get your physical all wrapped up. I'll walk with you to check-out where they registrar can print the contact information for the pharm and the ortho clinic for you." End the encounter by walking the patient to check-out.

My end goal will be to make sure I am compliant in my administration of the DOT physical AND that if the PMP issue is a mistake that I help the patient navigate the issue to get it corrected. 

I think it is really important to not accuse the patient of any wrong doing, explain the situation clearly and ensure they understand that I have an obligation to and will be complaint with the DOT guidelines.

[rev ronin]

OK, that seems like a general consensus is forming, I'll add some more information and give feedback so far.

First, where do you position yourself within the room? We have one person wanting you, the provider, to be closest to the door, presumably for a quick exit in case the situation turns violent.  That's a good choice if you expect that this person will assault you.  The other option is to take the position farther away from the door, so that the patient can make a quick exit and you're not in the way.  It's really a self-defense call.  Since I'm not small but not tall and not afraid of being overwhelmed by physical force, I chose to sit by the window, which wasn't necessary.

Ok, phase 2:

This patient states he does not drive commercial vehicles, but is instead a crane operator and a DOT medical examiner's certificate is a condition of his employment. He verbally denies any medications or surgeries.

When politely confronted verbally, the patient states he's not taking the hydrocodone.  When you point out that his last fill was yesterday and that he has been filling them regularly for the past year, he states what he means is that he isn't taking them while working.  When you note that taking 5 per day only after work is a highly unusual consumption pattern, he has no response.

Patient then admits he has lied on his last several DOT medical exams AND NO ONE HAS CAUGHT HIM BEFORE.  He states he has non-operable back pain, and that is why the Ortho clinic's pain team is taking care of him.

He is apologetic, states he needs the meds to function, needs the DOT card for his job, and needs the job to take care of his family. He asks you point blank what he can do to get a card, how should he handle the situation as it is right now.

Now what, if anything do you do in response to his plea?

[DiggySRNA]

8 hours ago, rev ronin said:

Patient then admits he has lied on his last several DOT medical exams AND NO ONE HAS CAUGHT HIM BEFORE.  He states he has non-operable back pain, and that is why the Ortho clinic's pain team is taking care of him.

"I am sorry you are in this situation but certifying you using my credentials is unsafe and illegal and I am unable to complete your DOT physical today." 

However, I'd refer him back to the prescribing provider at the Ortho clinic to obtain a written letter with the clinic's letter head stating the driver is safe to be a commercial driver while taking this medication.

Instruct him to return within 28 days on a day I am working with the letter and I will pass him. I will also explain to him that should the letter state he is unsafe to be a commercial driver while taking this medication, I will not pass him. Set the stage early so there is no confusion later on.

This is permissible according to the FMCSA guidelines. 

I'm sympathetic so I'd give him the benefit of the doubt and not fail him straight out (since he admitted to lying). I'd give him options so I don't play a part in ruining his livelihood. 

Edited July 27, 2020 by Diggy