This story appears in the May 8 print edition of Transport Topics.
The number of insulin-dependent diabetic interstate truck and bus drivers requesting exemptions to stay behind the wheel is on the rise, but the current approval process is time-consuming and medical guidelines can be vague, trucking and diabetes groups said.
Diabetic drivers filed 2,174 exemption applications in 2015, an increase of more than 67% from 1,298 in 2013, according to the most recent statistics from the Federal Motor Carrier Safety Administration.
Over that same period, the number of exemptions granted has more than doubled, with FMCSA’s approval rate climbing to 52% of all applications from 39% two years earlier — effectively allowing more insulin-dependent diabetic drivers on U.S. highways than at any other time since the program began in 2004.
While doctors say many diabetics do a good job keeping the disease in check, an insulin- dependent diabetic potentially can experience double or blurry vision, tiredness or weakness, unclear thinking, shaking or trembling, fainting, seizures or comas — putting them at risk for crashes.
And when left untreated, the disease in the long term can lead to strokes, heart attacks, kidney failure, sleep apnea and eye disease.
“There can be no doubt that diabetes, if not kept in control, can be a debilitating disease,” said Brian Morris, a medical doctor who is corporate medical director for Beverly, Mass.-based Quadrant Strategies Inc. and a member of FMCSA’s medical review board. “In the short term, an out- of-control diabetic can pass out without warning.”
FMCSA attributes the rising approval rates for diabetic drivers mostly to the rapid advancement in medical science and patient treatment and an increased awareness sparked by the agency’s medical exemption process since 2014, when FMCSA opened its national registry of more highly trained medical examiners, agency spokesman Duane DeBruyne said.
However, the number of diabetics is on the rise in the United States, and medical experts said the disease is more prevalent among truck drivers than the general population.
“With an increasing number of adult-onset [now Type 2] diabetics needing insulin treatment, FMCSA needs to develop a pathway for certification that does not require the current exemption program,” said Ellison Wittels, a Houston medical doctor who has filed written comments on FMCSA proposals. “The prolonged period between applying for and receiving an exemption will increase with increasing demand for insulin exemptions.”
Federal regulators have tenaciously defended their exemption process for insulin-dependent drivers as a way to ensure that only drivers with well-controlled diabetes can obtain two-year medical cards.
But the debate over whether a diabetic should even be permitted behind the wheel of a large truck or bus, and under what conditions, has continued since 1970.
And, despite an FMCSA proposed rule published in May 2015, medical examiners generally use best medical practices to screen possible insulin-dependent diabetics, even though the agency has yet to implement its final rule.
Along the way, the exemption process has amassed its share of critics, including American Trucking Associations and the American Diabetes Association, both concerned that granting an exemption can take up to six months from the time drivers apply until they are cleared to get back on the road.
“The delay associated with the agency’s review of the exemption application and publishing applications in the Federal Register have rendered the process prohibitive,” the diabetes association said in written comments. “Many commercial drivers have lost their jobs or were denied employment opportunities as a result of the protracted wait. Many others, unable to afford to wait out the time it takes to receive an exemption, delayed insulin treatment when insulin was the medically advisable way to manage their diabetes.”
ATA also has complained about the inevitable delays for insulin- using diabetic drivers but, in addition, has said that the agency’s medical review board recommendations are vague and, if accepted by FMCSA, would lead to “disparate treatment of drivers.”
“Should FMCSA move forward and issue a final rule adjusting the diabetes standard to permit drivers with [insulin-treated diabetes] to operate, it should eliminate the exemption process,” ATA said.
At present, the basic role of agency- certified medical examiners is to look at everything other than diabetes because FMCSA handles the diabetes when the driver uses insulin, said Morris, the FMCSA medical review board member.
“Some diabetics do diet and exercise and use pills for treatment,” Morris told Transport Topics. “As soon as you cross the threshold and start using insulin as part of your treatment, that’s an automatic disqualifier for the certified medical examiner to issue a card on the spot.”
Morris added, “So when the examiner fills out the [Department of Transportation] card, there’s a box to check that basically says everything is normal, except the individual isn’t qualified unless he or she gets the diabetes exemption from FMCSA.”
Michael Kelley, senior medical director at OhioHealth Neighborhood Care in Columbus, Ohio, and an FMCSA certified medical examiner, said examiners currently have to rely initially on a driver’s honesty in detailing their medical history when filling out paperwork accompanying their mandatory physicals.
“As a practitioner, the only way that we know if someone is on insulin or not is if the driver tells us they are,” Kelley, also a member of FMCSA’s medical review board, told TT. “It’s not impossible for some of the examiners to ask for records from the driver’s primary care doctor, but I don’t think that’s general practice. I suspect that some people do that, but most don’t.”
However, Kelley said examiners are required to conduct urine tests for glucose levels that, when high, can be a red flag for diabetes, which can trigger a need for a more thorough hemoglobin A1C test, as well as the basis for a further discussion between the driver and examiner.
“If the glucose levels are elevated, most of us would ask for more information from the driver’s primary care provider,” Kelley said.
Kelley said drivers are required to be truthful in filling out detailed paperwork indicating any health problems or drugs they take. If they lie, they can have their medical certificates suspended or even be hit with civil penalties, according to FMCSA regulations.
“If a driver’s glucose level is too low, it interferes with your mental status,” Kelley said. “If it’s too high, it can interfere with your mental status, but it can [also] cause problems with vision and attention. So both extremes are a risk.”
A longhaul driver’s lifestyle often involves risk factors for becoming diabetic, such as stress, unhealthy truck-stop food, sitting for hours with little exercise and being overweight, Kelley said.
“The most common form of diabetes, Type 2, is linked to body weight, and the driver population is more obese and overweight than the general population,” Kelley said.
“But the medical literature supports that if you’re under good glycemic control, a good sugar control, you’re less likely to have all the other complicating factors,” he added.
FMCSA’s 2015 proposed rule would give examiners more authority, with possible assistance from a treating physician, to make the final decision on whether a diabetic driver is fit for duty, rather than passing it up to the agency for approval.
In response to the proposed rule, the medical board issued its own recommended guidelines calling on insulin-dependent drivers to be free of severe hypoglycemic reactions, have no altered mental status or unawareness of hypoglycemia, and manage their diabetes pro- perly to keep blood sugar levels in the appropriate ranges.
To receive a two-year FMCSA exemption currently, diabetic drivers must show that they have had no severe hypoglycemic reactions resulting in loss of consciousness or seizure, requiring the assistance of another person,or resulting in impaired cognitive function that occurred without warning symptoms in the past 12 months.
The drivers also must have no recurrent severe hypoglycemic episodes in the past five years and have their endocrinologist verify that the drivers have demonstrated a willingness to properly monitor and manage the disease, receive education related to diabetes management and are on a stable insulin regimen.
They also must be proven capable of “achieving a level of safety equivalent to or greater than” otherwise healthy drivers.
For those drivers already given exemptions, to be recertified, they must, among other things, submit quarterly monitoring checklists completed by a treating endocrinologist as well as provide an annual checklist with a comprehensive medical evaluation. Each individual also must report within two business days all episodes of severe hypoglycemia, significant complications or inability to manage diabetes, plus any involvement in an accident or any other adverse event in a commercial or personal vehicle.
In the long term, Morris said, FMCSA would like to shift administration of the exemption program to medical examiners, who would step into the agency’s role in monitoring paperwork, ensuring that the driver is seeing an endocrinologist and ophthalmologist and that the diabetes is being treated properly.
Giving more control to the medical examiner may put the exam- iner closer to the driver and closer geographically, as well as in a better position to monitor the driver’s health, Morris said.
“The downside is it’s a lot of extra work for the medical examiner to take on a lot of responsibility,” he said. “While all medical examiners have received the same training, they don’t step into the role of medical examiner with the same background. Some are M.D.s, some are chiropractors or maybe physical therapists. They don’t have all the same diabetes knowledge, even though we’ve all passed the same exam.”
But whether the proposal will be followed soon by a final rule remains a question mark, Morris said.
“If you asked me a year ago, I would have said this will go through,” he said, “but who knows now, with an administration that doesn’t like regulation and wants to cut back on budgets?”