DOT Physical Exams: Infinity & Beyond!

1. DOT Physical Exams Infinity & Beyond! Michael Megehee, DC, NRCME, President TeamCME Certified Medical Examiners Network

4. National Registry Medical Examiner Requirements Medical examiner Requirements • MD, DO, DC, ANP, PA, others, • Maintain a valid State license • Complete Accredited Training • Pass the NR Certification Test • Complete periodic re-training and re-certification testing.

5. Commercial Motor Vehicle 49 CFR 390.5 Commercial Motor Vehicle Definition: • Has a gross vehicle or gross combination weight or rated to transport 10,001 lbs or more • Designed or used to transport more than 9 passengers (including the driver) for compensation or, • Designed of used to transport more than 16 passengers (including the driver) not for compensation • Transport requiring Placard for Hazardous Waste

6. Commercial Driver Medical Exam Includes: Interstate & Intrastate drivers Large Commercial Vehicles School Bus Vehicles with 9 or 16 passengers Trucks w/wo trailers over 10,001 lbs. Foreign Drivers

7. FMCSA Statistics: May 2014 - March 2017 14.7 million exams performed*** 14.1 million received Medical Examiner Certificates (MEC) 8.4 million received 2 yr MEC 4.4 million received a 1 yr MEC 330,000 received less than 1 yr MEC 147,000+ were temporarily disqualified 235,000+ were permanently disqualified ***Note: CMEs are not required to report exams perform on intrastate drivers

8. FMCSA Statistics: April, 2017 Profession #CMEs %TCME #U.S.** %CMEs MD 18,781 34% 238,000 7.6% Nurse, APN, NP 18,223 34% 238,000 7.6% Physician Assist 10,777 19% 105,000 10.3% DO 4268 8% 108,000 4.0% DCs 3806 7% 80,000 4.8% Total CMEs: 55,932 Naturopath 52 Acupunct/DOM 18 DrPT/PT 7 **approximated f/ various sources

9. DC CMEs State by State CA 554 (13,106) MN 269 TX 264 PA 260 FL 249 CO 221 IL 165 WI 159 IA 150 NJ 122 MO 113 OH 103 KS 84 OR 82 (1900) KY 65 GA 63 NC 62 AZ 61 AL 60 MA 60 IN 53 OK 52 TN 50 IS 46 SC 44 MT 42 NV 42 SD 36 UT 35 AR 35 NE 34 NS 33 LA 32 MD 23 DE 7 NH 6 ME 4 DC 2 MI 1 NY 1 WV 22 CT 19 MS 12 VT 9 WY 8 RI 7

10. Driver Concerns: Cost, Availability Nationwide CDL Exam Costs: $40-$225 TeamCME Member Average: $80 TeamCME Member Range: $50-$150 Price Variation by profession, facility, location, # of providers Initial: Prices were significantly lower Prices have risen over the past 2 years.

11. Over 60,000 Active Service members are assigned to military occupational specialty that involve the operation of a wide range of heavy vehicles for delivering needed supplies and equipment to U.S. forces across the world. Many are nearly identical to CMVs in the civilian sector, and the military utilizes for-hire carries to supplement its military distribution system. Federal regulation does not require military drivers to acquire a CDL license which poses unique challenges for these drivers as they transition from active duty to the civilian workforce.

12. Veterans Administration to provide CDL physical exams to active duty, reservists, and veterans. Program to Assist Veterans to Aquire CDLs Report to Congress (2013) FAST Act: Fixing America’s Surface Transportation Act Veterans’ Expanded Trucking Opportunity: HR 2547 FMCSA Proposed Rule: Excluded DCs(June? 2017) Jobs for our Heroes Act: Includes DCsS.1393 (Signed Jan 2018)

13. FMCSA Statistics: May 2014 - March 2017 14.7 million exams performed*** 14.1 million received Medical Examiner Certificates (MEC) 8.4 million received 2 yr MEC 4.4 million received a 1 yr MEC 330,000 received less than 1 yr MEC 147,000+ were temporarily disqualified 235,000+ were permanently disqualified Add: Intrastate drivers of CMV (10,001 lb) Veterans School Bus Drivers FTA: Taxi, Metro Van & Bus Drivers

14. TeamCMENational Network of DOT Medical ExaminersFAA BasicMed Flight Physical Michael Megehee, DC, President

15. FAA BasicMed Medical Exam On April 24, 2017, a new FAA medical exam became available to licensed Private Pilots. The new program allows Student, Recreational & Private Pilot, and Flight Instructors to use theBasicMed requirements in lieu of holding a 3rd Class Airman Medical Certificate performed by an FAA Aviation Medical Examiner . • There are 170,000 Private Pilots. This is expected to increase.

16. FAA BasicMed Medical Exam The BasicMed medical exam can be performed by an “Aviation Medical Examiner (AME)” or by a “State-Licensed Physician”. There are 5,000 FAA Aviation Medical Examiners that can perform the BasicMed Exam, but usually will not due to loss of FAA Malpractice Protection. There are 3600 Chiropractic Certified Medical Examiners (CDL Physicals)

17. “State-licensed Physicians” FAA Advisory Criteria (FAA AC 68-1A- BasicMed May 03, 2017) The FAA relies on the determination of each state (as well as each territory and possession of the U.S.) as to which persons it will license as physicians. If the person holds a license as a physician issued by any state, territory, or possession, then he or she meets the requirement as a state-licensed physician. The FAA notes that all States license MDs and DOs as physicians; although Federal and some State laws may permit the licensure of other persons, such as doctors of dental surgery as physicians. This group is referred to as “Specialty Physicians).

18. “Specialist Physicians” Continued FAA AC 68-1B: While the FAA expects that these specialist (e.g., DDS., dentist, podiatrist, etc.) who do not also hold an MD or DO license would not have the breadth of training for a BasicMed medical examination, the FAA will rely on each State-licensed physician to determine whether he or she is qualified to conduct the medical examination. Physicians should refer to their State medical licensing authority for further guidance. The FAA recommends checking with the medical licensing board or authority in your state for clarification as to whether other classes of “state-licensed physicians” are felt to have the privileges, training and experience to conduct all portions of the Comprehensive Medical Examination Checklist.

19. DC, DO, MD, BasicMed State-Licensed Physicians MDs and DOs: Are considered “Physicians” in all States and can perform the BasicMed exam with or without being a FAA Aviation Medical Examiner. DCs: Are eligible to perform the BasicMed exam as a "Specialty Physician" when considered by their State Chiropractic Licensing Board to be a “Chiropractic Physician” and as long as their State scope of practice allows performing the components of BasicMed exam. (31 States allow DC use of the word “Physician”. ANPs/PAs: Are physician extenders who are not physicians but who perform some medical activities typically done by a physician. Privileges vary by state. They are not specifically excluded, but the BasicMed Physician is responsible for conducting the exam and must sign the Comprehensive Medical Exam Checklist. Others: Dentists, Naturopaths and other “specialty physicians” may be eligible.

20. FAA BasicMed Physician Basics The BasicMed rule is consistent with FAA’s shift towards risk-based regulation and decision making, shifting responsibility from the agency to the airman, and his or her physician to collaboratively assess fitness for flight. The objective: keep pilots safe and flying affordable. State-licensed physicians performing the BasicMed medical exam can not contact FAA for medical advice for decision making. They may contact an AME but it is up to the AME to decide whether to offer assistance. The AME has no official capacity in this instance. BasicMed allows the physician to make a determination based on their clinical judgment. Physicians determine at the time of the exam that they are not aware of any medical condition that, as presently treated, could interfere with the pilot’s ability to safely operate an aircraft.

21. FAA BasicMed Physician Basics If the physician has reservations regarding the pilot’s current or future health status, they should discuss the concerns with the pilot and use clinical judgment to determine whether the comprehensive medical exam checklist should be signed. Medical Examiners can’t place restrictions or conditions on the pilot with BasicMed, the physician can only choose from a (4 year) yes-or-no flight determination.

22. BasicMed Exam Checklist Page 8

23. FAA BasicMed Recommended Resources Medical Examiners should consider the following resources for informational purposes only: • The FAA Guide to For AMEs: https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media/guide.pdf • The FAA Pharmaceuticals: http://www.faa.gov/go/dni • Chapter 8, FAA Aeronautical Information Manual (AIM 8-1-1): https://www.faa.gov/air_traffic/publications/media/aim.pdf • www.faa.gov/go/basicmed • www.faa.gov/GO/AME • 9-AWA-AFS-BasicMed@faa.gov (email for questions)

24. FAA Resources 77 Pages 436 Pages

25. FAA BasicMed FAA is committed to the success of the BasicMed program State Chiropractic Board Issues: • The Gold Standard: This is a first time significant opportunity for Chiropractic to be included in the most respected governmental physical exam program. • DCs have the training to perform the BasicMed exam (CCE) • Use of the term “Chiropractic Physician” meet the requirement as a State-licensed physician” in your State? • Without clarification from the State Licensing Board, will DCs have confidence that they can provide the BasicMed exam. • Will DCs be protected without an official opinion from the SLB? • Will there be backlash from the State Medical Boards/Associations?

26. State Board Determinations States: Yes to BasicMedStates: No to BasicMed Alabama California ArizonaGeorgia ArkansasMichigan DelawareMontana FloridaNew York IdahoTexas IllinoisWisconsin IndianaWyoming Kansas Minnesota Missouri Nevada New Jersey NRCME Required North Dakota Ohio Oregon NRCME & Training Required, South Dakota NRCME Required

27. Pending State Board’s Next Meeting “Yes” Expected“No” Expected Mississippi April 26 Colorado North Carolina April 27 Dist/Columbia Massachusetts May 10 Kentucky New Mexico May 17 Maine Alaska May 18 Maryland Vermont June 5 New Hampshire Louisiana June 14 Pennsylvania Oklahoma June 14 Virginia West Virginia June 17 Nebraska June 28 Rhode Island June 28 “Undetermined” Connecticut May 31, Jun/July Washington Tennessee July 19 Utah July 31 Iowa July ?

28. FAA BasicMed Status 51 of 659 TeamCME Member Clinics performing BasicMed DCs (12 member clinics) in Florida reporting more BasicMed Exams Performed CA, TX: Two Large States with both DCs and Pilots unable to participate Cost of BasicMed expected to be above amount charged for CDL exams Pilots reporting difficulty finding clinics that perform the BasicMed exam Inclusion in BasicMed helpful in being included in other exam programs

29. US Dept of Labor-Drivers of Migrant Workers 29 CFR§ 500.105 DOT standards adopted by the Secretary. Any farm labor contractor, agricultural employer or agricultural associationproviding transportation in vehicles other than passenger automobiles and station wagons used for transportation as provided in § 500.102 (b), (c), and (e) shall comply with the motor carrier safety standards listed in paragraph (b) of this section. (H)Certificate of physical examination. Every person shall have in his files at his principal place of business for every driver employed or used by him a legible certificate of a licensed doctor of medicine or osteopathy based on a physical examination as required by paragraph (b)(1)(ii)(G) of this section or a legible photographically reproduced copy thereof, and every driver shall have in his possession while driving, such a certificate or a photographically reproduced copy thereof covering himself. Exam Form: https://www.dol.gov/whd/forms/wh515.pdf 29 CFR 398.3(b) Qualifications of drivers or operators (Migrant)

30. Drivers of Migrant Workers Exam Form GENERAL INSTRUCTIONS Take this form to your doctor. Ask the doctor to read the following section, examine you, and fill in the certificate (located on the front of this form). After making a copy for your employer and yourself, submit the original with your Farm Labor Contractor or Farm Labor Contractor Employee application (Form WH-530). You must carry your copy with you whenever you are driving workers subject to the Migrant and Seasonal Agricultural Worker Protection Act (MSPA). TO THE DOCTOR Regulations 29 C.F.R. § 500.104(b)(1)(ii)(I) and 49 C.F.R. § 398.3(b) provide for the following minimum qualifications for persons who drive any motor vehicle carrying migrant workers subject to the regulations: (A) No loss of foot, leg, hand or arm. (B) No mental, nervous, organic, or functional disease, likely to interfere with safe driving. (C) No loss of fingers, impairment of use of foot, leg, fingers, hand or arm, or other structural defect or limitation, likely to interfere with safe driving.

31. Drivers of Migrant Workers Exam Form (D) Eyesight. Visual acuity of at least 20/40 (Snellen) in each eye either without glasses or by correction with glasses; form field of vision in the horizontal meridian shall not be less than a total of 140 degrees; ability to distinguish colors red, green and yellow; drivers requiring correction by glasses shall wear properly prescribed glasses at all times when driving. (E) Hearing. Hearing shall not be less than 10/20 in the better ear, for conversational tones, without a hearing aid. (F) Liquor, narcotics and drugs. Shall not be addicted to the use of narcotics or habit-forming drugs, or the excessive use of alcoholic beverages or liquors. (G)Initial and periodic physical examination of drivers. No such person shall drive nor shall any such person require or permit any person to drive any motor vehicle unless within the immediately preceding 36-month period such person shall have been physically examined and shall have been certified in accordance with the provisions of paragraph (b)(1)(ii)(H) of this section by a licensed doctor of medicine or osteopathy as meeting the requirements of this subsection.

32. Crane Operators Crane operators are required to be certified by a third party training agency or a qualified trainer through their employer, according to the National Commission for the Certification of Crane Operators (NCCCO). This certification is required under a ruling from the Occupational Safety and Health Administration (OSHA) that took effect on November 8, 2010. NCCCO National Commission for the Certification of Crane Operators: DCs Included the policy now states: “In appropriate circumstances, means of compliance with ASME physical requirements may include, but are not limited to, a current Department of Transportation (DOT) Medical Examiner’s Certificate.”

33. Crane Operators CIC Crane Institute Certification (Form A, Form B, every 3 yrs) DCs Included Medical Verification Form Policy and Agreement Medical Verification Policy Physical qualification requirements are taken from the ASME B30.5-3.1.2 (a) and are the physical requirements all candidates must meet in order to be certified by Crane Institute of America Certification, LLC. All candidates must indicate their compliance with the Medical Verification Form unless it can be shown that failure to meet the qualifications will not affect the operation of the crane. In such cases, specialized clinical or medical judgments and tests may be required. The Medical Verification Form Part B must be provided to CIC for verification that the requirements have been met. 110 Other Crane Training Providers

34. Forklift Operators OSHA does require that every forklift operator be trained and certified to operate the powered industrial truck in the workplace, and that the operator's performance be evaluated on the provisions of 1910.178(l)(3) every three years. ... That is the only operating "license" required by OSHA. OSHA has issued a letter of interpretation stating that an employer must determine if full vision is mandatory for the operations and advises that appropriate medical personnel be consulted. (Reference: October 20, 1976 OSHA Letter of Interpretation, which was edited in 2000.) OSHA has issued other interpretations addressing both visually and hearing impaired potential forklift operators. In general, OSHA states that it considers physical impairments on a case-by-case basis. If the employer can show that a physically impaired employee would be a danger to himself and other employees when operating equipment such as a forklift, the employer has the right to not allow that employee to become a forklift operator. Additionally, the ANSI/ITSDF B56.1-2005 safety standard for low lift and high lift trucks states in Section 4.18 "Operator Qualifications" that operators must be qualified as to visual, auditory, physical, and mental ability to operate the equipment safely.

35. U.S. Coast Guard Merchant Mariner Medical Exam

36. Merchant Mariners Commercial vessels: Cargo Ships Cruise Ships Ferry Tug Boats Fishing Vessels Touring Boats Fishing Guides Dive Boats Yachts

37. USCG Merchant Mariner Medical Advisory Committee (MEDMAC) • Acts solely in an advisory capacity to the Secretary of Homeland Security through the Commandant of the Coast Guard on matters related to:  • (a) medical certification determinations for issuance of licenses, certificates of registry, and merchant mariners’ documents; • (b) medical standards and guidelines for the physical qualifications of operators of commercial vessels; • (c) medical examiner education; and • (d) medical research. • 14 Appointed Members • 10 Medical Professionals • 4 Professional Mariners • Term: 5 years • Meetings: no less than 2 times yearly • National Maritime Center issues medical credentials to mariners

38. Merchant Mariner Medical Certificate Mariners must provide evidence of meeting the medical and physical standards of CG-179-K or CG-719-K/E Typical cost of the exam is $200+ Have the physical capability to fulfill all the requirements of basic training as required by Section A-VI/1 of STCW • Demonstrate adequate hearing and speech to communicate effectively and detect any audible alarms • Have no medical condition, disorder or impairment that will prevent the effective and safe conduct of the seafarer’s routine and emergency duties • Are not suffering from any medical condition likely to be aggravated by service at sea or to render the seafarer unfit for service or to endanger the health and safety of other personnel on board • Are not taking medication that has side effects that will impair judgment, balance or any other requirements for effective and safe performance of routine and emergency duties on board. 1st Class Pilots: Annual physical examination required

39. Merchant Mariner Medical Certificate NVIC 04-08 Enclosure (6) G. Medical Exams, Tests and Demonstrations of Physical Ability. All exams, tests and demonstrations must be performed, witnessed or reviewed by a physician, physician assistant, or nurse practitioner licensed by a state in the U.S., a U.S. possession, or a U.S. territory. Exams, tests and demonstrations performed, witnessed or reviewed by holders of foreign medical licenses and chiropractors or naturopathic doctors are not accepted under current regulations. MEDMAC meetings: Update Medical Evaluations Division A 3 year wait. Watch the Federal Register for available appointments to the MEDMAC.

40. Department of Defense The DOD hires civilians to perform duties on military bases that require a medical examination. These post-op “general” physicals can only be performed by Physicians (MD, DO) PAs and NPs. The value of performing these exams, alcohol and drug testing has been estimated to be $3 Billion a year.

41. Department of Homeland Security Civil Surgeon Designation The Civil Surgeon program is a component of the U.S. citizenship and Immigration Services (USCIS) in the Department of Homeland Security Depending on the immigration benefit sought, an applicant may be required to undergo a medical examination. Immigration medical examinations conducted inside the United States must be performed by a civil surgeon who has been designated by USCIS. (Immigration medical examinations conducted outside the United States must be performed by a panel physician who has been designated by the Department of State.) Generally, physicians interested in obtaining civil surgeon designation must apply using Form I-910.. Form I-910 Part 5. Medical Degrees You must possess a medical degree as a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil surgeon designation. A change in immigration policy could result in over 10 million exams.

42. Federal Railroad Administration Locomotive Engineer and Conductor Medical Exams • Locomotive Engineers and Conductors are required to a have a minimal physical exam that consists of visual acuity and hearing only. • 49 CFR 240.7 Medical Examiner means a person licensed as a doctor of medicine or doctor of osteopathy. • Any exam required for compliance…shall be performed by or under the supervision of a medical examiner or a licensed physician’s assistant such that: • A licensed optometrist or a technician • A licensed or certified audiologist or a technician

43. Federal Railroad Administration Locomotive Engineer and Conductor Medical Exams Docket No. FRA-2015-0123 FRA Interim interpretation to clarify provision in its locomotive engineer and conductor qualification and certification with respect to vision standards and testing. TeamCME comment was to expand the definition in 49 CFR 240.7 to include Doctors of Chiropractic.

44. OSHA Respirator Questionnaire, Medical Exam, Fit Test Respirators must be used in workplaces in which employees are exposed to hazardous airborne contaminants. When respiratory protection is required employers must have a respirator protection program as specified in OSHA’s Respiratory Protection standard (29 CFR 1910.134). Before wearing a respirator, workers must first be medically evaluated using the mandatory medical questionnaire or an equivalent method. Questionnaire Medical Exam Fit Test There are 5 million employees in the U.S. using respirators

45. Scuba Diving Physicals There are approximately 70 Certifying Agencies involved with recreational and profession diving certification (Free, Cave, Snorkeling, commercial, scientific, archeology, first aid and rescue diving). In the U.S. there are 3 main Agencies: PADI Professional Association of Diving Instructors NAUI National Association of Underwater Instructors CMAS The World Underwater Federation SCI/PDIC Scuba Education International These organization use the Recreational Scuba Training Council’s RSTC Medical Statement Participant Record (form) (most use 2007 version) The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

46. Instructions to the Physician Recreational SCUBA (Self-Contained Underwater Breathing Apparatus) can provide recreational divers with an enjoyable sport safer than many other activities. The risk of diving is increased by certain physical conditions, which the relationship to diving may not be readily obvious. Thus, it is important to screen divers for such conditions. The RECREATIONAL SCUBA DIVER’S PHYSICAL EXAMINATION focuses on conditions that may put a diver at increased risk for decompression sickness, pulmonary over-inflation syndrome with subsequent arterial gas embolization and other conditions such as loss of consciousness, which could lead to drowning. Additionally, the diver must be able to withstand some degree of cold stress, the physiological effects of immersion and the optical effects of water and have sufficient physical and mental reserves to deal with possible emergencies. The history, review of systems and physical examination should include as a minimum the points listed below. The list of conditions that might adversely affect the diver is not all-inclusive, but contains the most commonly encountered medical problems. The brief introductions should serve as an alert to the nature of the risk posed by each medical problem.

47. PADI Diving Physicals PADI Email: (NAUI has similar policy)  You are correct in that the industry practice (and training agency standard) in the United States is to require a physician’s approval prior to participating in recreational diver training, only if the student responds “yes” to a question on the Medical Statement. However, a dive professional or dive operation has the authority to require a physician’s approval if there are concerns about the individual’s responses on the form or the well-being of the diver while participating in scuba diving. Once a diver begins training at the professional level, for PADI at the Divemaster level, a physician’s approval is required and must be current within 12 months of the beginning of training. As to a DC signing the medical, the RSTC does not specify , but PADI’s position has been: M.D. or D.O. and a Physician Assistant (P.A.) or a Nurse Practitioner (N.P.) may also sign the Medical Statement as long as the Physician (M.D.) whom the PA or NP works with also signs or stamps the form.

48. Scuba Diving Physicals PADI has no desire to be biased against any medical professional who can properly evaluate an individual for medical fitness for participation in scuba diving. As you can see from the Guidelines and “Instructions to the Physician” the doctors who assisted the RSTC in developing the form attempted to call attention to those issues in the patient’s history and current medical state that warrant special attention. This allows doctors who may not be familiar with scuba diving to make the proper determination, or decide that he/she chooses not to determine fitness and refers the patient to another. I look forward to receiving additional information from you and further collaboration on this matter.

49. Scuba Diving Physicals NAUI: National Association of Underwater Instructors Those who are allowed to perform the RSTC Medical Participant record is determined by our provider of insurance: Divers Alert Network: Risk Potential Group

50. Race/Drag Car Drivers National Auto Sport Association - MD, DO, PA or NP must have co-signer Sportscar Vintage Racing Association- “Physician” National Hot Rod Association (Drag racing)- MD, DO Automobile Racing Club of America INDYCAR International Hot Rod Association International Motor Sports association National Association of Stock Car Auto Racing Rally America Sports Car Club of America (SCCA) United State Auto Cub United State Hot Rod Association