Many but not all physicians1 are aware that states have a requirement that an individual with epilepsy is restricted from driving for a defined period of time after a seizure.2 These requirements can vary from state to state.3 Six states— California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania—also have mandatory reporting to departments of motor vehicles when an individual has a seizure.4 What many physicians do not realize is that there are very specific regulation and guidance for those drivers who operate commercial motor vehicles, including trucks and buses.
Commercial Motor Vehicle Operators
The Federal Motor Carrier Safety Administration (FMCSA) is responsible for administering medical standards for commercial motor vehicle (CMV) operators who operate in interstate commerce. There are 13 medical standards and all but the ones for vision, hearing, seizures and the use of insulin leave some discretion to the commercial driver medical examiners. Exemptions have been issued by the FMCSA to some drivers who do not meet the vision or insulin standard, but to date there have been none granted for seizures or hearing. The medical standard5 which addresses seizures in CMV operators states that an individual is qualified to operate a CMV in interstate commerce if they have, “no established medical history or clinical diagnosis of epilepsy; or any other condition which is likely to cause the loss of consciousness, or any loss of ability to control a commercial motor vehicle.” The Advisory Criteria, guidance to examiners, which accompanies this medical standard, state that the following drivers cannot be qualified;
1.) A driver who has a medical history of epilepsy;
2.) A driver who has a current clinical diagnosis of epilepsy; or
3.) A driver who is taking antiseizure medication.
The Advisory Criteria also explain that drivers with a history of epilepsy/seizures cannot be qualified until they are off antiseizure medication and seizure-free for 10 years. If the individual has only a single unprovoked seizure, the seizure-free, off-medication waiting period is five years. The determination of whether a driver who has had a sudden episode of a nonepileptic seizure or loss of consciousness of unknown cause which did not require antiseizure medication can be made by the medical examiner in consultation with the treating physician. A six-month waiting period prior to commercial driving is recommended.
The FMCSA is currently in the process of reviewing most of the medical standards. The process includes the extensive, evidence-based review of the literature by a Medical Expert Panel (MEP) with recommendations presented to the Medical Review Board (MRB) and the FMCSA. The MRB, which is advisory to the FMCSA, makes their recommendation based on the expert panel and an understanding of the other issues that affect commercial driver medical certification. Based on input from the MEP, the MRB and other information, the FMCSSA would then issue updated medical standards and/or guidance. While a Medical Expert Panel on Seizures Disorders and Commercial Motor Vehicle Driver Safety6 recommended permitting some drivers on anti-seizure medications to operate CMV, the MRB did not believe the evidence was sufficient to ensure safety to overturn the current guidance.7 The FMCSA has not, to date, issued new guidance.
Most states have adopted Federal Medical Standards as the physical qualification for intrastate commercial drivers. Some will provide variance for those drivers who were operating solely in intrastate commerce (this is determined not only by where the driver is operating but what he is transporting and whether that property is moved interstate) when the state adopted those criteria.
There are also medical criteria for school bus drivers. Some states use the Federal Medical Standards for CMV operators while others have different criteria.
The Clinical Neurologist's Role
It is important to understand your patients' work tasks and whether (s)he is required to meet any medical standards prior to issuing a return to work note. Some employers will accept a note from a treating provider, assuming the provider is aware of any relevant medical standard, potentially placing both the provider and the employer at risk of liability. Some employers will have an occupational health professional evaluate the individual, and it is frustrating to both the patient/employee and the physician when the examiner tries to explain that although the treating provider may have released the patient to return to work, (s)he may not be permitted to do so.
Dr. Hartenabum is Chief Medical Officer of OccuMedix in Maple Glen, PA. Board certified in both occupational and internal medicine she is editor of The DOT Medical Examination: A Guide to Commercial Driver's Medical Certification.