The FMCSA is urging medical examiners to give clear explanations to drivers regarding certification determinations, and to distinguish between what is “required” by regulation and what is recommended as guidelines or best practices.  There are only 13 regulations, and only 4 of those are considered “non-discretionary” – hearing, vision, diabetes and epilepsy.  Non-discretionary means there is little to no interpretation required by the medical examiner.  Hearing has to be no greater than 40dB average loss in the better ear at 500, 1000 & 2000 Hz, Vision must be binocular, 20/40 or better in each eye, insulin dependent diabetes is disqualified without an exemption (which any diabetic can apply for if otherwise qualified), epilepsy is disqualifying.

The other 9 standards are discretionary and require interpretation by the medical examiner.  Some of these are still quite straightforward, like hypertension, with clear guides right on the exam form:


Others, not so much.  The medical examiner has multiple resources to consult regarding many, even most conditions s/he will come across.  The medical examiner handbook of course, but also numerous medical expert panel reports, the cardiovascular recommendation tables,  and FAQ sections.

These are the “guidelines” vs “regulations” and as with most guidelines, if not followed, the medical examiner has to be sure to document the reasoning for diverging from the guidelines.  Similarly, the driver should be informed why, based on these guidelines, the examiner feels a disqualification or temporary certification with additional testing may be required.

One common area stirring up controversy is obstructive sleep apnea (OSA) in commercial drivers.  I have written quite a bit about OSA on this site, please see these articles:

FMCSA Bulletin on Obstructive Sleep Apnea in Commercial Drivers

Worthless Epworth and Don’t Go to Berlin Either to Screen Drivers for Sleep Apnea

Screening for Sleep Apnea in DOT Physicals

There is a huge volume of research I have sorted through to present an evidence based, rational approach to these drivers.  You should not ignore that there are a huge number of drivers with under-diagnosed and untreated OSA, nor should you just knee-jerk send every driver with a certain BMI for testing.

Click here for more information on Obstructive Sleep Apnea in Commercial Drivers

Here is the FMCSA notice that came out today:

FMCSA Bulletin to Medical Examiners and Training Organizations Regarding Communication with Drivers
The purpose of this bulletin is to remind healthcare professionals on FMCSA’s National Registry of Certified Medical Examiners (the National Registry) to communicate clearly with individuals about medical determinations made during the medical certification process.
Distinguish Between Regulations and Best Practices
Of the thirteen physical qualification standards in the Federal Motor Carrier Safety Regulations (49 CFR 391.41(b)(1) – (b)(13)) , four standards (hearing, vision, diabetes and seizures) have specific requirements, and nine standards require the Medical Examiner to rely on medical judgment using medical best practices and relevant standards of care.
  • FMCSA urges Medical Examiners to explain clearly to drivers whether they are relying on best practices and standards of care rather than a regulation as the basis for their certification decision.
  • Training providers should teach the regulations and offer advice on how best to weave in best practices and standards of care.
Avoid Appearances of Conflicts of Interest
FMCSA reminds Medical Examiners, who are listed on the National Registry of Certified Medical Examiners, that the perception of a conflict of interest is possible if drivers are referred for costly testing at laboratories where the Medical Examiner has a financial interest.

Federal Motor Carrier Safety Administration Website:
Medical Review Board Website:
National Registry of Certified Medical Examiners Website: