President's Prescription

Patient: "I need something for energy, doc."
Me: "How's your sleep?"
Patient: "It's not good. I wake up all the time. I think I need a sleeping pill."
Me: "Are you using your CPAP?"
Patient: "Not really."
Me: "Why not? Is it broken? Does it need to be refitted? Does it bother someone else in bed?"
Patient: "The President told me I didn't have to anymore."
Me: …
Patient: "Yeah, I used to have to bring my chip in to prove I was using it so I could keep driving my truck."
Me: "Right! You drive long-haul."
Patient: "Yeah, that's why I even had to get that thing. They tested us. Then last fall, the President said I didn't have to bring my machine in anymore, that I didn't have to use it."
Me: …
Patient: "Do you have any sleeping pills?"
Me: "When you did use your CPAP, were you tired like this?"
Patient: "No."
Me: "Ok … I don't think I need to give you a sleeping pill or an energy pill…"
Patient: "…I guess I should start using my CPAP again?"
Me: "Let's start with that. Then you let me know how it goes."

I went home to figure out what in the world my patient was talking about. How did he come to believe that the President had told him he didn’t have to use his CPAP anymore?

A small study published in 2009 in Annals used simulated road courses and showed that while sleep and alcohol have negative effects on anyone's driving skills, they are more pronounced in patients with untreated sleep apnea (1). Based on these and similar findings, the Federal Motor Carrier Safety Administration (FMCSA), which regulates interstate commercial driving, established requirements that drivers with any disease that could interfere with their driving treat that disease and gain a “medically-qualified-to-drive” status before receiving their license (2).

This clearance is performed annually by approved Department of Transportation (DOT) medical examiners. Drivers diagnosed with moderate to severe sleep apnea must annually prove that they have been adequately and continuously treated in order to renew their license (3). Many states do this by requiring drivers with obstructive sleep apnea to bring their equipment log in for regular review to maintain their licensure. My patient was familiar with this process and had been doing it for some time because he does have moderate sleep apnea.

In March 2016, the FMCSA and other DOT agencies issued a joint advance notice of proposed rulemaking (ANPRM) “to consider regulatory action to ensure consistency in addressing the risk of OSA among transportation workers with safety sensitive duties” (4), presumably to establish not just monitoring regulations but also guidance for screening for these diseases. Currently, screening for obstructive sleep apnea and other diseases that may interfere with driving is not federally mandated, and the ultimate decision to screen for them is left to the clinical judgment of these DOT medical examiners. This was the “rule” my patient was talking about, which President Trump’s administration withdrew in August 2017.

Although neither the proposed rule nor the President’s subsequent actions changed the existing requirements for my patient, they did create a bit of confusion. For example, from conversations my patient described with his colleagues, he is likely not the only driver who misunderstood the President’s withdrawal of the rule as a fundamental rule change, stopping treatment of their chronic disease because they “didn’t have to” anymore.

Despite the fact that medical recommendations based on any of these rules would still rely on clinical judgment of physicians, my patient interpreted regulatory recommendation as medical prescription. Although the role of regulations is controversial, it is important that changes and their supporting evidence are clear to patients so that they do not misinterpret lack of regulation as lack of medical necessity. As physicians, we must in turn educate ourselves on issues relevant to our patients and rely on the integrity of our patient–physician relationships, hoping our patients’ trust our evidence-based clinical recommendations more than the rhetoric they hear on the news.

After a long conversation, my patient was convinced that his doctors were the only ones who should be prescribing his care. I hope this news travels just as quickly to his colleagues.

References

1. Vakulin A, Baulk SD, Catcheside PG, Antic NA, van den Heuvel CJ, Dorrian J, et al. Effects of alcohol and sleep restriction on simulated driving performance in untreated patients with obstructive sleep apnea. Ann Intern Med. 2009;151:447-55. [PMID: 19805768]
2. Federal Motor Carrier Safety Administration. Resources for Drivers: Driving When You Have Sleep Apnea. Washington, DC: Federal Motor Carrier Safety Administration.
3. Texas Sleep Docs. DOT Sleep Program. Austin: Texas Sleep Docs.
4. Federal Motor Carrier Safety Administration; Federal Railroad Administration. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. 49 C.F.R. Parts 391, 240, and 242 (2017).