President's Prescription - Annals of Internal Medicine: Fresh Look Blog


Wednesday, June 6, 2018

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.

  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).


  1. Comment by David L. Keller, MD, FACP

    I agree that this patient requires CPAP to safely operate a long-haul big rig on our crowded highways. I also agree with President Trump's efforts to decentralize the imposition and maintenance of regulatory authority. The closer these decisions get to the patient's own physicians, the more safe, correct and beneficial the decisions will be. To escalate these matters within our government's vast, uncomprehending, rigid-thinking army of bureaucrats does not benefit anyone. This patient's compliance with treatment can be assured in the most satisfactory way by his own physicians. Nobody wants him driving his big rig off his nocturnal CPAP; not the other drivers he would endanger, not the patient's family, who might bear the financial penalty of his liability risk, and least of all, the patient himself. Who can better explain these concepts to the patient than his doctors? His physician is also trained to recognize when improvement of a risk factor for obstructive sleep apnea, like obesity, is dramatic enough to warrant retesting and possibly the medically-supervised suspension of his CPAP mandate. Suspension of unnecessary CPAP could save healthcare dollars while making the patient's life easier, and is an option that no petty bureaucrat could originate.

    1. Thank you, Dr. Keller. I agree that we physicians are uniquely qualified to ensure that our patients receive unbiased, evidence-based recommendations. I wrote this piece because I worried that without a vocal message from physicians “clearing up” any misconceptions like this, more patients might follow an incorrect assumption and stop using necessary CPAPs. Thank you for reading!

  2. Congratulations to Dr. Chandler for convincing her patient to continue using his CPAP for his own safety and for the safety of others on the road. It might also to let him know that preventing his sleep apnea will greatly reduce his risk for developing heart disease, diabetes, kidney disease, stroke, and will significantly extend his life expectancy.

    1. Thank you for reading! Yes, treating Sleep Apnea has many benefits. With this patient, I focused on the safety of his driving since that seemed to be his personal priority. Thanks for your comments!

  3. Did Dr. Candler bill at the appropriate level for the "long conversation" that was required? More importantly, to whom should she send that bill?

    1. Ha! Great question. Since there is no corresponding counseling code for sleep apnea that I could find, no I didn’t add a CCM code to that visit. The bill did go to the federal government, but only because I work for the VA. Thanks for reading!

  4. The patient in this vignette was caught red-handed not using his CPAP as ordered, without claiming any of the valid excuses his doctor prompted him with. Facing possible suspension of his truck driver's license, the patient claims that President Trump abolished his requirement to use CPAP, based on an unfounded rumor he heard.

    The author uses this preposterous excuse to falsely imply that President Trump was somehow to blame for the patient's failure to use his required CPAP.

    These sort of biased and unfounded political aspersions do not belong in the Annals of Internal Medicine.

    1. Dr. Keller, to clarify I do my best not to place any “blame” (on patients, politicians, or anyone else) when my patients’ choices don’t align with my medical recommendations. Instead, I usually see this discrepancy as a symptom of a larger miscommunication, and I go looking for it. In this case, I found the miscommunication and was able to clear things up.

      I have no control over what other people (friends, celebrities, politicians) do or say that my patients may hear and interpret. However, I do have control over how I build trust with my patients so they see me as a reliable source when comparing disparate reports.

      In an era of social media and a 24hr news cycle, it’s important for our patients to know they should still go to their doctors to get evidence-based recommendations. If anything, I hope this message is a call to action to all physicians to renew their vigor in this relationship-building.

      I appreciate your insights — thank you again for reading!


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