The doctor is in

Tips for finding a first-class AME

June 1, 2009

The shrill sound of the pager pierced the quiet moment of early morning solitude in the office as I attempted to catch up on the necessities of being a flight physician. Reviewing the list of return phone calls to make, studying the upcoming patient visits, and signing electronic medical notes was being interrupted again. I picked up the phone.

“Doc, I’m having a little problem here,” said the voice on the other line. It was Bruce, a corporate pilot for a local food processing company who had been coming to the clinic for preventive care and flight physicals with his colleagues for years. The enjoyment of seeing annually a cadre of more than 500 pilots from all walks of life and all categories of aircraft never prevented me from assisting the airman in need.

“I have diarrhea and I have it bad,” was Bruce’s sullen remark. “What do you do for it? I have a trip on Thursday.”

After reviewing his unpleasant signs and symptoms, suggesting some over-the-counter remedies and adequate hydration, his instruction was to call if things weren’t better by the next day. If it persisted, he’d have to stand down and leave a stool sample.

The next afternoon, a nurse approached from the corridor. “There’s a pilot out front who says you told him to come in and—believe it or not—he’s got a stool sample.” Patient compliance gone overboard. “Put him in an exam room, please,” I said.

Bruce was perched on the exam room couch like a kid eagerly awaiting the opening of holiday presents. “Doc, I brought you a stool sample, just like you said.” Bruce held in his outstretched hand a small, black plastic film canister with a piece of tape affixed with his name and the words, “Stool Sample.” I immediately suspected something fishy. “Go on Doc, open it up,” he said. Reluctantly, the small canister was opened and a tiny wooden bar stool rolled onto my hand. I now recalled Bruce was a talented woodworker with a large wood shop at his home. “See? I brought you a stool, but it’s only a sample,” he grinned.

“Well, what about your diarrhea?” I queried.

“Oh, that’s cleared up,” he said. “The wife and I just came to town to go shopping and I just wanted to say hi.”

And so goes another day as a flight physician. Depending on the comfort level of the pilot and the aviation medical examiner (AME), the bond that develops between pilots and their doctors can be difficult to break. The key for the pilot is to pick out a “good” AME.

So, how does one go about finding this elusive relationship? Electronic lists provided by AOPA and the FAA don’t identify AMEs as “good” or “bad,” just as pilots don’t have “good pilot” or “bad pilot” placed in their logbooks. There are some hints, however, that pilots should recognize.

Your AME should speak airplane

To a nonpilot, the concept that the hours and hours of ground school, flight training, and continuing training and knowledge building throughout one’s aviation career could come to a screeching halt with a medical denial may just not compute. Not that the nonflying AME is any less medically competent or caring, but the energy and investment that most pilots place in their aviation avocation may be interpreted by some AMEs as overzealousness, or worse, that the urgency and compulsiveness interjected by most pilots is unnecessary. This may result in processing delays for some medical conditions requiring deferral to the FAA’s Aeromedical Certification Division. What’s more, when the pilot breaks into a story of how he was stuck flying his 172 VFR into weather when he contacted ATC for the local METAR, he may get a polite head nod and a glassy-eyed stare.

Avoid the six-foot pilot exam

Every pilot knows of an AME—or at least has a friend who knows an AME—with whom $60 and being within six feet of the examiner will predictably result in issuance of a medical certificate. In some cases in which the FAA has sent a mock patient to visit certain unknowing aviation medical examiners, the “airman” was not even touched with a stethoscope. While some pilots might flock to this environment, the real victim is the pilot himself.

Although the FAA medical involves a detailed review of systems and a physical examination, it is really a perfunctory exam of the special senses with a focus on visual and auditory acuity. Unless brought up by the AME, there is no required discussion of important preventive screening examinations or a review of other lifestyle issues that could result in future jeopardy of medical applications. As a result, the pilot may leave the examination armed with a new medical certificate and a false sense of medical security.

Cutting to the chase, the actual piece of paper upon which the medical is printed is worthless unless something bad happens while operating an aircraft—and then the entire medical application is scrutinized with a microscope. The key is to seek out an AME who will dot the I’s and cross the T’s and make every effort to minimize a medical cause for calamity.

Find a resource

There are AMEs who believe it is their role to single-handedly make their mark on aviation safety by grounding an airman. After all, the AME is a federal designate, right? However, the lion’s share of AMEs are serving pilots as a resource and not as a police force. Most of the time, the medical application can be held in abeyance until that visual acuity issue or abnormal urine dipstick result can be assessed and, if necessary, corrected. There are some conditions for which the AME doesn’t have a choice—it must be deferred for decision-making at the regional level or to the Aeromedical Certification Division in Oklahoma City, but those are the exception and not the rule. The successful AME-pilot relationship hinges on trust—and that’s a two-way street. Be honest with the AME. Work with your AME to make sure all medical conditions are reported correctly. It’s better to err on the side of too much, rather than too little information reported on the Form 8500-8 medical application.

When the going gets tough

OK, so you have a heart attack, develop a cancer, or get diagnosed with obstructive sleep apnea. What now? The special issuance road is an avenue shrouded in mystery. Who can you trust? Where do you go? What hoops will you have to jump through to climb back in the cockpit? Start with AOPA’s medical department. Talk to friends who have had good results with complex cases handled by their AME. Find reputable, veteran AMEs with plenty of experience in handling the tough ones, and who will take the time to understand the issues and walk you through potential land mines in the application process.

For example, at the Mayo Clinic, pilots come to “the Land of Misfit Toys.” Airmen with aortic valve replacements, atrial fibrillation, insulin-dependent diabetes, sleep apnea, and cancers wander the halls. Nearly half of the Aerospace Medicine practice is made up of some of the most complex and forensically challenging conditions to certify—and people come from across the country to seek advice there. When the chips are down, you will need an individual to advocate for you in terms of providing good advice to expedite your medical application. Your AME’s experience and know-how is invaluable. In fact, he is the best advocate for knowing when to pick up the phone to discuss your case with the physician reviewer in Oklahoma City. It may take extra AME time, but could trim months of waiting expectantly on an aeromedical certification decision to arrive in your mailbox. Yes, there is life after special issuance.

The needs of the pilot come first

Ultimately, you have choices as a pilot, and when considering your flying future, you should take the time to seek out the best and the brightest AME. Many practices are only as strong as the weakest link. Practices with friendly clinical assistants, competent nurses, and efficient secretaries may be more successful in rapidly processing your application, but those qualities are not always an accurate predictor. Practices with the ability to incorporate FAA updates rapidly, and whose staffs spend time teaching medical safety issues are ideal. The ability to discuss preventive health maintenance outside the minimum requirements of the FAA application form is even more important. The key is developing a strong relationship with your AME early in your flying career and nurturing it over time.

In the years of providing care to aviators and flight crews at Mayo Clinic, I have received the token “stool sample,” grieved with the depressed pilot who lost his wife to illness, celebrated with the airman who regained his medical after successful aortic valve replacement, and given “tough love” to the airline captain who gained 25 pounds and was jeopardizing his career with early type II diabetes. Many of the requirements of getting the job done right are not listed in a formal job description, outlined in a medical syllabus, or etched into a medical examiner’s guidebook. The best flight physicians provide excellent patient care while protecting the skies for the good of the general public.

Clayton T. Cowl, M.D., M.S., a commercial pilot, is the chief of the Section of Aerospace Medicine at Mayo Clinic in Rochester, Minnesota.

Search the AOPA aviation medical examiners database online to find an AME near you.