Medically Speaking: Never Give Up

You sit there in the examining room, blinking your eyes in disbelief at what the doctor in the white coat just told you—even as the words reverberate in your ears. “I’m afraid that you do not meet the requirements for a third class medical certificate.”

For many pilots, the aviation medical examiner’s words come as a surprise. Others don’t expect to walk out of the AME’s office with a fresh medical certificate in hand—likely the case for Malvern “Skip” Monaghan of Suwanee, Georgia, who received a heart transplant (see “ Medically Speaking: Second Chance,” page 88).

Those words don’t mean that your flying days are through. The vast majority of airmen are able to get back into the cockpit by getting a special issuance authorization—it’s a discretionary issuance granted by the Federal Air Surgeon that usually comes with requirements for periodic interim medical reports, as well as time limitations on the duration of the certificate, explains Gary Crump, AOPA director of medical certification.

A special issuance allows individuals to fly with medical conditions that the FAA considers to be acceptable risks, but require more frequent evaluations to mitigate that risk. These include heart disease resulting in myocardial infarction, bypass, or stents (approximately 15,000 cases); prostate or testicular cancers (about 15,000 cases); and other conditions, Crump said. It even includes a handful of pilots, like Monaghan, who have received heart transplants.

A special issuance differs from a waiver or Statement of Demonstrated Ability (SODA), issued for physical defects not likely to change such as useful vision in only one eye (monocular vision) or an amputation. In some cases, a medical flight test is conducted to show that the applicant can safely operate the aircraft.

The big news on the special issuance front is that the enormous backlog of unissued medical certificates awaiting review—which peaked at more than 110,000 in 2005—had shrunk to as few as 600 cases on a Thursday morning in late May. Processing time now averages 16 days from the time documents are scanned until a decision is made, says Dr. Warren Silberman, who manages the Aerospace Medical Certification Division, part of the FAA’s Civil Aerospace Medical Institute (CAMI) in Oklahoma City. “Before this, it was three to four months,” he says. “We’ve totally reengineered the way we do business.”

Understanding the process

The Aerospace Medical Certification Subsystem (AMCS), a component of the automated process, allows the AME to transmit the completed FAA Form 8500-8, Application for Airman Medical Certificate, to the FAA via the Internet (and, as a bonus, completes the medical certificate—no more typing; the AME simply prints and signs it). If the application is completed on paper, a copy—along with any supporting documentation—gets mailed to CAMI, and is among the 1,000 pieces of mail that arrives on an average day in a small mailroom.

From here, documents go directly to scanning, where they are converted into electronic records. Twenty new scanners can accommodate double-sided documents of as many as 44 pages. Documents normally are scanned into the Document Imaging Workflow System (DIWS) within 24 hours of arrival, Silberman explains. “At the peak, there was a 21-day backlog. Not long ago, it was seven days. Now they’re working on the previous day’s documents.”

There is still a lot of paper on file at CAMI—more than 1 million records still reside at the Aeromedical Certification Division. Before DIWS, bulging paper files were physically carried from office to office at each step of the process, and there was no effective way to track their locations. “It was a nightmare,” Silberman recalls. “The reviewers had tables and bookcases of files waiting for review. It could take four or five days just to locate a record.”

Now the scanned documents are reviewed on computer monitors; most paper records are held six months and then shredded. “We’re able to reduce what we keep right now—we’re not gaining additional paper,” says Stephen Smiley, manager of the medical review appeals branch.

When a file is begun for an airman, it’s assigned a PI (pathology index) number—a unique identifier that never changes. “That’s the best number to give us” when communicating about a case, says Silberman.

Review and appeal

Once an exam’s results are scanned, they’re reviewed by one of 35 legal instrument examiners. Cases where a medical certificate was not issued at the time of the exam are set as a priority, and are automatically routed to the examiner with the shortest in-box queue. In other cases, something was noticed during the exam that requires additional review. “Most of these, in the end, are issued medical certificates,” Smiley says. Ten examiners are dedicated to recertification and five to medical appeals cases; two handle only DUI issues.

The examiner—when necessary, working with one of the FAA’s seven staff physicians—will will work the case until the medical is approved, a waiver is issued, or the application is denied.

In one case, an airman reported during a March flight physical that he was taking a prohibited medication. He was sent a letter denying his medical on April 28, and responded with additional information that was received and scanned on May 21. A couple of days later, a reviewer had forwarded the case to a physician seeking approval for a time-limited issuance. That pilot appeared likely to receive a medical, although his condition will be followed closely under a special issuance authorization.

Another airman failed the color vision test. He apparently had obtained a waiver for defective color vision, and then changed to another AME who didn’t have his history or a copy of the waiver. CAMI will research his case and, if the waiver is located, issue a medical certificate without restrictions on night flying and the use of color signals.

Four reviewers examine the electrocardiograms required for a first class medical—some 5,000 to 6,000 per month—usually on the day they’re received. “They look at the graphs, and if they’re not normal they’re put aside for review,” Silberman says. “Most of them are normal.”

What changed?

Silberman and his team have focused on continual process improvements to reduce the backlog of cases. DIWS, developed and implemented over 10 years, has been key. And it had at least one unanticipated consequence. Scanner operators initially were temporary positions, Silberman explains, and turnover was high. The scanning process is critical to keeping the process moving, and training a new hire is a 10-week process, which exacerbated the problem. Dr. Fred Tilton, the federal air surgeon, made the scanning positions permanent—which put an end to the turnover problem.

Silberman also added staff where needed. For example, the medical appeals department was expanded by two specialists. More workers have been cross-trained to perform other tasks, and work is distributed more efficiently.

“It’s a different business process now. It emphasizes getting the case looked at,” Silberman says. “On average, a case is processed in 16 days. Before this, it was three to four months.”

In many situations, after the FAA has initially cleared the case, the pilot is granted a six-year authorization under an AME-assisted special issuance. “That speeds up renewals because the AME issues the certificate in the office—he just sends us the paper trail,” Silberman says.

Pilots can help

Pilots can speed the process by promptly providing supporting documentation at the beginning of the application process. A request from the FAA for additional information stops everything until the airman responds, Smiley explains.

“If a pilot develops a new medical condition, find out what’s needed and bring it to your AME,” says Dr. Steve Schwendeman, one of the FAA staff physicians at CAMI and an active general aviation pilot.

If possible, pilots should discuss any medical issues with their AME before the flight physical. AOPA members can consult with the association’s medical certification staff at 800-USA-AOPA or visit the Medical Certification Center online; AOPA’s medical certification staff responds to more than 20,000 member calls and e-mails annually. CAMI offers a variety of information on its site as well, including an online AME guide that pilots can reference.

The FAA authorizes about 30,000 special issuances each year. Final denials total only a few hundred cases each year, Silberman notes. “The majority of denials result from the airman’s failure to provide requested information. They shouldn’t give up if they really want to fly.”

“There’s nothing that makes my day more than getting a pilot back into the air,” says Schwendeman.

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