Fly Well: Five points of clarification

Physicians look after an individual’s health, predicated purely on what is best for that person at that time. Epidemiologists, however, study population health and make recommendations, for instance, about prenatal care—which, while important, is irrelevant to an individual, single middle-aged male. Regulatory medicine, whether imposed by the FDA or FAA, likewise addresses populations rather than individuals.

The FAA’s mandate is to anticipate risk and mitigate the likelihood of harm coming to airmen, their passengers, and earthbound mortals under our flight paths. A few examples might explain the FAA’s actions.

1. New drugs undergo extensive development over many years, three stages of clinical trials in several thousand patients, and FDA review. Healthy pilots are unlikely to take part in clinical trials, so there will be no information on how drugs may affect our ability to handle an aircraft. Therefore, the FAA will review a medication for aviation purposes after it has been FDA-approved for at least one year, depending on the medical condition for which the drug is approved. Clinical deployment post-launch will yield more data that might persuade the FAA whether the medication is safe for aviation use.

2. An otherwise healthy 50-year-old man experiences chest pain, and investigations reveal narrowed coronary arteries that are preemptively treated by stents. Or, following a small heart attack, the FAA requests a stress test deemed “normal” by one’s personal physician. The FAA Aerospace Medical Certification Division then requests a nuclear exercise perfusion scan that reveals a small area of ischemia (poor blood supply) that the cardiologist deems irrelevant and merits no therapy, but the FAA denies the medical. This is a perfect example where personal medical care and regulatory medicine guiding the FAA diverge. While the FAA is not responsible for your individual care, if a percentage of patients with a similar history could suffer a potentially incapacitating event in flight, the FAA considers the risk unacceptable. Remember, I’m just the messenger.

3. A man is treated for a metastatic prostate cancer and the FAA requires a brain MRI and other tests before providing a special issuance, even though the treating oncologist deems these tests unnecessary. Any cancer can spread around the body, with the brain, bones, and lungs as favored destinations. If this happens, the unfortunate patient may have no symptoms until one day a brain seedling causes a seizure that renders one unconscious—obviously undesirable while flying. Although your personal doctor may consider that you, as an individual patient, are at close to zero risk for such disease progression, the FAA is driven to anticipate and mitigate risk.

4. One known risk factor for a stroke is having a prior stroke. If a pilot makes a full recovery after a small stroke a year before, regardless, FAA generally requires 24 months following the stroke before considering an airman for a special issuance. Unfortunately, this evaluation requires extensive tests including neurocognitive assessment costing several thousand dollars—and which insurance will not cover. Does this make the airspace safer? Some doubt the value of certain tests, but if you put 10 doctors in a room you will get 11 opinions; regulatory doctors are no different, and “conservative” views will always triumph.

5. A patient with bipolar disorder is well controlled on medications since diagnosis. One might presume that FAA would prefer pilots with psychiatric issues diagnosed, properly medicated, and openly sharing their problem rather than hiding a problem or not being treated. The FAA allows pilots who are successfully treated for depression to fly (after some considerable hoop-jumping) if they are treated with specific SSRI drugs. However, bipolar illness is too far out of the FAA comfort zone and, again, conservatism holds the upper hand as bipolar treated with medications is a show-stopper.

The phrase “don’t shoot the messenger” was first coined by Sophocles in 442 B.C., later used by Shakespeare in Henry IV Part II, and Oscar Wilde saw a sign on a saloon in Colorado that gave the expression a western flavor: “Don’t shoot the piano player, he’s doing the best he can.” So is your correspondent—and the FAA.

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