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Flight MD A better way

Why not issue temporary medical certificates?

Bruce Landsberg, vice chairman of the NTSB, made a critical point during the NTSB aviation safety summit “Navigating Mental Health in Aviation.” To paraphrase, he said, “If the FAA gives pilots 60 days to respond to their request for records, then the FAA should only have 60 days to make their medical certificate decisions.” 

This will never happen, and the FAA will never have enough staff in its medical department to expediently evaluate pilot medical certificate issues given the sheer volume of applications. The problem is the FAA has been unwilling to make the necessary changes to fix the delays that are caused by self-imposed criteria, particularly in the mental health area. (For an excellent discussion of the aviation mental health issues and the FAA, see the NTSB summit on the NTSB YouTube channel, @NTSBgov.)

Let me make some suggestions that could be implemented quickly by government standards. First, since the FAA states that 99.9 percent of medicals are eventually approved (this number does not count pilots who give up during the process or abandon it before starting), how about giving pilots “temporary” medical certificates during the FAA’s protracted review? This stops penalizing the pilot for the FAA’s arduous, time-consuming deliberations. Of course, the obvious question is if 99.9 percent of certificates are eventually approved, from a statistical point of view, what purpose is the process at all?

Another area is trust. The FAA needs to trust aviation medical examiners and local health care providers to determine if a pilot is safe to fly. The FAA has so little trust in its AMEs that the agency has sent surveys to pilots after their medical examinations with questions like, “Did the AME personally do your exam?” and “Did the AME look in your ears?”

The FAA standards for pilot medicals are based on medical qualifications that were developed when most AMEs were in grade school. Medicine has not only changed dramatically, but also our ability to evaluate patients is beyond what I could have dreamt about in medical school during the last century.

Heart disease is the classic example of the FAA’s arrogant evaluation process. If a pilot has a minor heart attack—such as an inferior myocardial infarction—and has a stent placed, the FAA will require a cardiovascular evaluation, a stress ECG, and all the hospital records. If the pilot is applying for first or second class medical, they may be asked for a nuclear stress test and airline pilots may be required to have a follow-up catheterization. A pilot could have a cardiovascular evaluation done by a world-famous cardiologist at a major medical institution like the Cleveland Clinic, which states the pilot is fit to fly but the FAA will still require additional testing. Many times, the cardiologist will specifically state the additional testing is not indicated. However, the FAA uses a cardiology panel that has never seen the pilot, and uses a checklist of required tests, to judge whether the pilot is fit to fly.

According to the federal air surgeon, almost 30 percent of pilots flying under BasicMed had a special issuance at their last medical. Decisions on whether they are fit to fly are made by any state licensed physician based on the physician’s professional opinion, not FAA criteria. Since the accident rate for BasicMed pilots is the same as third class medical pilots, it illuminates the lack of value in the FAA’s requirements.

The FAA has made some improvements like the CACI program—Conditions AME Can Issue. But look at a CACI like hypothyroidism. The CACI requirements for the pilot to bring in are not too bad. The pilot must bring in the treating physician’s clinical note done for a visit within 90 days of the AME exam and a lab test within the last year. Even though most hypothyroid patients are stable on the same dose of medication for years, the FAA thinks that pilots need a recent office visit and annual blood work. That means the FAA is determining the medical standard of care. Sure, hypothyroidism could theoretically cause an accident, but an aircraft could theoretically be hit by a meteor. Why not let the AME decide if the pilot is safe to fly?

The FAA evaluation of mental health issues is so complicated, expensive, time consuming, without transparent criteria, and without proven validity, pilots hide mental conditions and/or avoid mental health care whether it is counseling or medication. The FAA has started an aviation rule-making process to look at mental health specifically but changes, if any, will take years.

Every pilot determines whether they are safe to fly prior to each flight. Given the 0.5 percent medically related accident rate, pilots and AMEs should have earned the trust of the FAA. Trusting AMEs to make decisions locally will reduce workload and maybe, someday, the FAA can make decisions within 60 days.
[email protected]
Dr. Brent Blue is a HIMS certified senior AME, practicing at the Driggs, Idaho, airport (DIJ) just west of Jackson Hole.

photo of brent blue
Dr. Brent Blue
Senior Aviation Medical Examiner
Dr. Brent Blue is an FAA senior aviation medical examiner and airline transport pilot with more than 9,000 hours of flight time. Through his company,, he introduced pulse oximetry and digital carbon monoxide detection to general aviation in 1995.

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