Reflections and Connections

December 9th, 2011

The FAA bureaucracy is often the target of derision, incredulity, and doubt as to the agency’s real mission.  Unfortunately, with the negative perceptions, we often forget that there are some really passionate and dedicated public servants who have served pilots through their work at the FAA.

One of those, Dr. Audie W. Davis, passed away recently at the age of 80.  Dr. Davis was the Manager of the FAA Aerospace Medical Certification Division in Oklahoma City, and was truly one of those extremely hard working FAA civil servants who devoted his professional career to advancing civil aviation safety through his work in aerospace medicine.  Audie had already been on board for many years when I came to work at AOPA, and we corresponded often by phone and mail when resolving issues with AOPA members’ medical certification problems.  He was a gentleman and a gentle man with a scope of knowledge of medicine that made him one of the true giants in the world of civil aviation medical certification.  Audie’s willingness to really go the extra mile to help out a pilot was his trademark, and that won him many tributes from thousands of pilots who he was able to help get through the morass of bureaucracy that is so much in evidence in government today.

Following Audie’s retirement in 1996, CAMI welcomed his replacement, Warren Silberman, who was recruited out of the Army by the FAA to fill some very large shoes.  There are plenty of tough jobs in the federal government, and I really believe the job of overseeing the operation of the AMCD has to be one of the most challenging.  Warren has handled the pressure for 15 years with patience, resilience, and professionalism, and during some extremely tough times as the FAA went through some major changes in the way they do medical certification.  He has the unique combination of personality and skill sets that has allowed him to deal with irate pilots at air shows, congressional inquiries, ridiculous policies coming from on high in government, his bosses at the FAA and DoT, high profile accidents, and the advocacy groups like us who probably caused him more than a few grey hairs along the way.

On December 31, 2011, Dr. Silberman will be retiring from the FAA.  This is really bittersweet for me because I have had so much fun and learned so much from Warren during our collaboration for the last decade and a half.  He is a terrific guy, and I know I speak for many, many people in the aeromedical segment of our industry who will miss his irreverent Philadelphia-style candor when I say “Thanks, Warren, for all you have done for all of us and the pilots we represent.”

Warren will remain in Oklahoma City and will actually be doing FAA physicals in Tulsa with Dr. Jack Hastings, who has an established aerospace medicine and AME practice.  Warren will also be doing aeromedical consulting, so he’ll still be very much in the thick of things, and we’ll probably see him occasionally in Oshkosh at AirVenture, and hopefully, at AOPA Summit in Palm Springs next year.

Once again, the FAA has some huge shoes to fill, and with Warren’s departure, Dr. Courtney Scott will be taking over the reins of the AMCD, so I’m looking forward to working with Courtney.

Medical Self Certification 2.0

November 2nd, 2011

By now, many of you have heard and read of the joint AOPA/EAA initiative to request an exemption from the FAA that would, if accepted, allow pilots flying recreationally to be able to do so with a valid driver’s license, provided there is no knowledge of a medical deficiency that would make the person unsafe to exercise those privileges.  This exemption request is the most current in a series of similar requests made by AOPA over the last 10 years or so. 

The current request for exemption, which is different from a petition for rulemaking, capitalizes on a number of factors that haven’t been available before.  One is the success of the Light Sport self certification initiative that came into being in 2004.  We now have some tangible data from the Light Sport experience that bears out the notion that medical self certification, at least for the Sport Pilot segment of General Aviation, doesn’t diminish aviation safety. 

To date, the data reflect that there have been no LSA accidents that were associated with a medical incapacitation.  There have been light sport accidents, to be sure; however, these accidents have been demonstrated to be transitional type mishaps associated with pilots who were scaling down to LSA from normal category Part 23 certificated airplanes and who were insufficiently familiar with the significantly different aerodynamic performance characteristics of light sport airplanes compared to the “heavier metal” they were accustomed to flying.

Another important consideration in these tough economic times is that the government is reaching high and low to save money, and the cost to pilots and to the federal government of administering 3rd class medical certification is nothing to sneeze at.  Based upon FAA’s data compiled during the review in 2007 that led to the extension of duration of first and third class medical certificates, we have calculated that easing the medical certification requirements under the exemption request could save pilots more than $240 million over 10 years, and over $8 million in savings for the federal government over the same time period.

The exemption, if granted, would allow pilots to operate aircraft up to 180 horsepower, single engine, fixed gear, under day, VFR conditions, with one passenger.  By adding the power limitation up to 180 HP, the GA fleet would be expanded by 50,000 or so airplanes that could be flown under the driver’s license self certification provision. 

In any encounter with the FAA, the initiative being asked for has to demonstrate an equivalent or greater level of safety than what is currently in place.  The argument against doing something different often is, “there is no data to support it.”  There is rarely, if ever, any data to support something that’s never been done before.  In 1996, when the FAA Federal Air Surgeon decided to consider insulin dependent diabetics for special issuance medical certification, that had never been done before, either.  Industry, the American Diabetes Association, and the FAA gathered the opinions of the best qualified experts in medicine, including researchers, physicians, nurse practitioners, and other health care providers, and opened up the docket to comments from the public, and the support was overwhelmingly positive, despite the fact that no pilot had ever flown “legally” while using insulin.  Since that policy took effect fifteen years ago, I’m not aware that there has been a single accident attributed to in-flight medical incapacitation as a result of a pilot’s use of insulin.  The data gathering came after the bold decision was made to change the policy. 

The same situation resulted more recently when the FAA began allowing medical certification for pilots using antidepressants (SSRIs).  A much newer program, in effect just since April, 2010, relied again on the opinions of leading clinicians and researchers, and very limited data compiled from other countries that had been certifying pilots with depression and on medications for some time, to arrive at the conclusion that the policy could be changed without compromising aviation safety.  Again, as in the case of insulin treated diabetics, the FAA Federal Air Surgeon had to make the case to his bosses in the FAA and Department of Transportation without an overwhelming body of strong data to support the move. 

Even though there are less than 30 pilots currently certified under this new program, the FAA is following them closely, so again, the real data comes after the decision is made to make the change.

We believe the same logic should apply with our request for an exemption to expand the drivers license self certification opportunity, and we even have some a priori data to work with from the LSA experience.  We recognize that there are many aviation medical examiners that really aren’t comfortable with allowing pilots with potentially significant medical conditions to fly without “medical supervision.”  We hear those concerns, and we get it. 

However, keep in mind that self certification still means that the pilot has to determine he/she is safe to fly every time they get in the airplane, just like we’ve always done.  We would hope and expect that every pilot would be conscientious about seeing a physician for periodic physical exams.  That only makes sense, especially in an aging pilot population.  The need for a medical certificate to fly should not be the motivation for staying healthy.  Rather, staying healthy should be the motivation itself for seeing your family physician for an “annual body inspection.”

And, if the exemption is granted, part of the cost of playing will be participation in an online educational course that will provide some insights into what “self certification” really means.  The course content, which is still being developed, will also include an overview of common medical conditions that could lead to possible incapacitation, and training about the effects of altitude on medication usages.   

We believe the time is right to rejuvenate general aviation and get more pilots flying again, but doing it safely.  One of the best ways to improve safety is to fly more proficiently, and proficiency comes from flying in the system. 

Hopefully, the FAA will see it that way and grant us the exemption.  Then the burden will be on us to prove that we can maintain that equivalent level of safety without the regulatory burden of a medical certificate for those operations covered under the exemption request.

When we file for the exemption early next year, we’ll be calling on your help to support the request.  I’ve added a link below that will allow you to sign up to receive updates on the progress, and we’ll also let you know when the docket opens so you can send your own comments.

http://www.aopa.org/advocacy/medical-certification-petition.html

The Six Year Authorization

July 26th, 2011

Probably the one thing that pilots fret more about than anything else is seeing their aviation medical examiner to renew a medical certificate.  We’re an aging population with an increasing amount of pathology, and having a medical deferred by the medical examiner for anything is the last thing we want to have happen.  The medical certification process can get really messy in a hurry if a medical application or the physical exam reveals anything that requires additional information for the FAA’s review.  If there isn’t any supporting documentation for the aviation medical examiner to review, a deferral is probably in your future, and that could mean being without a medical for weeks if not months.

Fast forward a bit, past all the frustration of getting information to the FAA, waiting for a decision, and finally getting the medical certificate in hand.  Depending upon the condition, the medical could be tied to a special issuance authorization that limits the duration of the medical and that requires annual or more frequent follow-up testing for continued certification. 

Years ago, AOPA worked with the FAA on an initiative to improve the efficiency of the review and certificate issuance process.  The result of that effort is the Six Year Authorization that allows medical examiners to reissue certificates for about 40 different medical conditions, after the FAA has cleared the case initially. This is a major improvement in the way the FAA does certification because it “decentralizes” to some extent the medical oversight process, and puts more decision-making authority in the hands of the AME.  The pilot, of course, still has to undergo the required testing or obtain the needed reports from the treating doctor annually, but the process bypasses the lengthy wait while the FAA staff wades through the queue of pending cases.

The FAA is still swamped, and as of this post, remains under a mandatory partial shutdown because of the failure of congress to pass funding legislation in light of the pending debt limit crisis.  The writing on the wall suggests that government funding shortfalls will be the rule and not the exception going forward, so FAA medical certification programs will continue to be resource-strapped.

Recently, we’ve seen a spike in the number of members who have one of these Six Year Authorizations (and you’ll know it’s a six year auth because it says that at the beginning of the letter that comes with the medical certificate) but for some reason have chosen to send their records to the FAA instead of taking them to the AME for reissuance.  I’m not sure what’s going on here, but it could be that pilots either aren’t carefully reading those six year letters and don’t know that their AMEs can reissue, even in the off-year when they are not due for an FAA physical exam, or they think that since in the past the FAA reissued their certificates  reasonably quickly, they don’t need to take advantage of the AME-issuance option. Granted, these six year letters are a little complicated to read and understand, and there is language in the letter that states that if the airman doesn’t want to take the records to the AME for an office issuance, they can send the records to the FAA for approval. We strongly suggest that you don’t do that unless you’re not in any big hurry to fly.

If you have a the luxury of a six year authorization, use it, even if you have to pay the AME a few bucks for his/her time to process the records.  For most pilots, the cost is well worth it to be able to walk out the door with a new medical certificate in hand with no lapse in flying privileges. 

Here’s a tip:  If you will be reporting anything new on your next medical application, be it a medical condition, a visit to health professionals, or a new medication, do your pre-medical briefing and know what records you will need for the AME.  If it is something fairly straightforward, like a new prescription for blood pressure medication or a back surgery for a disc removal without complications, the AME may be able to issue your medical in the office if you have the basic evaluation for the condition.  Even if the condition requires a deferral, having good supporting documentation when you see the AME will save you a lot of time and will get you certified faster.  AOPA Online is an excellent resource for medical certification information, and you can give us a call at 800 872 2672 and speak with our medical certification specialists for even more detailed information about your particular situation.

Fly Safe, and fly often!

Exam Prep

May 18th, 2011

I appreciated reader’s comments about “Unintended Consequences” last month.  The broad subject of the future of our health care delivery system is clearly one in which opinions are strong and passionate. Judging from some comments, readers may not have understood that I was simply suggesting “possible scenarios” that pilots might face under a government-managed health care system.  That was not an affirmation that our current system is running smoothly on all cylinders, nor was it necessarily an indictment of the health care legislation passed earlier this year. Regardless of which side of the argument one’s on, our current system, as good as it is, leaves much to be desired. Fraudulent Medicare claims payments and astronomical prescription drug prices are just two examples of some really low fruit that must be addressed, with or without a fundamental change in the way our nation’s health care is administered.

I heard from a couple of AME colleagues and that prompted me to comment on the valuable role of Aviation Medical Examiners in the medical certification process.  AMEs, much like Designated Pilot Examiners, are authorized by the FAA to perform airman medical examinations, and are under the supervision of their nine respective Regional Flight Surgeons around the country. The docs represent a diverse group of medical specialties such as Family Practice, ENT, Neurology, Cardiology, and Aerospace Medicine.  About 50% hold at least a Private Pilot certificate.  Many are full time private practice physicians who see patients all day and devote a few hours or more a week to performing FAA physical exams. 

The Medical Certification specialists in the Pilot Information Center are sometimes asked by members to recommend a “good” AME in the pilot’s local area.  We can’t really make recommendations, although I personally know a decent number of AMEs around the country, and if a pilot is in the general area of one of them, I will gladly suggest the pilot give them a call.  Of course, not all AMEs are created equally, so there are some really outstanding ones, some who are OK, and a small number who cause us to scratch our heads and wonder what were they thinking?

Finding an AME who “speaks airplane” and is willing to work with the pilot who has a medical certification issue is the ideal situation.  Word of mouth seems to be the mechanism by which most pilots find their medical examiners.  If you’re new to an area, hang out at the airport for a few hours on the weekend and it probably won’t take long to find out who the locals see for their flight physicals.  WWW.FAA.gov and www.aopa.org are two websites that can provide a database of aviation medical examiners.  On our AOPA site, you can use several different search parameters to locate an AME by his/her name, city, state, or zip code.  The list also identifies Sr. AMEs who can perform First Class physicals, and also lists their pilot credentials.

It’s important to consider that an FAA physical exam is not intended to replace a comprehensive work up with your own family doctor.  Some pilots’ AMEs also happen to be their treating physicians, and there are situations where that can be beneficial, and times when it isn’t.  The FAA generally suggests that your aviation medical examiner should be just your AME and not also your primary care doctor.  Placing the AME in the position of wearing both hats could create a conflict with physician/patient confidentiality and the AME’s responsibility as an FAA-designee. 

The encounter with an AME for a flight physical has two important elements that the examiner, and ultimately, the FAA, considers when issuing a medical certificate.  One is the medical history the pilot provides on the front side of the FAA Form 8500-8.  We pilots are responsible for the accuracy of the history part of the application, and for that reason AOPA developed TurboMedical as a pre-examination planning tool to help with the process. The other is the physical examination performed by the AME that could identify potential safety of flight issues such as an undetected inguinal hernia that could strangulate a loop of bowel, untreated high blood pressure, a significant change in visual acuity since the last exam, or a heart murmur that could suggest a failing valve. There are three, well actually, four choices for an AME when examining a pilot.  He can issue the medical, which we all hope for, hold the application for a couple of weeks and asks the pilot for some additional information before the certificate can be issued, defer the application to the FAA for a decision, which means the pilot leaves the office empty handed, or, even deny the application if the pilot clearly doesn’t meet the medical standards for the class of medical applied for. I’ll get into more details in future installments about the deferral process and how to avoid or deal with it when it happens.

Finding an AME who you can build a rapport with is like finding an A&P to do your annual inspection.  If the chemistry “clicks” and you feel comfortable in the relationship, stick with it as long as you can.

Unintended Consequences

March 25th, 2011

Although I’m not a hard core movie fan, my wife and I did see “The King’s Speech” a week before it won Best Picture at the Oscars.  Another favorite flick that never won an Academy Award nomination was the 2004 “50 First Dates,” in which Lucy (Drew Barrymore) suffers from “anterograde amnesia” as a result of a car accident she was in a year earlier. The condition has left her unable to convert short-term memories into long-term memories, so she literally can’t remember from one day to the next.

 Enter marine veterinarian Henry Roth (Adam Sandler), who meets her in a café, they hit it off, run into each other again the next day, but she doesn’t remember him from the day before, leaving Henry perplexed and dejected. The guy who runs the café clues Henry in on what’s going on, and Henry capitalizes on the chance to make a new first impression with Lucy every day. 

There are plenty of times when I could have benefited from a second chance at the first impression.  This premiere installment of Medical Sense probably isn’t one of those times, so this is my shot to make a good first and only first impression.  Let me know what you think.

There are many debates going on in politics right now, and depending upon the day of the week in the news cycle, government run health care is front and center as we hit the first anniversary of the signing of the legislation by the President.  As with just about any public policy debate, a topic that doesn’t always get much attention is that of the “unintended consequences” of the legislation. 

The federal government generally isn’t very successful at running anything it “subsidizes,” or outright “takes over.”   Delivering the mail and maintaining a national railroad are two examples that can’t seem to operate without regular infusions of taxpayer cash. Managing mortgage loans and building cars are more current examples, but all things aviation, however, are inherently governmental functions.  Aircraft certification, air traffic control, and pilot medical certification generally receive passing marks from most of the user community, despite their governmental oversight. 

The adverse unintended consequences of federalizing and mandating single-payer universal health care for everyone (except the special interest groups who are being granted “waivers” by the thousands) concerns me a lot.  In the evolving landscape of “ObamaCare,” one scenario of government proscribing “who gets what treatment and when” has potentially serious implications for pilots who are under tighter FAA oversight of their medical certification.

Special Issuance Authorizations are issued for lots of different medical conditions, and those authorizations are contingent on the FAA getting something from the pilot on a regular basis, usually every year.  Balancing the mandates of federal regulatory medicine against the accepted “Standard of Care” that our current health care system employs seems to be working fairly well.  Despite the protestations of some airmen about the FAA’s requests for “unnecessary” testing to determine one’s eligibility for medical certification, the FAA is, by most accounts, balanced and reasonable in what they ask for and how often they ask for it.

 A common example of this plays out with a private pilot with a third-class medical and a history of coronary artery disease treated with stents.  In our experience at AOPA, pilots and their cardiologists generally have no problem in complying with the FAA’s requirement for annual reevaluation with treadmill stress test, lipid profile, and a narrative report from the cardiologist.  Under our current health care “rules of engagement,” an annual follow-up examination with repeat treadmill test is an adequate and reasonable baseline study to identify possible progression of disease.

 Considering the worst case scenario under a government run “rationed” managed care system, the otherwise healthy, compliant airman with good control of risk factors who submits to an annual cardiac reevaluation for renewal of his medical certificate likely would not be covered under “the Plan” and would be denied the claim for the perhaps several thousand dollars in incurred expenses for a stress test, cardiology interpretation, lab work, and the physician’s narrative report. 

That airman would then have the untenable choice of paying all those costs out of pocket, or not be reissued an Authorization.  Our average general aviation pilot may finally say “enough” and will no longer continue to play in the aviation arena, or will, at best, opt for Light Sport self certification.  Our industry has been very resilient up to now, but in a world of a declining pilot population, forcing an additional expense on the cost of flying in the form of out of pocket medical expenses may be the tipping point for many.

 The scenario places the pilot between a rock and a hard place. The DoT/FAA won’t budge on the mandate for aviation/public safety.   So, we can’t expect that the FAA will no longer ask for an annual CT scan, a thyroid panel, a stress echocardiogram, or a heart catheterization from those airmen whose medical histories indicate such testing.  Nor can we expect that the costs of these services will decrease under managed care, as the Administration continues to claim. 

 Regardless of one’s views, it’s hard not to agree that this is a dramatically new paradigm of health care in the US, and it will be interesting to see how it plays out going forward.