The FAA Medical Mess

We have all seen pilot friends suffer through denials and endless expensive testing to retain or regain their flying privileges. Others have avoided doctors at their personal peril to maintain their flying status. On the other hand, some have just "passed" their FAA medical only to die suddenly from a heart attack.
Many pilots avoid medical procedures, therapy or necessary counseling just to maintain a "clean medical history" and suffer daily. Our FAA medical system needs a full re-examination and overhaul. This article was written by a long-time FAA insider who has personally suffered through these issues and wishes to remain annonymous.

The stated goal of the FAA’s medical certification system is to support safety by ensuring that those operating in the NAS are physically and mentally capable of performing their duties as pilots or controllers. However, the aeromedical system presently operates in a way that does not support this goal. On the contrary, it undermines safety because it strongly incentivizes “don’t tell/don’t treat” behavior among airmen.

In the words of one long-time aviator, pilots quickly learn never to conflate managing their FAA medical certificate with managing their actual health. The FAA medical system is widely perceived as capricious and punitive. Suggesting the existence of a medical condition to an AME or, worse, revealing anything requiring referral to Oklahoma City practically guarantees a deferral of unknown duration. Engagement with the FAA medical bureaucracy generally leads to a series of “because-we-said-so” demands for tests and procedures that are often expensive and almost never covered by insurance. In some cases, these tests are deemed irrelevant, unnecessary, or even harmful by the physician or specialist who knows most about both the condition and the airman.

The FAA justifies these demands in terms of “aerospace medicine.” These assertions are the subject of eye-rolling ridicule in the aviation community. Pilots at every level (private to ATP) and in every city can easily name at least one “go-to” AME for the expeditious handling of FAA medical certification paperwork. The flying public would be shocked to learn that five-minute FAA medical “exams” are the norm, whether for private pilots, active air carrier pilots with first-class medical certificates, and even special issuance.

As the safety record demonstrates, though, cases of pilot incapacitation at the controls are exceedingly rare. Those unfamiliar with the reality described above might attribute this result to the “effectiveness” of the FAA’s medical certification system. The truth is that those who cannot use BasicMed – an alternative Congress mandated because of the known vagaries in the FAA system – engage in some form of “don’t tell/don’t treat” behavior. In the best cases, pilots work with a trusted personal physician to treat conditions they dare not reveal to the FAA. In the worst cases, pilots fearful of entangling with the agency’s medical bureaucracy simply avoid treating health conditions that could indeed lead to an accident or incident.

In terms of both process and the outcome, the FAA’s traditional medical certification system is clearly inconsistent with the agency’s Compliance Program, its focus on the use of Safety Management Systems (SMS), and its initiative for risk-based decision making (RBDM).

The Compliance Program seeks to find problems and use the most effective means to fix them before they cause an accident or incident. It recognizes that in order to find and fix safety problems, there has to be an open and transparent exchange of information and data between the FAA and those who operate in the system. It recognizes that safety is not served by a system that incentivizes hiding problems to avoid punishment. In the case of medical certification, pilots currently have no incentive to do otherwise because they fear the punishment of costly and seemingly endless entanglement with a broken bureaucracy.

Open and transparent exchange of information, which is essential to achieving real safety, requires mutual cooperation and trust and “just culture” – a system in which self-disclosure is not punished.

Such trust is notably absent in the case of FAA medical certification, which is viewed as a punitive “gotcha” culture. The FAA medical staff, along with designated Aviation Medical Examiners who stand to lose substantial income, despise and openly disparage the BasicMed option as “unsafe.” In fact, however, the non-jeopardy nature of the BasicMed certification process is consistent with both the Compliance Program’s “find and fix” approach as well as with the concept of a just culture. As one BasicMed pilot puts it, “Now I can have an honest conversation with my doctor without worrying how the FAA will punish me.”

The operation of the FAA’s medical certification system is also inconsistent with the agency’s much-touted “risk-based decision making” strategic initiative (RBDM). RBDM holds that in order to truly improve safety, the agency needs to make smarter, system-level decisions that are based on data and risk analysis. The FAA medical certification system, by contrast, uses a one-size-fits-all approach. It seems to regard virtually any medical condition at any certificate level as a risk that requires significant time, energy, and resources by both the agency and the airman who has been foolish enough to report it. Meanwhile, actual risk increases because airmen whose work requires something beyond BasicMed patronize the five-minute “go-to” AMEs and/or practice some form of the “don’t tell/don’t treat” behavior described above.

As it currently operates, the FAA’s medical certification system also creates a substantial barrier to entry into the aviation workforce. For those considering an aviation career, a substantial investment of time and money is required to accumulate the 1,500 hours of flight time and the ATP certification level needed for employment in the industry. Those pondering whether to make such investments quickly become aware that even if they can qualify for issuance of an initial first- or second-class FAA medical certificate, they risk losing that certificate – along with the time and money already invested in training and logging flight time – every six months.

Medicine as a whole is currently "under the microscope" for it's pervasive profit motive. New procedures are marketed directly to consumers: "Ask your doctor..." Critics advocate for Gentle Medicine

"spurious disease categories are being invented, and existing disease categories expanded, for the aim of profit...the benefits of most new drugs are minimal and typically exaggerated by clinical research, and the harms of these drugs are extensive and typically underestimated by clinical research."

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Author: David St. George

SAFE Director, Master CFI (12X), FAA DPE, ATP (ME/SE) Currently jet charter captain.

6 thoughts on “The FAA Medical Mess”

  1. I think the best thing to do here is wait for Dr. Northrup to get comfortable in her job as FAS and see if we can get the aerospace medicine community together to look at where we can improve policy and reduce “mission creep”. There is an element of fear mongering in this blog which I don’t think is productive and a bit to early as Dr. Northup has only been in the job a few weeks.

    1. This was written last fall before Dr. Northrup and is addresses an enduring systemic problem. As a GA pilot and airplane owner (in addition to unimpeachable medical credentials) Northrup has the right background to effect positive change (fingers crossed!)

  2. Had a heart attack: Took almost four years & FIVE (5) Nuclear Stress Tests, all the same results, before I received my third class. Instead of “boards”, first two years, medical denied by a solitary contract doctor making a unilateral decision.

  3. I had two heart valves replaced three months ago. I am doing great. But I’m not sure it is worth the time and money to get a special issuance just to drop back to BasicMed again.

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