Pilot Medical Certification

Introduction

An FAA (Federal Aviation Administration) flight physical is a physical examination for "fitness of flight" performed by a physician who is FAA-trained, designated, and certified as an AME (Aviation Medical Examiner), of which there are approximately 2500 in the US.   These physicians are trained with an emphasis on examining and evaluating the medical entities that can cause "sudden incapacitation in flight and/or cause an interruption in the smooth flow of or threat to the safety of our nation's airspace." FAA flight physicals fall into three different classes, intuitively designated FIRST, SECOND, and THIRD, which are commonly printed/typed in all capital letters. The requirements and valid timeframe of the medical examination are dependent on the class of medical licensure, the airman's age, and Special Issuances (SI) or special circumstances. A FIRST or SECOND automatically defaults to a SECOND or THIRD after the valid timeframe of the FIRST or SECOND. AME's perform FAA Medical exams focusing on exam findings and take a medical history focused on things that may be considered aero-medically significant.[1][2][3] 

The HIMS (Human Intervention and Motivational Study) is a joint program between the FAA and aviation industry for initial evaluation usually followed by ongoing monitoring wherein there may have been issues with potential concerns about mental health or chemical dependency. HIMS exams and monitoring is weighted more heavily towards history and examination monitoring for sobriety, mental health, drug screening, and correlating reports such as, but not limited to, psychiatric, neuropsychological, pilot performance, flight instructor, AA, NA peer-pilots, and chief pilot.  

These examinations are not only performed on pilots but also on ATC's (Air Traffic Controllers)  ASI's (Aviation Safety Inspectors), who may or may not also be pilots. Holding an FAA medical certification is also a standard for a certain degree of overall health. Occasionally, individuals who are not involved in aviation at all are examined and given medical certificates. Examples of such persons are workers on offshore oil rigs where healthcare may be delayed, racecar drivers, and occasionally executives in organizations that cannot afford high-rate or unpredicted turnover in certain positions. Student pilots cannot fly solo without an instructor or another pilot until they have passed their medical exam and been issued an FAA medical certificate.

The Aviation Medical Examiner

Any physician (MD/DO) interested in becoming an AME is best suited by having an interest in aviation and an understanding of the concept of a forensic examination, as well as a love of learning and interest in all entities of medicine and capable of performing a comprehensive, thorough medical examination regardless of the Specialty of Origin (SOO). There is no residency training that is not acceptable to become an AME; board certification in the physician's primary specialty is required, and an unrestricted medical license in the state where the FAA medical exams are to be performed.   Regardless of SOO, the AME must be thoroughly competent in the ENT, ophthalmologic, neurologic, musculoskeletal, cardiovascular/cardiopulmonary, and psychiatric examination.

The AME must also be computer literate, fluent in English, be able to adapt to changing regulations/guidelines, and be tolerant of a degree of bureaucracy. Fellowships in Aerospace Medicine are available, but few programs have a small allotment of positions, and fellowship is not a requirement for AME certification.[4] The vast majority of AME's practice medicine full-time and do flight physicals in-between regular patients, and the FAA only requires ten exams per year to maintain certification. 80% of AME's perform less than 25 per year. There are very few AME's who do nothing more than FAA medicals as their primary job as a physician, but many AME's semi-retire from their SOO and restrict their practice to flight physicals as they scale back towards total retirement. The AME must understand that they are not there to diagnose or treat the airman, and while the AME is a doctor, they are not the treating doctor but often speak with the treating physician(s) regarding potential changes in a treatment regimen that make the difference between issuance of the medical vs. denial or deferral. The AME must understand they are a representative of the FAA and by follow-through the federal government when interacting with non-AME physicians in attempting to assist in the processing of FAA medicals and understand that the average non-AME physician most likely does not even know such as thing as an FAA AME even exists. The AME must recognize clinically significant deterioration of any serious condition that needs urgent or emergent treatment and reach out to the appropriate treating physician if indicated.

An AME often is but is not required to be a pilot. The AME reports to and is assisted by one of 9 Regional Flight Surgeons, who are then responsible to the Federal Air Surgeon (FAS) in Washington DC. The FAS is assisted by Deputy Federal Air Surgeon(s), and there is an additional International "Regional" flight surgeon (RFS). Any AME can contact any RFS or FAS for assistance, which is often helpful after 5 p.m. in the AME's respective time zone. AME's are well-supported by the RFS and OKC.

The AME Training and Progression

AME's are initially trained by the Federal Aviation Administration during a seven-day timeframe in Oklahoma City, OK. Advanced practitioners such as physician assistants and nurse practitioners are not eligible to be AME's, and as of this publication, there is no plan to authorize physician-extenders for certifying FAA medicals. This training is a comprehensive and universal review of every specialty and subspecialty from the standpoint of how they pertain to general aviation and maintenance of health rather than focus on direct treatment. This initial training involves what can be an enjoyable comprehensive review of all medical topics. Additionally, there is training in aeromedical-specific topics such as decompression, the decompression chamber, Time of Useful Consciousness (TOC), evacuation and rescue operations, accident investigation, common patterns of injury, and accident analysis. A static ground-based aircraft is used for simulated emergencies and fake "Hollywood Smoke," as well the option of another fuselage suspended over a swimming pool used in training airline attendants in emergency slide use and emergency evacuation into an aquatic environment. The AME trainee is shown how the FAA trains its inspectors, controllers, and administrators. The training is also heavily focused on federal rules and regulations appropriate to aviation and policy and procedure of being a designee of the Federal Government.   There are several written "open-book quizzes" and one final multiple-choice exam. The exam has a reputation of being difficult but fair,  well-covered in the training course. It does not seem intended to fail or "weed out" AME candidates but rather to train and prepare to pass an exam with the caveat that this is somewhat esoteric material. Very few physicians would pass the exam without taking the course. 

Following initial training and certification, the physician is designated a Junior AME and can perform SECOND and THIRD-class medicals for the next three years. During this timeframe, their examination decisions and documentation are evaluated, and the FAA visits them to inspect the office and equipment. Following this three-year timeframe, if the error margin is acceptable, the physician can petition to become a Senior AME and can examine the airman for and issue FIRST class medicals. At this point, the physician can register to be able to perform physical examinations for ATC's, ASI's, and other FAA employees. AME's are currently required to undergo online training known as MAMERC every two years and in-person training for three days every four years. This training covers various topics and tends to focus heavily on neurology and cardiopulmonary, but most major medical topics and guideline updates are covered. The chart of an examined airman may be reviewed periodically; If an AME is contacted, usually by email, identified errors and positive and negative feedback may be given. This training continues throughout the career of the AME. This is usually high-quality CME but may not count towards specific requirements in the AME's SOO.

The FAA maintains an archive known as the "FAA TV: AME Minute," which is a series of short videos covering various topics pertinent to AME exams that are a good review of salient points in training and often help explain guidelines to airmen. Physicians interested in becoming an AME could benefit from reviewing these videos. 

After three years as a senior aviation medical examiner, the AME can request training to be designated for the Human Intervention and Motivational Study (HIMS) program and be designated as an Independent Medical Sponsor (IMS) to assist with certification of an airman who has had difficulty with substance abuse, mental health issues, or needs special issuance surrounding antidepressant therapy.[5]   There are currently, The HIMS AME often works closely with a HIMS psychiatrist or a general psychiatrist familiar with aviation requirements following a specific template. Additionally, they work with a neuropsychologist designated by the FAA and certified to do the appropriate neuropsychological testing specific to aviation. There are currently only 112 FAA-certified HIMS neuropsychologists worldwide. The AME is also responsible for monitoring the airman, often with a portable breathalyzer, office-based encounters commonly requiring 14 random urine drug screens in a 12-month timeframe, and periodic reports to the FAA before and after the SI is issued. The AME is then responsible and held accountable for reporting deviations and concerns to the FAA. There are only 187 HIMS AME's in the US and 20 international HIMS AME's in 12 other countries at the time of publication.

"Think Twice" What the AME Candidate Should Know

The AME candidate leaves with a clear understanding that they have civil and criminal liability based on their decision(s) beyond medical malpractice, and that standard medical malpractice liability does not usually cover forensic exams.

Declining insurance reimbursements and patient sense of entitlement have led to a burst of "concierge programs," and many new medical school graduates are focused on cash-only business models, such as IV fluids and cosmetic procedures. The search for non-insurance-based reimbursement is almost an unfortunate necessity in the modern reimbursement climate. While there is no doctor without the potential to be a good AME, the reasons behind obtaining this designation should be carefully self-analyzed. Following initial training, the AME is left with an understanding that you are a designee of the Federal Government and your superiors are agents of the federal government, and there will be oversight and evaluation of your exams, and your designation can be rescinded based on your documentation, decisions or failure to fulfill training and currency requirements. The number of people killed in large commercial airplane crashes rose in 2020. Accident analysis and your role as an AME in prevention are emphasized. While the initial training provided to AME's by the FAA is an outstanding review of nearly every aspect of medicine, portions of the training cover unpleasant, sad, graphic, and preventable disasters wherein the AME was responsible or had the opportunity to prevent the incident, are appropriately discussed. At the end of this initial training, the AME candidate is left with a strong understanding of just how serious their responsibility is to the airmen, vulnerable passengers, vulnerable people on the ground, the United States, and humanity in general. During training, the question is posed of "How many people can an impaired surgeon kill at one time compared to how many people a 777 can kill based on one bad decision?"  Other questions were asked about what the passengers expected and how they felt when they fastened their seat belts. The AME candidates were asked to think about the phone calls we made as a passenger on our way to this (the training that day)  or any conference to which we took air travel, and when the door to the plane was closed, we were asked what degree of trust and control we had over the situation and "You were worried about peanuts or chips, not if your pilot was sober, unhealthy or insane."

The AME needs to take one of two three-day courses, one strongly weighted towards neurology and the other strongly towards cardiovascular, every five years. Also, to do an online re-training every two years. The courses are free to the AME, covered by taxpayers, and the CME counts towards a regular medical license (Cat 1A), but travel and other expenses are the responsibility of the AME just like any other conference.

Additional considerations for any doctor wanting to be an AME is understanding the basic pilot mentality and personality profile, which can range a wide gamut from narcissistic, impulsive adrenaline-junkies to extremely professional, almost rigid captains who are extremely methodical and very used to being in control of everything.  

The average pilot is intelligent, dedicated, hard-working, respectful of authority, and usually of a slightly higher economic and educational status simply due to the cost requirements and opportunities to get into aviation. The AME should understand the delineation between  GA (General Aviation) pilots who fly for business, pleasure, and some degree of reimbursement as a flight instructor or persons who have a small airplane and fly mostly on weekends in good weather conditions to things like pancake breakfasts, another type of GA pilot that may have a more technically advanced aircraft with higher performance who flies predominantly for business 250 miles or longer and has additional rating making them able to fly the aircraft purely by reference to flight instruments, and then the truly professional pilot who has achieved the highest rating possible known as the ATP (Airline Transport Pilot) which is often referred to as the "Ph.D. in aviation."

ATP pilots are full-time professional pilots who are as involved and professional as any cardiothoracic or neurosurgeon at a quaternary center. Many are highly-disciplined, elite ex-military, and are accustomed to, comfortable with, and do not flinch at the responsibility of having several hundred lives in their hands, flying 12 or 14-hour flights internationally, and landing safely and smoothly in utterly abhorrent weather conditions. The AME, their office, and staff must be able to interact with and serve all these personality profiles both in person and on the phone or email.

MedExpress

The FAA maintains a site known as MedExpress. The student pilot is usually introduced and instructed by their flight instructor to set up an initial account that follows the pilot throughout their lifetime. The student pilot or established pilot will log in before the exam and do the initial entry or update of their current medical history and demographics in what is known as the 8500 form. The 8500 form is not unlike any "new patient paperwork" filled out when seeing a new primary care provider. They then save their information or update, and a unique code for that exam is generated and valid for 90 days. They bring this code to the exam, and the AME logs in to the AME's account, enters the code from the pilot or student pilot, and the chart populates. The AME then reviews the history, confirms ID and demographics then enter the exam portion of the encounter. This is similar to an EMR, but there is no impression or plan section. The AME then submits the completed exam to the FAA electronically as either Issued, Denied, or Deferred for further review. If issued, the AME can print the medical certificate, sign it as the AME and have the pilot or student pilot sign it. The pilot/student pilot then leaves with the certificate in hand.   AME's are permitted "designees," usually staff members who log in and enter demographic data and vitals but cannot enter any other exam information.

Specifics of the Aviation Medical Exam

All exams start with basic demographics, height, weight, BMI calculation, vitals, general medical exam of heart, lung, abdomen, and what one would consider a basic internal medicine and neuromusculoskeletal annual exam.[6] Scars, tattoos, and any distinguishing body markings must be noted. The exam is documented online by checking normal or abnormal in 24 boxes, in addition to vision and hearing, corresponding to exam items, then providing comments on any abnormals.   Color vision, visual fields, Near and distant vision, and optic fundi examination are completed. Heterophoria testing is required for all SECOND AND FIRST CLASS medicals. Intermediate vision is necessary for SECOND and FIRST class medicals after age 50. An external anal exam for hemorrhoids is performed, but the digital rectal exam is not required. Females do not require a pelvic exam. Urine dipstick is performed for protein and glucose only with no drug screen. BMI and OSA (obstructive sleep apnea) risk are assessed on all airmen, and all airmen are placed into one of six categories regarding their OSA status. Hearing requirements for all three classes are simply a "conversational speech test" with the AME's back turned to the candidate.   ATC requires audiometry at 500, 1000, 2000, 3000, and 4000 Hz. A 12-lead EKG is only needed for FRIST class medicals, initially at age 35 and then yearly after age 40, and must be transmitted electronically as a PDF.   Military flight physicals do not apply to the civilian world and vice versa.  

As a forensic exam, the FFA medical is not covered by insurance, and prices roughly range from 100 to 200 USD. EKG is usually an add-on cost of 25 to 50 USD. Many airlines have fixed reimbursement for their airmen getting FIRST class medicals. With no published reference,  estimates 170 USD average for FIRST class medical with EKG, 120 USD THIRD class, and uncomplicated SECOND class medical. ATC exam pricing is fixed by the FAA at 170 USD for controllers who are federal employees, although some ATC are not federal employees.   FAA employee reimbursement for a new potential ATC candidate with a full audiogram and EKG is  190 USD at the time of this edit. HIMS program can be anywhere from 8000 USD to 15000 USD over a 1-3 year time frame with a complicated cost breakdown. These numbers vary based on geography. 

Aeromedicine consultation, which is not an FAA medical but consultation leading up to possibly applying for an FAA medical or advice to go in the direction of Sport Pilot and/or pursue other life interests, is commonly billed at the same price as a THIRD class medical. Usually, within one hour of exam and chart/case review, it becomes evident that the candidate will or will not ever be able to obtain a medical and what barriers are evident, but this is ultimately not the decision of the AME. Occasionally, an aeromedical consultation is requested for such a minor medical issue, such as a CACI issue like HTN or simply needing reading glasses. The aeromedicine consult is converted to an FAA medical exam, and a medical may be issued that day.

There is a section of the exam where the AME can type general comments below a place where the airman can enter general comments about their medical history. There is a section for "other tests" that may be performed by the AME, such as SaO2 (pulse oximetry), all of which require a comment.  

All medical requirements are publicly accessible in "The Guide for Aviation Medical Examiners," often referred to simply as "the Guide," which can be found in PDF format from any internet browser. AME's and persons involved in assisting airmen with getting their medical certificates, such as aviation attorneys and other pilot advocates, need to make sure they have the most recent copy of "the Guide," which is under constant revision. Another resource for such persons and agencies is the "Federal Air Surgeons Medical Bulletin," which is a quarterly publication with case studies, topics of interest, and proposed or impending changes to federal policy.

This guide is periodically updated, and when the examiner logs onto their MedExpress account to do a flight physical, all updates are mandatory acknowledgments before being able to progress to the main website to issue or document an exam.

The Outcome of the Exam

The result of the exam is either Denial, Deferral, or Issuance. Cases of issuance may have restrictions such as the requirement for vision correction, not valid above a certain altitude, not valid for night flight, or only valid for a period of time less than the length of time the class of medical would usually be valid. Such as in the case of monitoring. The AME may issue the medical, and the pilot gets a letter from the FAA either requesting additional information or, if the AME made an error, a notice of withdrawal of the medical. It should be noted that the medical certification does not mean the student can fly solo. The decision as to when the student can fly solo is made by the instructor/flight school. The medical certificate is simply one mandatory requirement before being allowed to fly a plane alone without another pilot or instructor. This is referred to as "executing PIC (Pilot in Command) privileges."

Issues of Concern