The Aviation Medical Certification Examination

By Robert D. Bloodwell, M.D.

Sport Aviation, October 1996

Hey, are you ready for football? For school starting again? For fall weather? For hunting season? For the new revision of the airman medical standards and certification becoming effective on September 16, 1996?

These changes are much more consistent with current medical and health care practices than any regulations advanced since the inception of civil pilot medical standards in 1959. Realistic guidelines for pilot evaluation are the goal of the revised FAR Part 67 Airmen Medical Standards. Pre-flight inspection of the pilot, and evaluation of his predictable functional status, is the primary aim of the Aviation Medical Examination. Below are a couple examples of changes in the new standards and background on the opportunity for special issuances.

The new vision standards are clearly more practical with deletion of all uncorrected distant visual acuity standards for all classes of medical certification. Examination with eyeglasses or contact lens is now the only standard. The "whispered voice test" for hearing is replaced for all classes by a "conversational voice test" at six feet using both ears.

In the past, third class certification permitted a blood pressure reading of 170/100 without medication. This was not only unrealistic, but also medically unsound and risky. Now the blood pressure limits of all classes are set not to exceed 145/90. This is accompanied by the FAA’s acceptance of most anti-hypertensive medications. Some of these drugs, which often may induce sedation or dizziness as a frequent side effect are still not acceptable. However, issuance of such a medical certificate is done by your local AME, after he obtains several medical tests needed by any hypertensive patient requiring medication for blood pressure control.

Encouraging pilots to continue with an inordinately high blood pressure without treatment was an unhealthy practice. Hypertension is notorious for the "company it keeps." Heart enlargement, coronary artery disease, peripheral artery arteriosis, kidney disease, and cerebral stroke are often associated with elevated blood pressure. These should be ruled out by ECG (electrocardiogram) at rest or after exercise, blood test, and chest x-rays. When abnormalities are found, they can be treated, evaluated in detail, and be reviewed for consideration of a "special issuance." More on that later.

Interestingly, issuance of an airman medical certificate after the medical examination is the doctor’s attempt to predict the future for a specified duration of time. He predicts that the pilot will experience no sudden incapacitation during that time period. Based on the medical history obtained from the applicant and the findings of the physical examination, the AME certifies that, at the time of examination, no evidence of a disqualifying medical condition exists.

Specifically, nine disqualifying conditions are designated in FAR Part 67. These are:

• heart attack,
• angina pectoris or other evidence of coronary disease,
• presence of certain implanted cardiac devices,
• diabetes mellitus requiring insulin,
• psychosis and bipolar disorder,
• behavioral and other mental disorders,
• seizures (epilepsy),
• disturbance of conscientiousness or transient loss of control of nervous system function without a satisfactory explanation and
• substance dependence and substance abuse (including alcoholism).

Each of these nine entities is of concern because it has the potential to produce in-flight incapacitation. All nine have one characteristic in common: there are nearly no findings from physical examination that establish the diagnosis of each disqualifying condition; the history determines the diagnosis in all cases!

Since 1982, the Federal Air Surgeon has adopted a new procedural mechanism called "Special Issuance." This discretionary authority has allowed pilots with "disqualifying clinical conditions" to obtain medical certificates sometimes of shorter duration and perhaps requiring additional medical tests to periodically assess the stability or progress of these conditions. These are different from waivers or statements of demonstrated ability (SODA) which are issued when disqualifying conditions are static and non-progressive. Guidelines for timing and the nature of special examinations after acute medical events are clearly described in the current "Guide For Aviation Examiners" provided to each AME by the Federal Air Surgeon. They are developed and modified in conjunction with medical specialists and consultants to the FAA. These guidelines may be changed or dropped as new information develops in clinical medicine without requiring or involving governmental processing or formal rulemaking.

The best methods for recurrent follow-up exist when objective measurements are available that can demonstrate changes or stability of these medical conditions. Among the classes of medical certificates, there are guidelines established for the frequency and complexity of report testing. Less complex studies, done less frequently, are specified for third class applicants to be medically recertified to fly when they have a special issuance certificate related to the disqualifying diagnosis.

Some might think self certification is a solution for pilots with apparently disqualifying medical conditions. It is not. This is especially evident when we realize that the pilot-in-command must evaluate and determine the fit-to-fly status of his aircraft and its pilot before each flight. The pilot has an advantage over his doctor, who may have no physical findings to guide him, since the pilot knows about each symptom he has experienced and together they may discover a condition before it becomes a contributing factor to an aircraft accident.

(Robert D. Bloodwell, M.D., EAA 101024, AME, CFII, A.T.P.M.E., is a surgeon in Jonesboro, LA and a member of the EAA Aeromedical Advisory Council.)