Clearing patients for takeoff a new duty for internists

If Mr. Jones believes he's healthy enough to fly a plane, he might just ask his internist to clear him for takeoff.

As of May 1, private not-for-hire pilots no longer need to go to aviation medical examiners to be medically qualified to fly. Instead, provisions in the Federal Aviation Administration (FAA) Extension, Safety, and Security Act of 2016 allow them to use an alternative pathway, FAA BasicMed, to acquire medical qualification without obtaining a Class III medical certificate. Congress passed the legislation that was signed into law by President Obama on July 15, 2016.

In effect, eligible pilots (aviators flying five or fewer passengers in an aircraft weighing up to 6,000 pounds at altitudes of up to 18,000 feet, even in weather requiring dependency on instruments alone) can now request a comprehensive physical examination and medication review from any state-licensed physician.

Each year, more than 100,000 pilots will be eligible for the alternative pathway to medical qualification, said pulmonologist and aerospace medicine specialist Clayton T. Cowl, MD, MS, president of the Civil Aviation Medical Association, which represents FAA-designated aviation medical examiners. “It's not exactly down the middle of the fairway for the ACP constituency, but they're going to be directly affected by this,” he said.

Dr. Cowl, a commercial pilot, chairs the division of preventive, occupational, and aerospace medicine and holds a joint appointment in the division of pulmonary and critical care medicine at Mayo Clinic in Rochester, Minn. He recently spoke with ACP Internist about what internists need to know if they're asked to sign off on a pilot's health.

Q: What kind of paperwork is involved? Does the patient provide it?

A: The pilot is told in the instructions to print off and bring the form (FAA Form 8700-2) with them to the visit as a hard copy. It will be available on the FAA website, so a physician could print it off. A physician is not obligated to do the exam; it's at their discretion. And if they do elect to do the exam, they use their clinical judgment as to what additional testing might be required to establish clinical stability. They're signing an attestation statement on the form that says, “I think this pilot is safe to fly.” So if someone comes in with four-vessel coronary artery disease and had a heart attack six months ago, the internist may elect to do some sort of functional study after reviewing the records from their cardiologist. For example, the internist may suggest an exercise stress test or laboratory evaluation, or maybe even have them bring back a report from their cardiologist saying, “I think that the pilot is clinically stable.” To sign off on something without having any data at all is probably not the best decision in the world in terms of liability.

Q: What kind of exam will internists be expected to perform?

A: For an average internist seeing a pilot, most of them aren't doing, for example, visual acuity or color vision, which are testing requirements outlined on the form. It is required that the internist do the full exam, review all medications, and then sign off and say, “I attest that I've done the full exam, I've talked to them about all potential medication effects, including any untoward side effects of drugs (meaning prescribed or not),” and then [physicians] are required to enter their name, office address, their medical license number, and the state where they practice on it.

As an organization of aviation medical examiners who have undergone training at the FAA and complete required recurrent training every three years, we're trying to make sure that internists are aware that this evaluation isn't a summer camp physical. For some of those practices that don't see pilots regularly and don't really know FAA medical regulations, it could be perceived as a liability issue. At a minimum, the exam really shouldn't be something that's signed off as an afterthought. These exams will likely be audited and, frankly, when it really matters, of course, is if some untoward event happens, and then the exams could be scrutinized.

Q: How long should physicians expect the exam to take?

A: I think for any doctor who performs a comprehensive examination, such as a full annual physical, they know what that encompasses. It should probably fit into that paradigm, plus there should be a review of records for pilots with multiple conditions with the potential to affect piloting performance. In other words, this isn't a brief, 10-minute follow-up visit to discuss someone's blood pressure medication; this is a full, comprehensive exam, and it probably should be scheduled as such. Since the signoff on the exam is at the discretion of the physician, having a clear paper trail showing that all chronic medical conditions, such as diabetes, coronary disease, cancer, psychiatric conditions, substance abuse, or other conditions, are followed closely and are clinically stable is necessary.

Q: What are the most important things that internists should know about FAA regulations as they pertain to BasicMed?

A: There's an entire FAA examiner's guidebook available online on the FAA.gov website. There's roughly 3,000 aviation examiners nationally who are available to answer questions and serve as a resource, but I think using common sense and having a little bit of diagnostic curiosity and taking a very good medical history, making sure that if there are things that are unanswered (for example, a stroke without any follow-up or substance abuse without treatment or aftercare), there probably needs to be some additional materials obtained before that individual should be signed off.

Q: If a doctor does not clear a patient, does the pilot have any recourse? Can they go to a different doctor?

A: Sure. They can go to as many different providers as they want until they get someone to sign off on it. The only stipulation in the legislation is that the individual who signs off must be a state-licensed physician. In essence, the signoff must come from someone who's willing to put their medical license number down on it and attest that they've done the full exam and it is their opinion that, based upon the data they have reviewed, the individual pilot is safe to fly.

Q: How often are pilots required to renew their medical qualifications?

A: Not every pilot gets a new exam every year, with the exception of professional pilots. For a healthy pilot over age 40, the usual FAA Class III exam is good for two years, and if you're under age 40, it's good for five years. Using FAA BasicMed, pilots over 40, even if they have serious health problems, it's four years until that pilot actually has to undergo another exam. Every two years, the pilot exercising the BasicMed alternative to medical certification must take an online course and attest to the fact that he or she is under the care of a state-licensed physician for their medical conditions. For specific neurological issues like stroke, loss of consciousness without a specific known reason, or seizure disorder, then pilots pursuing BasicMed must certify every two years that they are under the care of a state-licensed specialist. Same thing for psychiatric-related diseases. And then every four years, the specialist or an internist needs to examine the pilots, complete a comprehensive medical examination checklist, and state that the pilot remains safe to fly.

Q: What is the likelihood that internists will encounter this exam request? Are some more likely than others to see these pilots?

A: Looking at the FAA data, last year there were approximately 98,000 Class III medical exams completed. There are some geographic regions with populations of more pilots, typically in areas where the weather is more conducive: the Southeast, particularly in Florida, Texas, and the Southwest. But there are a lot of private pilots throughout the country. For many pilots, FAA BasicMed provides a simpler alternative, especially for those in rural areas where there may be FAA-designated aviation medical examiner shortages. But regardless, internists asked to complete the paperwork should take the evaluation seriously and check with their practice risk managers, administrators, or legal counsel to review the level of exposure a specific practice is willing to bear.