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I was talking on the phone yesterday with a friend who’s had the distinct non-pleasure of going back and forth with the FAA about his special issuance medical. In the spirit of full disclosure, he has two health issues the FAA is concerned about, one, atrial fibrillation, that’s arguably justly concerning, and the other, prostate cancer that’s been treated.
This isn’t about what a morass of bureaucracy the FAA’s medical division is, and it is. Want to talk to a live person? Good luck. Want to leave a voicemail for them to follow up on? Ha! My buddy after all this time finally got the paperwork from the FAA for his special issuance, and it took nine months to do so, only to be informed by the FAA that his medical clock started ticking when he started the process not when he finished it, so all this work was for three months of flying. Then he gets to start again.
My even bigger issue is that the FAA is concerned about his prostate cancer, which isn’t there any more. The heart issues I get. If someone has a stroke or a heart attack—and they can come without warning—while flying, then it could be game over for everybody onboard, that is if he could no longer fly the plane and if the person in the other pilot position couldn’t fly it either. It’s exceedingly rare when that happens, maybe a couple of times a year, maybe a few more times that are suspicious but can’t be proven. Still, I get their concern, even if the risks aren’t very high. I mean, every time we go flying the engine could quit over a landscape of water and alligators, but we do it anyways. There’s risk.
But the prostate cancer is another issue altogether. With this one, what is the FAA really worried about? This is the slowest spreading cancer, and if it goes bad and the person gets sick, you can bet he is not going to be out flying. In short, it’s an illness that doesn’t have a sudden onset component and that the pilots affected by it will self regulate. So why is the FAA getting involved? You got me. I have to assume it’s because they’re big and powerful, so they can.
Just how important are flight physicals to safety of flight? I think they have a really minor impact on it. In fact, I wonder if aviation would be safer if every pilot instead of getting a regular flight physical attended a three-hour long presentation on how to avoid in-flight loss of control. If the FAA were to do that, the accident rate might not drop precipitously, but it would save more lives that flight physicals do.
How do I know this? I don’t. But the evidence strongly suggests that safety education results in fewer accidents and fewer deaths. Although they don’t publicize it much, the airlines have achieved a nearly perfect safety record due to the innovative safety programs they’ve adopted, not to mention the requirement that airline pilots get checked every six months, as opposed to every two years for most of us, or even less, depending on your age and the type of medical certification you opt for.
Ideally, politics and medicine would be separate disciplines (admitting that the term “discipline” is generous when applied to politics). Medicine is a science, and while it’s practiced imperfectly, the idea has its roots in the scientific theory. In medicine that translates into treating patients with medications and procedures that the evidence shows work and have the fewest associated risks. So as researchers study the effect of particular treatments, doctors can then modify their practices in order to come up with better outcomes.
Another central tenant of medicine is to do no harm. This can be tougher to stick to than you might think. To do no harm might be to avoid doing a surgery when doing it gives the patient worse odds than not doing it. Again, evidence based care rules the day, and individual outcomes and overall survival rates almost always increase, sometimes dramatically, when doctors use best practices based on hard evidence.
So let’s get back to the FAA and the subject of medical certification. If the FAA requires pilots to get a medical certificate to go flying a certified airplane, and they do, shouldn’t there be an evidence-based model to justify that decision? Who is benefitting? How many lives are saved? How long should pilots go between flight physicals, and what evidence supports those intervals? The answer to all of these questions is, we don’t have supporting data on any of those practices. So if the FAA keeps a pilot out of the cockpit because they’re taking a medication that’s on the agency’s banned list, right or wrong that is doing harm to the pilot, and if there isn’t any evidence showing that there’s an increased risk to the pilot or the public, then that’s unethical.
I don’t think it’s too much to ask for the FAA to provide supporting documentation for its medical determinations. After all, if the agency is making decisions based on what’s best for the public, it will be able to produce the evidence and that evidence will support those decisions, right?
In some cases, that’s certain to be the case. With pilots who’ve undergone major coronary surgery, the FAA would surely be able to find data to back up their determinations. The problem comes when they can’t find any supporting data or when the data they can find contradicts the FAA’s actual practices. In those cases, I think the agency should be required to amend their guidance to reflect the evidence.
BasicMed has proven a popular route to medical certification. It’s not as basic as I’d like, but when the FAA studies the safety implications of it, I’m guessing it will find that there’s been no loss of safety for pilots flying under BasicMed. That should be all the evidence it takes to make conventional certification a lot more basic itself.