A problem of trust

I can hear you now: “Why? What for?”

Nothing devious. Many pilots on special issuance medicals are required to submit annual—and sometimes even more frequent—testing and consultation progress notes, which may not be readily available. Appointments with a cardiologist may take months and an echocardiogram may take even longer. Then the required information must be sent to the FAA, which has notorious long turnover times.

This is where having a BasicMed certificate comes in handy. You are not deferred or denied but, for lack of a better word, “pending” when these delays happen. You can still fly under the new BasicMed rules, which have increased weight limit to 12,500 pounds and six passengers, but still will not be able to go to the flight levels or more than 250 knots. At least you can still fly.

A standard special issuance is different from an AASI, which is an AME assisted special issuance. With an AASI, the AME can issue the medical on the spot if the criteria in the issuance letter from the FAA have been met. However, the caveat is that if a condition has changed in a way that the AME must defer to the FAA for issuance, you will not be able to use BasicMed in the interval because of the “deferral,” which is an exclusion for BasicMed.

The FAA has made some progressive changes (seems contradictory) in several areas. The CACI (conditions AMEs can issue) criteria for several conditions have been expanded so medicals may be granted on the spot with any paperwork, if required, to be sent in after the exam. The list of CACI conditions does not mean that all variations of these conditions can be issued by the AME, but the vast majority may be. AOPA is working with the FAA to expand the list of CACI conditions. As I mentioned in a previous column, the rules for mental health have been modernized to some extent (“Flight MD: Baby Steps,” December 2024 AOPA Pilot).

I have said multiple times that it does not make sense that a pilot on a coronary disease (heart attack) special issuance could have a cardiologist, who has personally examined the pilot, say they were fit to fly but the pilot would still have to undergo annual testing required by the FAA. As of May 29, 2024, the FAA will accept a completed form from a cardiologist certifying a pilot’s health without “check the box” testing. This is a major advancement. 

The FAA has also made a commitment to additional education of AMEs. However, this increase in education has no effect because of the use of strict template guidelines for most conditions. Most templates use a flow chart or a yes/no questionnaire the AME must follow. In almost all cases, the FAA says if AMEs have “concerns” for any reason, they should defer. However, conversely, the FAA does not allow the AME any latitude if one of the answers on the template is “yes.” A lot of time, money, and frustration would be eliminated if the AME had the option to say “yes, but….” Since most deferment cases eventually get their medical granted (about 99 percent according to the FAA), the months-long delays at the FAA would vanish if AMEs were allowed discretion.

The underlying problem is trust. The FAA does not trust AMEs, nor does it trust local providers like psychiatrists or other specialists. Persistent arrogance in Oklahoma City that reviewers there can evaluate a pilot just by requiring tests and reviewing medical records better than a provider or AME who has seen the pilot, interviewed the pilot, and examined the pilot is ludicrous.

A lot has changed and dramatically improved in the diagnosis and detection of diseases and conditions, which could affect a pilot in the aircraft environment since the last century. Twenty-first-century medicine has made these evaluations routine for non-aviation trained physicians. It is time for the FAA to enter the twenty-first century and stop the bureaucratic nightmare it needlessly creates for pilots.

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Dr. Brent Blue is a senior AME who flies out of Driggs, Idaho, near Jackson Hole, Wyoming. He flies a Cessna 185.