The Art and Science of Medicine: One Size Doesn't Fit All!

Our medical certification staff of six specialists has a combined 60-plus years of experience in the often-complex, bureaucratic, time-consuming, and frustrating process of satisfying the FAA safety regulators that we, that subgroup of homo sapiens aviators, are medically safe to occupy the national airspace. Knowledge is power, and knowing what to do and when to do it is so important in getting a good outcome.

Medicine is a multifaceted discipline. Most of us as patients and consumers of health care services and products know medicine “clinically.” We see the physician, nurse practitioner, lab technician who draws blood, or physical therapist in a clinical setting.

There’s also research medicine in which new medications are developed by pharmaceutical companies, treatment therapies are identified and studied for cancers, neurologic conditions such as Alzheimer’s and Parkinson’s, autoimmune diseases like rheumatoid arthritis, and genetic manipulation to predispose diseases before they attack our bodies, all through clinical trials at well-funded institutions around the country and internationally.

Administrative medicine is the business end of the healthcare industry that builds hospitals and treatment centers, standalone surgical centers, and urgent care centers that can keep people with less serious illnesses or injuries out of busy hospital emergency departments where the really sick people go.

Then, there’s “regulatory medicine,” the world we in the PIC medical certification group live and where pilots with medical hiccups find themselves when they receive a letter from the FAA asking for more information. The distinction between regulatory and clinical medicine is important to understand because it often puts the pilot in the middle of a philosophical and operational impasse between the treating physician – the “clinician” – and the FAA – the “regulators” – whose roles are sometimes in conflict with respect to the pilot caught in the middle.

Consider heart disease, one of the most common medical diagnoses affecting pilots in the US. Clinically, the pilot’s cardiologist is treating that disease with respect to symptoms, diagnostic procedures to assess the severity of disease and determine appropriate treatment, the patient’s ongoing quality of life with the goal of a favorable prognosis, and, not insignificantly, the overall appropriate recognized “standard of care” for the diagnosis. This becomes a consideration for pilots because health care providers, that is, insurance companies and hospital administrators, and medical ethics boards have input about what treatment and what is reasonable and appropriate.

 As long as the patient is symptom free, happy or as happy as can be expected, and has no clinical indications or a progression of the condition that could threaten quality of life, the treating physician is doing his or her job to render care within the constraints of the established standard if care.

Now, let’s say that patient with coronary heart disease that is partially obstructing one or more of the coronary arteries that supplies blood to the heart muscle has the standard diagnostic procedures, usually a treadmill stress test with nuclear perfusion scan or cardiac catheterization, or both. If that testing reveals obstructive lesions in the coronary circulation, blockages that reduce the blood supply through the affected artery, a condition called “myocardial ischemia,” the cardiologist determines the best treatment plan for the patient that meets the desired objectives mentioned above.

What if the patient with that history is having no chest pain, fatigue, or shortness of breath and responds to conservative treatment that might include medications, exercise, and diet changes? If the patient isn’t a pilot, it’s all good. However, that same patient who presents to the FAA a CVE, a cardiovascular evaluation, in support of a medical certificate is most likely going to be denied certification because of the findings of ischemia.

The FAA’s role in protecting the public and the national airspace has an additional layer of bureaucracy over and above the clinical evaluation of the available medical history – an assessment of risk of the pilot applicant having an incapacitating event during the time the medical certificate will be in force. In the case of our cardiac patient, the objective findings of ischemia on the stress test is considered an unacceptable risk for any class of medical.

It is this “crystal ball” forward-looking risk assessment that makes regulatory medicine so mysterious, confusing, and frustrating. In future articles, we will talk more about how the FAA exercises its authority to determine qualifications for medical certification.