It’s All in Your Head!

Hello, and happy spring! Although our winter was mild here in the Mid-Atlantic, many of you in the northern and far western climes may still have snow on the ground and less than tropical temps.  As I write this, Sun 'n Fun is underway in Florida, so the flying season has begun in earnest! 

While some policies in federal bureaucracies change rarely if ever, the FAA Office of Aerospace Medicine (OAM) is always looking at current medical literature and listening to their specialty consultants to determine the correct balance of “regulatory medicine” to assure the safety of the airspace, while reducing the amount of “stuff” needed to make a sound certification decision that keeps pilots flying.  As you have read in my columns before, the FAA’s primary mission is safety, as it should always be, but they are also committed to medically certificating as many pilots or prospective pilots as possible if it can be done within that margin of safety.

We live in a data-driven society, and it’s the data that is the “proof in the pudding.” A great example of that is the recently published report to Congress regarding the safety of the BasicMed program, which is now in its sixth year. That report, compiled by the FAA Flight Standards, the Office of Aerospace Medicine, and the Office of Accident Investigation and Prevention, confirms no difference in safety with comparing private pilots flying with BasicMed medical qualification to private pilots who fly with a third-class medical certificate.  Overall, the general aviation accident rate is at its lowest level in decades and has trended downward continuously since the 1990s.  This is a fact that all of us who fly GA in the national airspace system can be proud of! 

This fact, combined with the leadership of the FAA OAM and a very resolute team of FAA employees throughout the OAM line of business, allows the FAA to “loosen the reins” just a bit in their review of certain medical conditions that fall into the “red zone” of risk management.  Neurology pathology presents some of the more demanding medical challenges that often require an extensive review of records and imaging studies. 

Just about any neurological condition will require a standard “Neurologic Evaluation” as a key component of the review process. “Cerebrovascular disease “covers a spectrum of brain pathology that includes aneurysms, brain bleeds, tumors, and strokes or transient ischemic attacks (TIA).  These conditions pose a risk for impairment or incapacitation that understandably makes the FAA a bit more conservative, but keep in mind that FAA doesn’t have a “quota” system that limits the number of medicals they issue!  Everyone who applies gets a thorough, individualized review of their records before a decision is made.  That’s the way it should be.    

The risk with any brain insult is for seizure. Imaging studies would include brain MRI, CTA (Computed Tomography Angiography), or MRA (Magnetic Resonance Angiography).  The basic neurologic evaluation is an office evaluation with a board-certified neurologist, and depending upon the actual medical history, the imaging studies would be needed along with the treatment and hospital records. The late Jack Hastings, MD, one of my many mentors in aviation medicine, was a highly respected aviation neurologist and former FAA neurology consultant.  He always taught that in neurology, history is everything, because there isn’t always a “smoking gun” that leads to a diagnosis. When there isn’t sufficient evidence of the diagnosis, determining the risk for a subsequent event is more challenging, and that is how the FAA operates—determining an acceptable level of risk that keeps the system safe. To fill in the gaps, extensive testing is often the norm, and that need for data drives the review process and increases the time it takes to reach a decision.

In the case of stroke or TIA, the risk for a subsequent event is still there, and the FAA often requires a 24-month recovery and stabilization period before one can be considered for special issuance.  Pilots with this history are often caught off guard by this seemingly onerous recovery time, but there is sound logic behind that.  Not all strokes present the same way; some are very mild with symptoms no worse than tingling in the fingers or a mild but fast recovering muscle weakness. Other symptoms can be much more dramatic with speech impairment, loss of motor function on one side of the body, visual deficits, or worse.  The FAA wait time of 24 months is in place to provide the patient with plenty of time to recover neurologically from the deficits that resulted from the event. 

The neurological evaluation will often include a need for neurocognitive testing to assess the extent of the recovery and discovery of any residual neurologic deficits.  Neurocognitive testing for pilots is controversial in the aerospace medicine community, and the FAA is reevaluating the situations in which the testing would be required, but most cases involving the potential for neurologic deficit will require the assessment as part of the review process.

FAA Aeromedical is really striving to be more transparent and efficient.  They are making headway, but it is a big task to change a bureaucracy that has “done it this way for a long time.” 

Stay tuned.  As we become aware of the implementation of changes to the system, we will keep you in the loop.

Enjoy the spring flying!

Portrait of Gary Crump, AOPA's director of medical certification with a Cessna 182 Skylane at the National Aviation Community Center.
Frederick, MD USA

Gary Crump

Gary is the Director of AOPA’s Pilot Information Center Medical Certification Section and has spent the last 32 years assisting AOPA members. He is also a former Operating Room Technician, Professional Firefighter/Emergency Medical Technician, and has been a pilot since 1973.

Related Articles