Introduction

An FAA (Federal Aviation Administration) flight physical is a physical examination for "fitness of flight" performed by a physician who is FAA-trained, designated, and certified as an AME (Aviation Medical Examiner), of which there are approximately 2500 in the US.   These physicians are trained with an emphasis on examining and evaluating the medical entities that can cause "sudden incapacitation in flight and/or cause an interruption in the smooth flow of or threat to the safety of our nation's airspace." FAA flight physicals fall into three different classes, intuitively designated FIRST, SECOND, and THIRD, which are commonly printed/typed in all capital letters. The requirements and valid timeframe of the medical examination are dependent on the class of medical licensure, the airman's age, and Special Issuances (SI) or special circumstances. A FIRST or SECOND automatically defaults to a SECOND or THIRD after the valid timeframe of the FIRST or SECOND. AME's perform FAA Medical exams focusing on exam findings and take a medical history focused on things that may be considered aero-medically significant.[1][2][3] 

The HIMS (Human Intervention and Motivational Study) is a joint program between the FAA and aviation industry for initial evaluation usually followed by ongoing monitoring wherein there may have been issues with potential concerns about mental health or chemical dependency. HIMS exams and monitoring is weighted more heavily towards history and examination monitoring for sobriety, mental health, drug screening, and correlating reports such as, but not limited to, psychiatric, neuropsychological, pilot performance, flight instructor, AA, NA peer-pilots, and chief pilot.  

These examinations are not only performed on pilots but also on ATC's (Air Traffic Controllers)  ASI's (Aviation Safety Inspectors), who may or may not also be pilots. Holding an FAA medical certification is also a standard for a certain degree of overall health. Occasionally, individuals who are not involved in aviation at all are examined and given medical certificates. Examples of such persons are workers on offshore oil rigs where healthcare may be delayed, racecar drivers, and occasionally executives in organizations that cannot afford high-rate or unpredicted turnover in certain positions. Student pilots cannot fly solo without an instructor or another pilot until they have passed their medical exam and been issued an FAA medical certificate.

The Aviation Medical Examiner

Any physician (MD/DO) interested in becoming an AME is best suited by having an interest in aviation and an understanding of the concept of a forensic examination, as well as a love of learning and interest in all entities of medicine and capable of performing a comprehensive, thorough medical examination regardless of the Specialty of Origin (SOO). There is no residency training that is not acceptable to become an AME; board certification in the physician's primary specialty is required, and an unrestricted medical license in the state where the FAA medical exams are to be performed.   Regardless of SOO, the AME must be thoroughly competent in the ENT, ophthalmologic, neurologic, musculoskeletal, cardiovascular/cardiopulmonary, and psychiatric examination.

The AME must also be computer literate, fluent in English, be able to adapt to changing regulations/guidelines, and be tolerant of a degree of bureaucracy. Fellowships in Aerospace Medicine are available, but few programs have a small allotment of positions, and fellowship is not a requirement for AME certification.[4] The vast majority of AME's practice medicine full-time and do flight physicals in-between regular patients, and the FAA only requires ten exams per year to maintain certification. 80% of AME's perform less than 25 per year. There are very few AME's who do nothing more than FAA medicals as their primary job as a physician, but many AME's semi-retire from their SOO and restrict their practice to flight physicals as they scale back towards total retirement. The AME must understand that they are not there to diagnose or treat the airman, and while the AME is a doctor, they are not the treating doctor but often speak with the treating physician(s) regarding potential changes in a treatment regimen that make the difference between issuance of the medical vs. denial or deferral. The AME must understand they are a representative of the FAA and by follow-through the federal government when interacting with non-AME physicians in attempting to assist in the processing of FAA medicals and understand that the average non-AME physician most likely does not even know such as thing as an FAA AME even exists. The AME must recognize clinically significant deterioration of any serious condition that needs urgent or emergent treatment and reach out to the appropriate treating physician if indicated.

An AME often is but is not required to be a pilot. The AME reports to and is assisted by one of 9 Regional Flight Surgeons, who are then responsible to the Federal Air Surgeon (FAS) in Washington DC. The FAS is assisted by Deputy Federal Air Surgeon(s), and there is an additional International "Regional" flight surgeon (RFS). Any AME can contact any RFS or FAS for assistance, which is often helpful after 5 p.m. in the AME's respective time zone. AME's are well-supported by the RFS and OKC.

The AME Training and Progression

AME's are initially trained by the Federal Aviation Administration during a seven-day timeframe in Oklahoma City, OK. Advanced practitioners such as physician assistants and nurse practitioners are not eligible to be AME's, and as of this publication, there is no plan to authorize physician-extenders for certifying FAA medicals. This training is a comprehensive and universal review of every specialty and subspecialty from the standpoint of how they pertain to general aviation and maintenance of health rather than focus on direct treatment. This initial training involves what can be an enjoyable comprehensive review of all medical topics. Additionally, there is training in aeromedical-specific topics such as decompression, the decompression chamber, Time of Useful Consciousness (TOC), evacuation and rescue operations, accident investigation, common patterns of injury, and accident analysis. A static ground-based aircraft is used for simulated emergencies and fake "Hollywood Smoke," as well the option of another fuselage suspended over a swimming pool used in training airline attendants in emergency slide use and emergency evacuation into an aquatic environment. The AME trainee is shown how the FAA trains its inspectors, controllers, and administrators. The training is also heavily focused on federal rules and regulations appropriate to aviation and policy and procedure of being a designee of the Federal Government.   There are several written "open-book quizzes" and one final multiple-choice exam. The exam has a reputation of being difficult but fair,  well-covered in the training course. It does not seem intended to fail or "weed out" AME candidates but rather to train and prepare to pass an exam with the caveat that this is somewhat esoteric material. Very few physicians would pass the exam without taking the course. 

Following initial training and certification, the physician is designated a Junior AME and can perform SECOND and THIRD-class medicals for the next three years. During this timeframe, their examination decisions and documentation are evaluated, and the FAA visits them to inspect the office and equipment. Following this three-year timeframe, if the error margin is acceptable, the physician can petition to become a Senior AME and can examine the airman for and issue FIRST class medicals. At this point, the physician can register to be able to perform physical examinations for ATC's, ASI's, and other FAA employees. AME's are currently required to undergo online training known as MAMERC every two years and in-person training for three days every four years. This training covers various topics and tends to focus heavily on neurology and cardiopulmonary, but most major medical topics and guideline updates are covered. The chart of an examined airman may be reviewed periodically; If an AME is contacted, usually by email, identified errors and positive and negative feedback may be given. This training continues throughout the career of the AME. This is usually high-quality CME but may not count towards specific requirements in the AME's SOO.

The FAA maintains an archive known as the "FAA TV: AME Minute," which is a series of short videos covering various topics pertinent to AME exams that are a good review of salient points in training and often help explain guidelines to airmen. Physicians interested in becoming an AME could benefit from reviewing these videos. 

After three years as a senior aviation medical examiner, the AME can request training to be designated for the Human Intervention and Motivational Study (HIMS) program and be designated as an Independent Medical Sponsor (IMS) to assist with certification of an airman who has had difficulty with substance abuse, mental health issues, or needs special issuance surrounding antidepressant therapy.[5]   There are currently, The HIMS AME often works closely with a HIMS psychiatrist or a general psychiatrist familiar with aviation requirements following a specific template. Additionally, they work with a neuropsychologist designated by the FAA and certified to do the appropriate neuropsychological testing specific to aviation. There are currently only 112 FAA-certified HIMS neuropsychologists worldwide. The AME is also responsible for monitoring the airman, often with a portable breathalyzer, office-based encounters commonly requiring 14 random urine drug screens in a 12-month timeframe, and periodic reports to the FAA before and after the SI is issued. The AME is then responsible and held accountable for reporting deviations and concerns to the FAA. There are only 187 HIMS AME's in the US and 20 international HIMS AME's in 12 other countries at the time of publication.

"Think Twice" What the AME Candidate Should Know

The AME candidate leaves with a clear understanding that they have civil and criminal liability based on their decision(s) beyond medical malpractice, and that standard medical malpractice liability does not usually cover forensic exams.

Declining insurance reimbursements and patient sense of entitlement have led to a burst of "concierge programs," and many new medical school graduates are focused on cash-only business models, such as IV fluids and cosmetic procedures. The search for non-insurance-based reimbursement is almost an unfortunate necessity in the modern reimbursement climate. While there is no doctor without the potential to be a good AME, the reasons behind obtaining this designation should be carefully self-analyzed. Following initial training, the AME is left with an understanding that you are a designee of the Federal Government and your superiors are agents of the federal government, and there will be oversight and evaluation of your exams, and your designation can be rescinded based on your documentation, decisions or failure to fulfill training and currency requirements. The number of people killed in large commercial airplane crashes rose in 2020. Accident analysis and your role as an AME in prevention are emphasized. While the initial training provided to AME's by the FAA is an outstanding review of nearly every aspect of medicine, portions of the training cover unpleasant, sad, graphic, and preventable disasters wherein the AME was responsible or had the opportunity to prevent the incident, are appropriately discussed. At the end of this initial training, the AME candidate is left with a strong understanding of just how serious their responsibility is to the airmen, vulnerable passengers, vulnerable people on the ground, the United States, and humanity in general. During training, the question is posed of "How many people can an impaired surgeon kill at one time compared to how many people a 777 can kill based on one bad decision?"  Other questions were asked about what the passengers expected and how they felt when they fastened their seat belts. The AME candidates were asked to think about the phone calls we made as a passenger on our way to this (the training that day)  or any conference to which we took air travel, and when the door to the plane was closed, we were asked what degree of trust and control we had over the situation and "You were worried about peanuts or chips, not if your pilot was sober, unhealthy or insane."

The AME needs to take one of two three-day courses, one strongly weighted towards neurology and the other strongly towards cardiovascular, every five years. Also, to do an online re-training every two years. The courses are free to the AME, covered by taxpayers, and the CME counts towards a regular medical license (Cat 1A), but travel and other expenses are the responsibility of the AME just like any other conference.

Additional considerations for any doctor wanting to be an AME is understanding the basic pilot mentality and personality profile, which can range a wide gamut from narcissistic, impulsive adrenaline-junkies to extremely professional, almost rigid captains who are extremely methodical and very used to being in control of everything.  

The average pilot is intelligent, dedicated, hard-working, respectful of authority, and usually of a slightly higher economic and educational status simply due to the cost requirements and opportunities to get into aviation. The AME should understand the delineation between  GA (General Aviation) pilots who fly for business, pleasure, and some degree of reimbursement as a flight instructor or persons who have a small airplane and fly mostly on weekends in good weather conditions to things like pancake breakfasts, another type of GA pilot that may have a more technically advanced aircraft with higher performance who flies predominantly for business 250 miles or longer and has additional rating making them able to fly the aircraft purely by reference to flight instruments, and then the truly professional pilot who has achieved the highest rating possible known as the ATP (Airline Transport Pilot) which is often referred to as the "Ph.D. in aviation."

ATP pilots are full-time professional pilots who are as involved and professional as any cardiothoracic or neurosurgeon at a quaternary center. Many are highly-disciplined, elite ex-military, and are accustomed to, comfortable with, and do not flinch at the responsibility of having several hundred lives in their hands, flying 12 or 14-hour flights internationally, and landing safely and smoothly in utterly abhorrent weather conditions. The AME, their office, and staff must be able to interact with and serve all these personality profiles both in person and on the phone or email.

MedExpress

The FAA maintains a site known as MedExpress. The student pilot is usually introduced and instructed by their flight instructor to set up an initial account that follows the pilot throughout their lifetime. The student pilot or established pilot will log in before the exam and do the initial entry or update of their current medical history and demographics in what is known as the 8500 form. The 8500 form is not unlike any "new patient paperwork" filled out when seeing a new primary care provider. They then save their information or update, and a unique code for that exam is generated and valid for 90 days. They bring this code to the exam, and the AME logs in to the AME's account, enters the code from the pilot or student pilot, and the chart populates. The AME then reviews the history, confirms ID and demographics then enter the exam portion of the encounter. This is similar to an EMR, but there is no impression or plan section. The AME then submits the completed exam to the FAA electronically as either Issued, Denied, or Deferred for further review. If issued, the AME can print the medical certificate, sign it as the AME and have the pilot or student pilot sign it. The pilot/student pilot then leaves with the certificate in hand.   AME's are permitted "designees," usually staff members who log in and enter demographic data and vitals but cannot enter any other exam information.

Specifics of the Aviation Medical Exam

All exams start with basic demographics, height, weight, BMI calculation, vitals, general medical exam of heart, lung, abdomen, and what one would consider a basic internal medicine and neuromusculoskeletal annual exam.[6] Scars, tattoos, and any distinguishing body markings must be noted. The exam is documented online by checking normal or abnormal in 24 boxes, in addition to vision and hearing, corresponding to exam items, then providing comments on any abnormals.   Color vision, visual fields, Near and distant vision, and optic fundi examination are completed. Heterophoria testing is required for all SECOND AND FIRST CLASS medicals. Intermediate vision is necessary for SECOND and FIRST class medicals after age 50. An external anal exam for hemorrhoids is performed, but the digital rectal exam is not required. Females do not require a pelvic exam. Urine dipstick is performed for protein and glucose only with no drug screen. BMI and OSA (obstructive sleep apnea) risk are assessed on all airmen, and all airmen are placed into one of six categories regarding their OSA status. Hearing requirements for all three classes are simply a "conversational speech test" with the AME's back turned to the candidate.   ATC requires audiometry at 500, 1000, 2000, 3000, and 4000 Hz. A 12-lead EKG is only needed for FRIST class medicals, initially at age 35 and then yearly after age 40, and must be transmitted electronically as a PDF.   Military flight physicals do not apply to the civilian world and vice versa.  

As a forensic exam, the FFA medical is not covered by insurance, and prices roughly range from 100 to 200 USD. EKG is usually an add-on cost of 25 to 50 USD. Many airlines have fixed reimbursement for their airmen getting FIRST class medicals. With no published reference,  estimates 170 USD average for FIRST class medical with EKG, 120 USD THIRD class, and uncomplicated SECOND class medical. ATC exam pricing is fixed by the FAA at 170 USD for controllers who are federal employees, although some ATC are not federal employees.   FAA employee reimbursement for a new potential ATC candidate with a full audiogram and EKG is  190 USD at the time of this edit. HIMS program can be anywhere from 8000 USD to 15000 USD over a 1-3 year time frame with a complicated cost breakdown. These numbers vary based on geography. 

Aeromedicine consultation, which is not an FAA medical but consultation leading up to possibly applying for an FAA medical or advice to go in the direction of Sport Pilot and/or pursue other life interests, is commonly billed at the same price as a THIRD class medical. Usually, within one hour of exam and chart/case review, it becomes evident that the candidate will or will not ever be able to obtain a medical and what barriers are evident, but this is ultimately not the decision of the AME. Occasionally, an aeromedical consultation is requested for such a minor medical issue, such as a CACI issue like HTN or simply needing reading glasses. The aeromedicine consult is converted to an FAA medical exam, and a medical may be issued that day.

There is a section of the exam where the AME can type general comments below a place where the airman can enter general comments about their medical history. There is a section for "other tests" that may be performed by the AME, such as SaO2 (pulse oximetry), all of which require a comment.  

All medical requirements are publicly accessible in "The Guide for Aviation Medical Examiners," often referred to simply as "the Guide," which can be found in PDF format from any internet browser. AME's and persons involved in assisting airmen with getting their medical certificates, such as aviation attorneys and other pilot advocates, need to make sure they have the most recent copy of "the Guide," which is under constant revision. Another resource for such persons and agencies is the "Federal Air Surgeons Medical Bulletin," which is a quarterly publication with case studies, topics of interest, and proposed or impending changes to federal policy.

This guide is periodically updated, and when the examiner logs onto their MedExpress account to do a flight physical, all updates are mandatory acknowledgments before being able to progress to the main website to issue or document an exam.

The Outcome of the Exam

The result of the exam is either Denial, Deferral, or Issuance. Cases of issuance may have restrictions such as the requirement for vision correction, not valid above a certain altitude, not valid for night flight, or only valid for a period of time less than the length of time the class of medical would usually be valid. Such as in the case of monitoring. The AME may issue the medical, and the pilot gets a letter from the FAA either requesting additional information or, if the AME made an error, a notice of withdrawal of the medical. It should be noted that the medical certification does not mean the student can fly solo. The decision as to when the student can fly solo is made by the instructor/flight school. The medical certificate is simply one mandatory requirement before being allowed to fly a plane alone without another pilot or instructor. This is referred to as "executing PIC (Pilot in Command) privileges."

Issues of Concern

Underlying Medical Conditions

Most underlying medical conditions are not necessarily disqualifying. Simple osteoarthritis or the need for near vision correction along with various underlying medical conditions may qualify outright, require Conditions AME's Can Issue (CACI), or require SI (Special Issuance) (SI).[7]

Seldom is a medical denied outright. Noting that issuance of a medical requires that the airmen "May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges"  means that entities such as terminal metastatic disease, rapidly progressive multiple sclerosis, or structural cervical stenosis with myelopathy would be cases for denial. Denial by the AME is discouraged by the FAA and requires an additional letter to the FAA. Deferrals are common in many medical conditions, such as coronary artery disease. The candidate usually gets follow-up correspondence from the FAA, usually certified letter, following the deferral outlining exactly what else is required for review, such as hospital records, labs, stress tests, echocardiogram, etc., commonly with a 60 to 90-day deadline. It is not uncommon for several reviews and requests to go back and forth with the FAA requesting additional information based on the ongoing review. The AME must be tolerant of this process and be able to explain and counsel the candidate through the process. It is not uncommon to request an extension to the deadline. If there is no response to the request from the FAA, then the medical is invalidated or denied outright for what is considered to be "failure to provide."

SI  (Special Issuance)

There are 15 FAA "Disqualifying Conditions"; however, in many cases, when the condition is adequately controlled, the FAA will issue medical certification contingent on periodic reports. This is known as a Special Issuance. The AME is responsible for the actual exam and makes the deferral. The FAA responds, noting what they need, and the AME may or may not help in the response to the FAA. The FAA then makes the SI or denies outright based on the information they get. In the case of the SI, the FAA does the actual issuance of the medical certificate, which bears the signature of one of the regional flight surgeons. The initial SI insurance outlines what the AME needs to do for subsequent medical issuances for the duration of the SI. A FIRST class SI for CAD through a senior AME or an SI thought a HIMS AME for a history of more than one episode of driving under the influence are both examples of SI. The initial letter from the FAA for the SI outlines exactly what is to be done at the time of the repeat SI (reports from counselors or peer pilots, reports of echocardiogram and stress tests, etc.) and notes the valid period, usually six months or one year, rather than the standard time frame for the class medical. The SI usually does not revert to a lower class of medical certificate when it is past the designated SI time frame. A FIRST class medical issued for CAD often has the restriction "not valid for any class after six months"  The AME then follows the FAA outline, and the AME is responsible for communicating deterioration in the SI condition and has liability outside of medical malpractice if they fail to do so.

CACI (Conditions AMEs Can Issue) 

CACI is a group of conditions that allow AMEs to regularly issue, without correspondence back and forth to the FAA, whether the applicant meets the parameters of what is known as a CACI Condition Worksheet. There are currently 19 CACI conditions that can be found in "the Guide."  These are not disqualifying conditions but rather cases such as stable, retained nephrolithiasis controlled HTN or hypothyroidism. The worksheets provide detailed instructions to the examiner and outline condition-specific requirements for the applicant.[8] This is not the same as an SI. If all the CACI criteria are met and the applicant is otherwise qualified, the AME may issue it on the first exam or the first time the condition is reported to the AME without contacting AMCD/RFS. Document the appropriate notes in the area known as Block 60 of the 8500 and keep the supporting documents with the AME. They do not need to be submitted to the FAA at the time of the issuance but need to be kept in a file by the AME. If the requirements are not met, the AME must defer the exam and send the supporting documents to the FAA. If an astute physician were to look at the guidelines on the flowsheet for the conditions, they would likely find that these are very reasonable up-to-date medical guidelines that comply with standard-of-care in whatever area of medicine they fall.

Medication Use

The FAA maintains a list of acceptable medications, all of which require a period of monitoring. Certain medications in combination are not permitted, and certain meds such as clonidine, all, and any chronic use of any controlled substances are not permitted.[9] Insulin-dependent diabetes mellitus is an absolute contra-indication for a FIRST class medical due to the risk of hypoglycemia, but an IDDM may potentially qualify for SECOND or THIRD class medicals with an initial SI. Medications that can cause drowsiness are the most common drugs found in a deceased pilot at autopsy in the FAA's report on incidental autopsy findings produced in September 2018. These medications are permitted after six half-lives, while a list of approved medications is identified in the Air Force Aerospace Medicine Approved Medications list. The most common drug found at autopsy is diphenhydramine.

Acute vs. Chronic Conditions

Acute issues such as upper respiratory infection and orthopedic fractures are the airman's responsibility to ground themselves until they are healthy and recovered. Many airlines have their own policy on returning acutely ill/injured pilots to active flight status. An airman who needs an elective procedure such as cosmetic surgery colonoscopy is permitted to return to flight status once they are fully recovered, off all medications such as pain meds, but pilots may elect to consult their AME regarding return to flight status. Airlines often have their own guidelines on these return-to-cockpit timelines.

Pregnancy

The FAA has little to say about medical status and pregnancy leaving it to a discussion between the woman and her OB/GYN. Pregnancy under normal circumstances is not disqualifying, and generally, pregnancy during air flight is considered safe.[10][11] It is recommended that the applicant's obstetrician be made aware of all aviation activities so that the obstetrician can properly advise the applicant. The Examiner may wish to counsel applicants concerning piloting aircraft during the third trimester. Few flight instructors will knowingly take a pregnant student up in an aircraft for numerous reasons. It should be noted that pregnant flight students/pilots can take and pass ground exams and maintain proficiency in simulators until the period of confinement is over and the woman has recovered from the outcome of pregnancy.

Statement of Demonstrated Ability (SODA)

The FAA issues a SODA as an option for an airman with a "static non-progressive defect" to have an opportunity to demonstrate that their impairment is not AERO-medically significant. A SODA is often issued after a "Medical Flight Exam."  The most common SODA is issued for color vision deficiency where a local FAA representative observes a pilot identifying red, white, and green light gun signals from an air-traffic control tower.[12] This may or may not require flight. Other examples are monocular vision and amputated limb with or without a prosthetic limb, which may require that the limb must be worn while executing PIC privileges. The AME does not perform the Medical flight Exam, but a designated pilot examiner or safety officer from the FAA who is obviously capable of safely flying the aircraft used in the Medical Flight Exam. The SODA does not need to be repeated with each medical, and airmen with  SODA will have it for a lifetime, and the number will need to be entered and noted on all subsequent medical exams. There have indeed been a number of "interesting" medical flight exams in the FAA history.

Equipment List

The FAA has a minimum equipment list that the AME must have available in their office. These include simple things such as a sphygmomanometer, stethoscope, otoscope and Ophthalmoscope, and Snellen eye chart. There are alternatives for the visual field, conjugate gaze testing, and color vision testing.   There are many "either-or" options and a list of several different types of vision tests that are acceptable. The FAA issues a mandatory standard near and intermediate vision card, and pre-paid envelopes for SI and CACI documents are provided on request.

Aircraft and Phase Considerations

The class of medical examination may also be related to the aircraft being flown. The THIRD class medical permits a pilot to fly any aircraft under 12,500 pounds (5670 kg) gross weight and less than three engines. Any flying that is done for hire, such as transporting passengers or paid cargo, requires SECOND or FIRST class certification, plus there are other requirements such as commercial rating, in addition to endorsements such as pressurized endorsement, and instrument rating, which is beyond the scope of this article but is mentioned because they should not be confused with medical class requirements.[13]   The medical certification alone does not qualify the pilot to fly any particular aircraft.  

The initial rating a pilot reaches is known as the  PPL (Private Pilot License),  and there are two initial phases of this training. Initially, a student pilot flies with an instructor. Then, that student flies solo, and they are not allowed to have anyone else in the aircraft which is not an instructor or another pilot that is not an instructor, in which case the student is merely a passenger. Eventually, the student passes their written and practical exams and earns their PPL, at which point is then allowed and takes passengers. During the initial phase of training with the instructor, the student is usually sent to get the medical exam. The medical exam is required before the first solo flight. Some aeronautical institutions, flight schools, colleges, and even private flight instructors require the medical exam before accepting and investing time and energy in the student. Additionally, financial aid programs may require passing the medical before considering funding aviation education.

Much the way a driver needs car insurance, pilots need aircraft insurance on personally owned aircraft. If hangered at an airport, the airport usually requires to be listed as "additionally insured." This is relevant because recent trends in insurance aviation have, in some cases, exceeded FAA requirements. There are currently no aviation insurance companies that will insure a pilot over age 70 in any aircraft with retractable gear, regardless of having a FIRST class medical. Some insurance companies may not accept "Basic Med," discussed later, in cases of "complex high performance" (defined as engine greater than 200 brake HP at sea level, flaps, variable pitch propeller, and retractable landing gear). They may even mandate the exam every six months for insurance purposes, and while the medical may be valid for two years, the airman needs to visit the AME and recertify if they want to continue to be insured. It should be noted that insurance is not a legal requirement. Many private airstrips and pilots are not insured but may not be permitted to land at certain airports for this reason.

Monocular Contacts

This topic warrants mention because it has been an ongoing source of confusion and unfortunate accidents.

Many persons will wear one contact in their non-dominant eye for near vision correction, enabling them to avoid wearing near-vision reading glasses. There is a specific question in the 8500 form " Do you wear near-vision contact lenses when flying?"   While this may be convenient for the average middle-aged person in their day-to-day life, it disables accurate depth perception, especially at relatively high speeds, and is thus an absolute no in terms of FAA medical certification. Such persons often end up with a restriction of "Must have near vision correction available" on their medical certificate and then wear low-profile "readers." Similar to driving a car, the pilot looks over them when looking out the cockpit window and looks down through them to read things such as maps and checklists in their lap. There are anecdotal reports of "teams" or couples that fly together often where one reads the near vision and the other does not. The PIC (Pilot In Command) is only one person, and that person needs to be able to manage all aspects of flight and handle the airplane alone. This includes reading instruments at the intermediate vision, reading charts using near vision, and looking outside the aircraft for distant vision. This should be differentiated from planes that require two pilots, often PIC ad SIC (Second in command), or more complicated aircraft that require other crew such as navigators, flight engineers who may need nothing other than near vision, but still need to hold a medical certificate.    

"Basic Med" a non-FAA THIRD class Substitute

Technically "Basic Med" is not an FAA or AME topic, but it is relevant to aviation medicine and the practice of the AME.

In addition to issuing a follow-up THIRD class medical to an airman with or without an SI, there is an option known as BM (Basic Med). Airmen requiring FRIST to SECOND class medicals are NOT able to execute those privileges under basic med. 

This is a comparatively recent program whereby any medical doctor, including an AME, can examine the patient, fill out actual paperwork, sign, and the airman effectively can fly as if they had a THIRD class medical. The airman needs to do an online course initially every two years and be seen by the MD/DO every four years. Two caveats are that they must have had a previously valid THIRD class medical, and their most recent medical cannot have been denied, deferred, or revoked. Again this is only the THIRD class and only after an initial certification by an AME. Pilots cannot do Basic Med as initial certification. There may be other factors to consider, such as aircraft liability insurance companies who routinely want to know about continued training, certification, and medical status of the pilot and aircraft they are insuring. It may substantially increase rates if the pilot is flying under Basic Med. Many medical doctors pause once they look at the paperwork and attestation they are asked to sign. Medical Mal insurance carriers were known to send policy clarifications to insured physicians; they are not covered for Basic Med. Likewise, many hospitals systems and large groups have made it clear they do not provide that service and recommend/refer to an AME. When redone year after year for stable disease, SI's often require additional testing and labs that may not be covered by health insurance. Such cases are often simplified by getting Basic Med. Pilots requiring a FIRST or SECOND class medical based on their job or the type of plane they fly are not eligible. 

Issues have arisen, and it is not uncommon for pilots who attempted to get a medical, had it deferred or denied, then went to a non-AME and got the paperwork filled out. While they may have the paperwork in hand, it is not valid. Furthermore, the course clearly covers under what circumstances the Basic Med is and is not valid, and, at the end of the course, there is an attestation to this effect. Pilots ignoring this or saying they "didn't know" when they had to pass a quiz about under what circumstances Basic Med is not valid as a defense in front of the NTSB, their insurance carrier, or any one of a number of regulatory agencies.

Clinical Significance

Most healthcare professionals are unaware that a pilot needs a separate medical certification from an FAA-designated AME or that such a thing as an AME even exists. There are cases of mid-level practitioners or other non-physicians writing something to the effect of "OK to fly the airplane" on a prescription pad or return-to-work slip, and the student pilot then brings this to their flight instructor thinking it is a valid "Flight Physical." There are cases of candidates being confused and setting up and getting Department of Transportation (DOT) exams thinking it is the same thing.

It is important to understand the difference between a clinical exam and a forensic exam. Similar to an IME (Independent Medical Exam) for Worker's Comp or Personal Injury, an FAA flight physical completed on a civilian, military/government pilot, or air traffic controller is not a medical clinical exam but rather a forensic examination. No diagnosis is made, and no treatment is rendered. As always, during the examination, clinical concerns may arise in the physician must report on them and or render any emergent treatment felt to be necessary to avoid further injury or impairment such as notation of melanoma, diastolic murmur, evidence of severe edema, or abnormal EKG.  

With such regular follow-up and strict guidelines, pilots, even ones with underlying disease, usually receive regular care and follow-up that they might not otherwise have gotten. Many take better care of themselves and are more mindful of their health simply so they can enjoy the hobby of flying or engage in their profession.