Basic medical vs a full physical: how much is enough?

 - May 7, 2008, 10:09 AM

A growing number of aviation medical professionals are questioning pilots’ reliance on their required annual (or, in the case of first-class medicals, six-monthly) medical examinations as their primary source of personal health monitoring. Chief among them are Annette Ruge, M.D., Ph.D, medical coordinator for the European JAA, who has gone on record as saying that even though the JAA’s medical regulations are stringent (in many ways more stringent than the FAA’s), a flight physical by no means tells pilots everything they need to know.

In a recent study published by the Flight Safety Foundation, Ruge cautioned aviators that while the aftermath of a successful flight physical leaves them “fit to fly, there are some sicknesses that will not be detected in an aviation medical examination. There is a difference between regulatory medicine and health care that is the private obligation of the pilot.”

When preparing their respective physical requirements, the JAA and FAA approach the issue with different general philosophies. The FAA’s requirements predate by decades those promulgated by the far newer rules of the JAA, whose medical regulations were developed well into the modern era of preventive, lifestyle-
oriented medicine. When those requirements were being developed, aerospace medicine authorities from some of the JAA member nations believed that the physical should not only determine whether the pilot was fit to fly during the time period covered by the medical certification, but that the exam carry with it the task of keeping the airman as healthy and alive as long as possible.

Dr. Warren Silberman, who manages the FAA’s Civil Aerospace Medical Institute’s Aerospace Medical Certification Division, routinely tells pilots that their personal health does not begin and end at the flight medical. “I tell them they shouldn’t expect their aviation medical exams to provide them with all the medical attention they require and that they should visit private physicians for preventative testing such as a cholesterol test, resting ECG, a rectal exam and, for women, a pelvic exam, a Pap test and a breast exam.

“This sort of preventive medical care is something I think people should do for themselves,” Silberman said. “Just what tests depends on risk factors, such as the pilot’s family medical history, personal medical history and age.”

Indeed, many veteran AMEs recommend their pilot patients undergo a complete physical with their personal physician a month or so before their flight physical, with the earlier visit intended for early detection of physical issues that may create more serious professional problems if left to detection by an AME.

“If you can, get your health issues taken care of before the flight physical,” said Dr. Arthur Madorsky, a long-time AME and pilot who has published a series of taped interviews and is a frequent guest on aviation-related talk shows on cable TV and radio. “If you can handle the problem before the physical with your AME, you can avoid going through the whole appeals process that comes with diagnosis of a showstopper.”

A Matter of Philosophy

The question of just how thorough a flight physical should be boils down to the purpose of such an exam. While the underlying methodologies seem to differ, the stated purposes of the FAA and JAA exams are the same–to eliminate the chances that a pilot will suffer a sudden incapacitating event, such as a heart attack or stroke, during the period in which the medical certification is in effect. To calculate those odds, the JAA uses what is called the “1-percent rule,” a rating developed during a series of workshops hosted by the UK Civil Aviation Authority throughout the 1970s and 80s.

The rule holds that all of a pilot’s risk factors, including incapacitation due to heart attack or stroke, are statistically weighted and numbered. And if that number amounts to less than 1 percent, the airman’s medical certificate is renewed. Part of this decision is an assessment of the candidates’ risk factors, such as age, hypertension and possibly elevated cholesterol.

For those with ratings nearly equaling one, a restriction or waiver limiting that pilot to roles other than PIC might be arranged. Ratings much higher than one would result in medical certification denial pending further administrative action.

The 1-percent methodology has not caught on in the U.S. Despite its reputation, the FAA is much more flexible with its medical certification standards, especially in the cardiovascular category, where the general guidelines have recently undergone substantial liberalization. “We’re aware of the 1-percent methodology,” said Silberman. “The FAA just doesn’t automatically rule out medical certification if there’s a greater than one rating.”

As for the fairness that may seem missing from the potentially arbitrary quality of the 1-percent rule, Dr. Claus Curdt-Christiansen, ICAO’s chief of aviation medicine, in an interview published by the FlightSafety Foundation, called the 1-percent rule “a good tool for flexibility” in cases where pilots fail to meet prescribed standards. “I can see a point in not excluding someone from flying if it can be shown tha