Ten aeromedical things
I wish pilots knew (that most don’t)
By Dr Brendan Adams of YBW Aeromedical Clinic - www.aviationdoc.com
Aviation lore abounds with stories of pilots summarily losing their flight privileges after running afoul of seemingly arbitrary, mysterious medical requirements. And yet, in my opinion, this usually wasn’t really the case.
Most of these stories have, at their root, one or more of the following ten factors I’m going to tell you about. I have been a Civil Aviation Medical Examiner for over thirty years and work for some of Canada’s largest airlines. In that time, I have watched these factors take out the majority of my pilots that lost their flight privileges due to a medical problem.
My purpose in reviewing them for you today is to allow you to benefit from the experience of others, and take corrective action while there is still time to influence the outcome.
I would stress the following represents my opinion, and my opinion alone. Other physicians may have their own particular views on these issues, and of course, I do not speak for Transport Canada, Civil Aviation Medicine.
1. Let’s start with your medical home. Do you have one? The concept of a “medical home” is a relatively new one, centering around your relationship between yourself, and your family physician/primary health care team. I ran a very busy family practice for twenty year in Calgary, and so have a close affinity to family doctors and the kind of medicine they practice. In my opinion every pilot should have a family physician, even if the pilot is relatively young and free of ongoing health problems. I explain this to my pilot clients by stating “tell me about the car accident you’re going to have next week and the complex rehabilitation of your broken hip”. None of us plan to have major health events in our life, often they simply just happen. Trying to arrange a family physician, and establish any kind of working relationship or bond of trust, when you are in the middle of some medical calamity is nearly impossible. So job one is to find a family physician, which these days can take some doing, and ensure that you trust them and have discussed a health maintenance plan with them. Which leads us straight to point number two.
2. The concept of the “annual physical” has undergone substantial alteration and refinement down through the years. Most family physicians now custom tailor a health maintenance and disease prevention programme to the specific needs of each client. Assuming that you are basically healthy, and perhaps relatively young, very little needs to be done beyond ensuring that you don’t have any emerging genetically based diseases such as hypertension, some forms of heart disease and cholesterol problems. As we age, further prevention is added into this. Examples are annual fit testing (fecal occult blood to screen for bowel cancer), prostate exams for males and a breast cancer prevention programme for females. Many forms of these diseases, if caught early, can either be prevented or nipped in the bud before they affect your flying career. These tests and exams are quite different and distinct from your licensing medical that you receive from a Civil Aviation Medical Examiner like myself. We are concerned about your fitness to fly for the next 6 to 12 months, not necessarily prevention of disease twenty years hence. As such, if you only do aviation medicals you will miss out on a lot of this health maintenance and disease prevention.
3. What are “the big five” that I see taking pilots out on an ongoing basis? The first, and most preventable, would be smoking. While the last couple of decades have seen smoking plummeting in popularity, it is still all too common among some segments of the aviation community. Now we are contending with vaping and cannabis smoking as further drivers of this behaviour. I view smoking as the number one preventable health issue that, if tackled early, can add many years to your flying career. The second one is hypertension (high blood pressure). Too many pilots have a strange misunderstanding that taking high blood pressure medication (antihypertensives) will invalidate their medical certificate. The exact opposite is true. Transport Canada accepts virtually all antihypertensive agents, provided that you do not experience untoward side effects, and by judiciously lowering your blood pressure to acceptable levels, you will prevent a whole host of cardiovascular complications such as stroke, heart attack, and some forms of peripheral vascular disease (“poor circulation”). The next is too much bad cholesterol (called hyperlipidemia). There are a series of interventions beyond the scope of this review article that can safely lower blood cholesterol and turn your lipid profile into a more desirable one. You are strongly encouraged to discuss this with your family physician. The fourth would be cancer in all its many varied forms. Again, cancer is not one disease but in fact a host of diseases, many of which can be screened for, or prevented using a variety of methods. This is where an individualized history, including a family history, is indispensable in deciding what forms of cancer you may be uniquely susceptible to, and designing countermeasures to deal with this reality. Lastly, and most commonly ignored, is mental health. This is being written in the heart of the Covid-19 pandemic and I routinely now see people severely stressed by the social and economic chaos this has caused. There are a variety of mental health promoting activities that can be undertaken by the pilot community, and again, you are strongly urged to explore these with a family physician that you know and trust.
4. There is one thing your family physician cannot really help you with, and therefore there is a second type of health practitioner that I strongly believe every pilot should have on their team. That is an optometrist, or even an ophthalmologist (optometrists, who are not medical doctors, do routine eye health and maintenance, as well as refractions, whereas ophthalmologists, who are surgeons, specialize in more in-depth eye diseases requiring surgical intervention. I have both for myself.). I believe under age 40, a pilot should consider having an eye examination every two years, and over age 40 this should be annually. These eye exams encompass simple measurements which are not done in family practitioner’s offices, such as eyeball pressure (to monitor the development of glaucoma), and documentation of retinal health as well as the possible evolution of early cataracts. Advice can be given about proper ultraviolet and blue light filtration and corrective lenses to optimize eye performance in the flight environment. It is always terribly sad to see someone come in with glaucoma, which could have been prevented relatively easily years ago, and only got diagnosed because of loss of vision, by which point it is almost always too late to do very much.
5. So far, I have been quite complementary towards family physicians, which is honestly the way I feel. Things are not always perfect however. There is one area where I would issue a strong caution to pilots - that is that your family physician does not know the aviation environment, nor do they know the Canadian Aviation Regulations. They do their best, but they are often advising you based on their understanding of operating a car or motorized equipment, rather than an aircraft. Almost weekly, I have a pilot come before me who was told that a certain medical condition, or certain medication, would be quite acceptable to fly with, and that is not the case. In the worst-case scenario we are now facing a lengthy grounding of many months to withdraw from the medication or deal with the medical problem, when that could have been avoided. Before taking all but the most minor medications, please check with your Civil Aviation Medical Examiner to ensure that it will not affect the validity of your medical certificate. The prime offenders in this area are psychological drugs (antidepressants, tranquilizers), impairing medications including sedatives and painkillers, and specific medications, for instance Accutane (for acne) which is not accepted in the aviation environment.
6. This next one is a bit of “buyer beware”. If a mechanic told you that a certain, highly expensive repair was required on your aircraft, would you ask for a second opinion? I suggest that most of us would do exactly that. There are some diagnoses which are commonly made, in my opinion, too casually. Prime examples of these would be “major depression” and “attention deficit hyperactivity disorder” and “posttraumatic stress disorder”. If Transport Canada sees any of these diagnoses on your medical, there will be extensive documentation required, and likely a period of grounding while things are sorted out. That is not to say that these are not legitimate diagnoses, they most certainly are, but they should only be made with an adequate interview/examination, often entailing several visits, perhaps specialty consultation, and a great deal of back-and-forth consultation between the doctor and the patient. Never be shy to ask for a second opinion or a second look before being saddled with what may be a challenging diagnosis in terms of your medical validity. This goes double for taking medication for these diagnoses.
7. The other issue which has only emerged in the last decade as an entire discipline within medicine itself, is sleep. We spend approximately one third of our lives sleeping, and yet until recently, this vast area of human endeavor has largely gone unstudied. Sleep disorders are responsible for daytime tiredness and accidents. In addition, specific conditions like obstructive sleep apnea and periodic limb movement disorder are things that Transport is taking a renewed interest in. Previously, pilots suffering from obstructive sleep apnea merely had to report this, and were rarely asked any specific questions. Over the past year I have found Transport is now sending out detailed questionnaires to each pilot suffering from obstructive sleep apnea asking for some very specific testing and results. Any pilot suffering from these conditions, or suspecting that they might, should familiarize themselves with the new reporting and treatment requirements. Your Civil Aviation Medical Examiner can help you with this.
8. So far, we’ve been focusing on disease, but another common factor that takes out too many pilots is accidents. Interestingly, these are almost never aviation related. In my entire thirty years of practice I think I have only seen less than half a dozen pilots seriously injured by something that happened in an airplane or around aircraft. The number one culprit seems to be home renovations. I have seen several penetrating injuries of the eye from flying metal particles (radial saw, hammering on metal), sustained without the use of eye protection. I have seen lots of traumatic amputations from industrial and farm accidents, often stemming from lack of personal protective equipment. Just remember that you are an “A model” human. They don’t make spare parts for you, and once something is damaged beyond repair, it’s permanent. Focus on eye protection, fall protection, helmets, proper protective gloves and what ever other personal protective equipment is recommended for the activity you are about to engage in. Your flying license will thank you!
9. These last three aeromedical issues now focus on the specifics of Transport Canada and your licensing exam. The first, problematic behaviour I see is the concealed diagnosis. There was an old joke in aviation that every pilot has two doctors, one they tell the truth to and the other is their Civil Aviation Medical Examiner! In the modern days of the electronic medical record all of your Provincial health care tests, consultations and hospitalizations flow into the electronic records of the Examiner. I have had heartbreaking cases where pilots concealed a significant issue in their past, which might have been proactively dealt with, only to find it emerged much later in their flying career and caused, at the very least, a significant interruption. The worst-case was someone who concealed a seizure disorder, and after spending almost $70,000 on a multi-engine instrument rated commercial license found himself permanently grounded. While the temptation may be to gloss over something that has happened in your past, believe me, it is better to get it out in the open, effectively dealt with, and then it will not come back to haunt you. Remember, the other issue in a concealed diagnosis is that it invalidates your insurance. You do not want to find yourself in the ugly position of having smacked the wingtip of a passing Learjet and have an insurance company come after you for every penny you own to pay the $1 million repair bill!
10. The next low percentage move which is the bane of my existence is the pilot who ignores the Transport Canada letter requesting further information. There are a variety of medical conditions, diabetes comes to mind, where Transport issues a fairly standardized form letter telling you exactly what testing and reporting they want on an annual basis. It is vexing to deal with the pilot who comes in, medical after medical, with none of these tests or consultations arranged, and then expresses frustration to me when their medical renewal is held up for many months while we await the things which could have already been done or underway. Like most bureaucracies, Transport Canada hates to be ignored. You may thoroughly disagree with them, and I’m sympathetic to your point of view, but it doesn’t change the fact that you’re going nowhere until you give them what they’ve asked for. If you’re confused about how to go about getting the various appropriate consultations or tests, your Family Practitioner or Civil Aviation Medical Examiner can advise.
There you have it. My top ten list of things you can do to prolong your flying career and make it more stress-free and enjoyable. I hope you found this helpful and look forward to seeing you in the sky as we both do that thing we love.
Dr Adams is an instrument rated commercial pilot, first licenced in 1974, who flies a Mooney 231. He practices aviation medicine at YBW Aeromedical Clinic and his website is www.aviationdoc.com
My purpose in reviewing them for you today is to allow you to benefit from the experience of others, and take corrective action while there is still time to influence the outcome.
I would stress the following represents my opinion, and my opinion alone. Other physicians may have their own particular views on these issues, and of course, I do not speak for Transport Canada, Civil Aviation Medicine.
1. Let’s start with your medical home. Do you have one? The concept of a “medical home” is a relatively new one, centering around your relationship between yourself, and your family physician/primary health care team. I ran a very busy family practice for twenty year in Calgary, and so have a close affinity to family doctors and the kind of medicine they practice. In my opinion every pilot should have a family physician, even if the pilot is relatively young and free of ongoing health problems. I explain this to my pilot clients by stating “tell me about the car accident you’re going to have next week and the complex rehabilitation of your broken hip”. None of us plan to have major health events in our life, often they simply just happen. Trying to arrange a family physician, and establish any kind of working relationship or bond of trust, when you are in the middle of some medical calamity is nearly impossible. So job one is to find a family physician, which these days can take some doing, and ensure that you trust them and have discussed a health maintenance plan with them. Which leads us straight to point number two.
2. The concept of the “annual physical” has undergone substantial alteration and refinement down through the years. Most family physicians now custom tailor a health maintenance and disease prevention programme to the specific needs of each client. Assuming that you are basically healthy, and perhaps relatively young, very little needs to be done beyond ensuring that you don’t have any emerging genetically based diseases such as hypertension, some forms of heart disease and cholesterol problems. As we age, further prevention is added into this. Examples are annual fit testing (fecal occult blood to screen for bowel cancer), prostate exams for males and a breast cancer prevention programme for females. Many forms of these diseases, if caught early, can either be prevented or nipped in the bud before they affect your flying career. These tests and exams are quite different and distinct from your licensing medical that you receive from a Civil Aviation Medical Examiner like myself. We are concerned about your fitness to fly for the next 6 to 12 months, not necessarily prevention of disease twenty years hence. As such, if you only do aviation medicals you will miss out on a lot of this health maintenance and disease prevention.
3. What are “the big five” that I see taking pilots out on an ongoing basis? The first, and most preventable, would be smoking. While the last couple of decades have seen smoking plummeting in popularity, it is still all too common among some segments of the aviation community. Now we are contending with vaping and cannabis smoking as further drivers of this behaviour. I view smoking as the number one preventable health issue that, if tackled early, can add many years to your flying career. The second one is hypertension (high blood pressure). Too many pilots have a strange misunderstanding that taking high blood pressure medication (antihypertensives) will invalidate their medical certificate. The exact opposite is true. Transport Canada accepts virtually all antihypertensive agents, provided that you do not experience untoward side effects, and by judiciously lowering your blood pressure to acceptable levels, you will prevent a whole host of cardiovascular complications such as stroke, heart attack, and some forms of peripheral vascular disease (“poor circulation”). The next is too much bad cholesterol (called hyperlipidemia). There are a series of interventions beyond the scope of this review article that can safely lower blood cholesterol and turn your lipid profile into a more desirable one. You are strongly encouraged to discuss this with your family physician. The fourth would be cancer in all its many varied forms. Again, cancer is not one disease but in fact a host of diseases, many of which can be screened for, or prevented using a variety of methods. This is where an individualized history, including a family history, is indispensable in deciding what forms of cancer you may be uniquely susceptible to, and designing countermeasures to deal with this reality. Lastly, and most commonly ignored, is mental health. This is being written in the heart of the Covid-19 pandemic and I routinely now see people severely stressed by the social and economic chaos this has caused. There are a variety of mental health promoting activities that can be undertaken by the pilot community, and again, you are strongly urged to explore these with a family physician that you know and trust.
4. There is one thing your family physician cannot really help you with, and therefore there is a second type of health practitioner that I strongly believe every pilot should have on their team. That is an optometrist, or even an ophthalmologist (optometrists, who are not medical doctors, do routine eye health and maintenance, as well as refractions, whereas ophthalmologists, who are surgeons, specialize in more in-depth eye diseases requiring surgical intervention. I have both for myself.). I believe under age 40, a pilot should consider having an eye examination every two years, and over age 40 this should be annually. These eye exams encompass simple measurements which are not done in family practitioner’s offices, such as eyeball pressure (to monitor the development of glaucoma), and documentation of retinal health as well as the possible evolution of early cataracts. Advice can be given about proper ultraviolet and blue light filtration and corrective lenses to optimize eye performance in the flight environment. It is always terribly sad to see someone come in with glaucoma, which could have been prevented relatively easily years ago, and only got diagnosed because of loss of vision, by which point it is almost always too late to do very much.
5. So far, I have been quite complementary towards family physicians, which is honestly the way I feel. Things are not always perfect however. There is one area where I would issue a strong caution to pilots - that is that your family physician does not know the aviation environment, nor do they know the Canadian Aviation Regulations. They do their best, but they are often advising you based on their understanding of operating a car or motorized equipment, rather than an aircraft. Almost weekly, I have a pilot come before me who was told that a certain medical condition, or certain medication, would be quite acceptable to fly with, and that is not the case. In the worst-case scenario we are now facing a lengthy grounding of many months to withdraw from the medication or deal with the medical problem, when that could have been avoided. Before taking all but the most minor medications, please check with your Civil Aviation Medical Examiner to ensure that it will not affect the validity of your medical certificate. The prime offenders in this area are psychological drugs (antidepressants, tranquilizers), impairing medications including sedatives and painkillers, and specific medications, for instance Accutane (for acne) which is not accepted in the aviation environment.
6. This next one is a bit of “buyer beware”. If a mechanic told you that a certain, highly expensive repair was required on your aircraft, would you ask for a second opinion? I suggest that most of us would do exactly that. There are some diagnoses which are commonly made, in my opinion, too casually. Prime examples of these would be “major depression” and “attention deficit hyperactivity disorder” and “posttraumatic stress disorder”. If Transport Canada sees any of these diagnoses on your medical, there will be extensive documentation required, and likely a period of grounding while things are sorted out. That is not to say that these are not legitimate diagnoses, they most certainly are, but they should only be made with an adequate interview/examination, often entailing several visits, perhaps specialty consultation, and a great deal of back-and-forth consultation between the doctor and the patient. Never be shy to ask for a second opinion or a second look before being saddled with what may be a challenging diagnosis in terms of your medical validity. This goes double for taking medication for these diagnoses.
7. The other issue which has only emerged in the last decade as an entire discipline within medicine itself, is sleep. We spend approximately one third of our lives sleeping, and yet until recently, this vast area of human endeavor has largely gone unstudied. Sleep disorders are responsible for daytime tiredness and accidents. In addition, specific conditions like obstructive sleep apnea and periodic limb movement disorder are things that Transport is taking a renewed interest in. Previously, pilots suffering from obstructive sleep apnea merely had to report this, and were rarely asked any specific questions. Over the past year I have found Transport is now sending out detailed questionnaires to each pilot suffering from obstructive sleep apnea asking for some very specific testing and results. Any pilot suffering from these conditions, or suspecting that they might, should familiarize themselves with the new reporting and treatment requirements. Your Civil Aviation Medical Examiner can help you with this.
8. So far, we’ve been focusing on disease, but another common factor that takes out too many pilots is accidents. Interestingly, these are almost never aviation related. In my entire thirty years of practice I think I have only seen less than half a dozen pilots seriously injured by something that happened in an airplane or around aircraft. The number one culprit seems to be home renovations. I have seen several penetrating injuries of the eye from flying metal particles (radial saw, hammering on metal), sustained without the use of eye protection. I have seen lots of traumatic amputations from industrial and farm accidents, often stemming from lack of personal protective equipment. Just remember that you are an “A model” human. They don’t make spare parts for you, and once something is damaged beyond repair, it’s permanent. Focus on eye protection, fall protection, helmets, proper protective gloves and what ever other personal protective equipment is recommended for the activity you are about to engage in. Your flying license will thank you!
9. These last three aeromedical issues now focus on the specifics of Transport Canada and your licensing exam. The first, problematic behaviour I see is the concealed diagnosis. There was an old joke in aviation that every pilot has two doctors, one they tell the truth to and the other is their Civil Aviation Medical Examiner! In the modern days of the electronic medical record all of your Provincial health care tests, consultations and hospitalizations flow into the electronic records of the Examiner. I have had heartbreaking cases where pilots concealed a significant issue in their past, which might have been proactively dealt with, only to find it emerged much later in their flying career and caused, at the very least, a significant interruption. The worst-case was someone who concealed a seizure disorder, and after spending almost $70,000 on a multi-engine instrument rated commercial license found himself permanently grounded. While the temptation may be to gloss over something that has happened in your past, believe me, it is better to get it out in the open, effectively dealt with, and then it will not come back to haunt you. Remember, the other issue in a concealed diagnosis is that it invalidates your insurance. You do not want to find yourself in the ugly position of having smacked the wingtip of a passing Learjet and have an insurance company come after you for every penny you own to pay the $1 million repair bill!
10. The next low percentage move which is the bane of my existence is the pilot who ignores the Transport Canada letter requesting further information. There are a variety of medical conditions, diabetes comes to mind, where Transport issues a fairly standardized form letter telling you exactly what testing and reporting they want on an annual basis. It is vexing to deal with the pilot who comes in, medical after medical, with none of these tests or consultations arranged, and then expresses frustration to me when their medical renewal is held up for many months while we await the things which could have already been done or underway. Like most bureaucracies, Transport Canada hates to be ignored. You may thoroughly disagree with them, and I’m sympathetic to your point of view, but it doesn’t change the fact that you’re going nowhere until you give them what they’ve asked for. If you’re confused about how to go about getting the various appropriate consultations or tests, your Family Practitioner or Civil Aviation Medical Examiner can advise.
There you have it. My top ten list of things you can do to prolong your flying career and make it more stress-free and enjoyable. I hope you found this helpful and look forward to seeing you in the sky as we both do that thing we love.
Dr Adams is an instrument rated commercial pilot, first licenced in 1974, who flies a Mooney 231. He practices aviation medicine at YBW Aeromedical Clinic and his website is www.aviationdoc.com
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