By David Fletcher, MD
While nearly every occupational health program is looking to gain some competitive edge, especially during the COVID-19 pandemic, getting one of the providers designated as an FAA Aviation Medical Examiner (AME) is one way to offer an additional service line that is often overlooked by many programs and will help a program become even more elite.
Becoming a designated FAA medical examiner is like joining an exclusive club of physicians. Less than 0.3% of physicians nationwide are certified to perform aviation medical examinations. There are only 2,560 physicians out of nearly 985,000 practicing physicians nationwide designated as FAA medical examiners in the US. This small cadre of physicians performs exams on an estimated 664,565 active certificated pilots as of the end of 2019. This number has been declining gradually over the past several decades, down from a high of over 827,000 pilots in 1980 but is expected to rebound during this decade.
The onset of the “BasicMed” system has cut down the number of potential exams on private pilots. This system allows non-AME physicians to certify private pilots who used to get 3rd class exams. There are, however, still more than 300,000 1st class and 2nd class physicals performed each year. Only AMEs can perform these exams. The handful of physicians designated as AMEs who perform these 1st and 2nd class exams also had to perform expanded services, as 34,000 of these pilots were subject to special issuance exam requirements for various medical conditions that required additional medical documentation to certify a pilot to fly.
Aviation Medical Examiner Role in FAA Safety Management System
The Air Commerce Act of 1926 first mandated that all pilots be medically qualified to fly. Medical conditions, such as heart disease, epilepsy, and insulin-dependent diabetes, that could cause sudden incapacitation or could otherwise compromise aviation safety were disqualifying pilots from any class of medical certificate issued.
The FAA uses an Aviation Medical Examiner (AME) System to conduct medical examinations of airmen and apply medical standards prescribed in the Federal Aviation Regulations (FARs). AMEs are authorized to assess airman fitness and to issue, defer, or deny the issuance of FAA medical certificates.
Unlike the FMCSA system to certify truck drivers, where mid-level providers and incredulously chiropractors are permitted to certify truck drivers, only medical doctors can be appointed to become FAA medical examiners.
AMEs are specifically trained and designated by the FAA to give aeromedical physical exams and certification to civilian pilots and air traffic controllers. As a requirement, an AME applicant must first complete a 4 1⁄2-day Basic AME Seminar. The Basic AME seminars are conducted four times a year at the FAA Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma. The training seminar has the following objectives:
- Recognize the importance of the AME’s role in the overall goal of achieving aviation safety;
- Develop a clear understanding and recognize the importance of the medical certification process and the AME’s responsibilities in that process;
- Learn the airman medical certification standards and FAA policies and regulations;
- Review the latest medical and technical information and clinical examination techniques in the various medical specialty fields that an AME will need to use to assure that airmen meet the medical certification standards for the class of airman medical certificate applied for;
- Recognize the basis for disqualification of the airman with a medical problem and the conditions necessitating deferral or denial as outlined in the Federal Aviation Regulations;
- Understand, and be able to explain to an airman, the denial process to include steps necessary for certification appeal rights.
The impetus for me in 1995 to start the 1st physician training program for commercial driver medical exams at ACOEM’s America Occupational Health Conference came out of my FAA experience. The FAA provides a dedicated national system, ensuring pilot fitness for flying, which includes medical staff from the Regional Flight Surgeons (RFSs) and the Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma. The CAMI acts as a central medical certification and record repository for the FAA. The RFSs and CAMI staff review the examinations of AMEs and can pull an airman’s certificate if the AME has made an error. The fact that the FAA system is a national system prevents doctor shopping and allows an AME the ability to defer to CAMI to make the final determination about an airman’s medical certificate.
After working as an AME for several years, I began to advocate in the early 1990s that the Federal Highway Administration (now the Federal Motor Carrier Safety Administration) develop an FAA “look-alike” certification system for truck drivers. Unlike the current decision-making certification process for truck drivers, the FAA system allows the AME the option to defer to CAMI. This deferral process allows the AME to get a “consult” with the FAA Regional Flight Surgeon to assist with reviewing applicants who present with challenging medical issues before issuing certification.
As I reflect on some of my proposals from the 90s, when I served on the FHWA medical certification committee, many of my proposals morphed into the watered-down National Registry for Certified Medical Examiners (NRCME) system for truck drivers. New AMEs who also do FMCSA certification exams will understand quickly how superior and efficient the FAA system is for aviation safety.
AMEs get an annual report card that grades their performance (includes errors in decision-making, delays in submitting exams, etc.) and upgrades their performance. AMEs are subject to on-site audits by FAA support staff and sometimes even by RFS to ensure that the clinic has the correct medical equipment to conduct aviation examinations and the facility meets FAA quality standards.
The FAA’s Medxpress On-Line Medical Certification Process
The FAA’s MedXPress system requires anyone submitting an FAA Medical Certificate to electronically complete their medical application (FAA Form 8500-8) online. The application is then reviewed online by the AME to complete the physical examination, make comments on Block 60 about an applicant’s medical conditions, and make a final determination to certify or defer that pilot.
Unlike the current FMCSA Form 5785 (DOT Long form) which does not require the medical examiner to determine the risk of obstructive sleep apnea OSA in a truck driver, there is one whole page that requires the AME to make a determination about the pilot’s risk of (OSA).
Again, the AMEs who certify both pilots and truck drivers will wish FMCSA would adopt a MedXPress system for certifying truck drivers.
AMEs that identify applicants with disqualifying conditions must complete examinations within seven days via MedXPress, noting that there’s a problem. AMEs will often work with their pilots to be able to clear an applicant with a disqualifying medical condition by obtaining appropriate medical documentation. Once CAMI receives appropriate information a decision will be made regarding certification.
Just like the FMCSA system, there are “short cards” where a pilot with a certain medical condition has to be certified every year as opposed to a longer certification period. A good example is a pilot who has OSA can obtain a 3rd class medical certification by receiving an FAA Special Issuance certification from CAMI. However, the pilot must send in a letter from a treating physician noting that the OSA is adequately treated. The pilot must also sign a statement attesting to OSA treatment compliance, and finally submitting CPAP compliance data (FAA requires 6 hours a night of CPAP compliance). Take note, that pilots 40 and older must still renew a 3rd class medical certification every 24 months. After review, the pilot will receive a Special Issuance letter from the FAA (copying the AME on the letter). The letter assigns them a PI# which will follow them throughout their flying career, and it is also utilized as a private identifier to transmit information. The Special Issuance letter outlines all the requirements needed in order to maintain certification, including how often information must be reported to the FAA, through the airman’s AME, who will be authorized to do AME-Assisted Special Issuance (AASI) exams going forward in the future.
In addition to AASI exams, the AME may issue CACI certifications for minor medical conditions. Conditions AMEs Can Issue (CACI) is a series of conditions that allow AMEs to issue a medical certificate if the applicant meets the parameters of the CACI Condition Worksheet. For example, an AME can do a CACI certification for hypertension if the medication prescribed is on the approved list, the blood pressure is adequately controlled, and the airman denies any serious side effects.
How I Became an AME
Getting appointed to the elite class of physicians to certify pilots is challenging. I first became an aviation medical examiner in 1988. It was not easy then to receive an appointment because the private practice of medicine still was the dominant mode of practice and a lot of private practitioners relied on doing aviation medical exams for extra income. The FAA limits the number of physicians in a geographical area. Most physicians would not usually receive an appointment unless the area was underserved. In fact, the first time I applied I was turned down.
Undaunted by being turned down and having inside knowledge that one local AME was about to retire, I sought out the help of my local congressman Richard J Durbin (now Senator Durbin who is currently the Senate Majority deputy leader but back in 1988 represented the Congressional seat that used to be Abraham Lincoln’s in 1846). He advocated on my behalf and I was appointed to do 2nd and 3rd class exams. When the local senior aviation medical examiner was retiring, Senator Durbin wrote a letter to the FAA in 1989 recommending my appointment as a senior aviation examiner first in Decatur and later in Champaign, Illinois as well.
When I first started doing FAA exams in 1988 I had to use a manual typewriter to type exams on messy carbon-paperless 8500 exam forms. I had to type out the medical certificate and mail out exams to CAMI. For 1st class exams that required ECGs, I used an old analog coupler modem to transmit ECGs to CAMI which cost more than $5,000. Now fast forward 30 plus years and the FAA Medical system is a high-tech and mostly paper-free system, though the FAA still uses the secure FAX system for transmission of medical records.
How to Become an AME
The FAA only allows fully licensed physicians in good standing in their communities to be designated as AMEs based on training and experience, adequacy of facilities for performing the prescribed examinations, and the need for examiners in the geographic area. Training or experience in a particular medical specialty may sometimes be required because of agency needs. The responsibility and trust associated with designation as an AME may necessitate background investigation to determine the applicant’s personal and professional suitability.
Any non-military physician interested in becoming an AME should contact the applicable FAA Regional Flight Surgeon’s (RFS) office listed for your area. The RFS in your area is responsible for determining the current need for AMEs in their region.
I recommend any medical doctor interested in becoming an AME should first go online and research how many AMEs are in your area (designee.faa.gov/#/designeeLocator). If the area is underserved, your chances of being appointed are greater.
Registration, application, and approvals are handled through an online portal called the Designee Management System (DMS) which the FAA introduced in June 2014. DMS is a secure web-based portal designed to allow AMEs to have an active role in their management. DMS provides the AME with performance reports, location information, training information, a secure messaging center, and much more.
If you are appointed by the RFS to become an AME, you are required to attend the week-long Basic AME Seminar at CAMI. The Aeromedical Education Division of CAMI has designated the Basic AME Seminar as a continuing medical education (CME) activity that is valid for 32.5 credit hours in Category I of the Physician’s Recognition Award from the American Medical Association. The FAA does not charge a fee for attending the Basic AME Seminar. However, applicants must pay all personal expenses (travel, accommodations, and meals) associated with their training.
Along with the Basic AME seminar, subsequent training is required at three-year intervals. This training is available through 3-day weekend AME Seminars held at various locations in the United States though some AME training can be completed online and does earn Continuing Medical Education (CME) credits.
Renewal of the FAA appointment is contingent upon the interest of the AME, the accuracy and number of examinations performed, and compliance with the regulations and guidelines.
Business Side of AME Service Line
On average, I perform around 200 plus exams a year. The FAA does not dictate fees for AMEs with the only exception when the FAA hires an AME to conduct air traffic controller exams and there are set fees. I charge $150 for all classes of FAA medical examinations. There is an extra service charge for 1st class medical exams, as I must submit an ECG to CAMI. Our office requests that the fee be paid upfront at the time the exam is scheduled which has cut down on no-show visits. I do charge extra for services beyond just a standard FAA medical examination. For example, I charge for record review and authoring reports sent to CAMI on behalf of a pilot regarding special issuance (AASI) medical conditions. It is important to outline additional costs upfront to pilots who usually understand the necessity for additional fees. They need to understand the value of your time to advocate for them and navigate them through the FAA system by assisting with special issuance and other medical issues.
There are no guidelines concerning costs and pricing, other than the limits of what the FAA itself pays for an Air Traffic Controller (ATC) FAA exams are not bundled services. It is permissible to charge a fee for an exam one day and a fee to review records and reports at another, separate visit. Processing an AASI without performing an actual physical exam is still a professional fee. You should be paid for each service you provide.
Don’t be embarrassed to ask to be paid for your time as you belong to an elite specialized group of physicians who keep up to date with constant training and whose performance for meeting FAA standards is continuously monitored.
I refuse to do BasicMed exams because I believe that the program has negatively affected air safety. BasicMed allows physicians who have no training in aviation medicine to certify the flightworthiness of patients, who are often older males with multiple age-related medical conditions.
Often, I will have a pilot who will want an FMCSA certification as well as an FAA medical certificate at the same time. Though there is some overlap in the exams, it still requires the examiner to submit two separate exam forms to two different DOT agencies. You will have to charge twice because they are separate services.
Hospital-based occupational health program managers must be aware that the FAA Medical Examiner designation stays with the medical providers. I know first-hand that when I left employment at Decatur Memorial Hospital in 1989 to start my private practice, the hospital was surprised that the medical records remained the property of the AME, not the hospital-based program, as I did not give up my designation when I left employment.
Keep this in mind if the physician in your program undertakes the training and becomes designated an AME, they can go to another facility in the same geographic area and use this elite appointment to attract pilots to come to their new facility. Non-compete language and reimbursement of training expenses in provider employment agreements need to be in order.
NAOHP Among Leading Health Organizations to Call on OSHA and CDC to Issue Guidance on Preventing Occupational Exposures Due to Aerosol Transmission of SARS CoV-2
Nine leading scientific organizations have endorsed recommendations for OSHA, the CDC, NIOSH, and other federal agencies to create specific guidelines for workers and communities related to the aerosol transmission of the virus SARS-CoV-2, which causes the disease COVID-19.
“As businesses open and workers across many industries return to work, the time is now for our federal agencies to establish complete guidelines addressing worker safety,” said AIHA CEO Lawrence D. Sloan, CAE. The Joint Consensus Statement summarizes what occupational health professionals and scientists currently know about airborne transmission and outlines recommendations:
- In light of concerns about aerosol transmission of SARS-CoV-2, the CDC and state health departments review their guidance for occupational prevention and respiratory protection.
- OSHA issues a temporary emergency standard for SARS-CoV-2 or COVID-19, harmonizing diverse state and departmental rules and guidelines within a single federal standard to ensure a unified national approach.
- OSHA continues the rulemaking process for an infectious disease standard applicable to all industries and issues it as soon as possible.
- Federal funding is provided to support state, local, and professional efforts to research and develop workplace hazard assessment and control programs that recognize airborne exposure routes and prioritize workplace engineering and administrative controls.
- Federal health agencies receive additional funding to address research gaps.
- Federal priority goes to providing frontline workers with better respiratory protection options, including elastomeric and powered air-purifying respirators.
- The Defense Production Act is implemented to address the critical national shortages of respiratory protection equipment, PPE, and medical supplies.
The American Industrial Hygiene Association endorsed these recommendations with the American Association of Occupational Health Nurses, Association of Occupational Health Professionals in Healthcare, American Conference of Governmental Industrial Hygienists, American Public Health Association-Occupational Health and Safety Section, International Safety Center, National Association of Occupational Health Professionals, Organization for Safety Asepsis and Prevention, and Workplace Health Without Borders.
Outlined in the contract, another contract language point that I recommend is that in the event the employed physician who is an AME leaves the program, they must resign their FAA appointment to open up that geographical need.
My office has been open throughout the COVID-19 pandemic. Even though the FAA had given an extension for medical certification, several pilots still wanted to have their expiring medical certification renewed during the early part of the pandemic. I have had several pilots drive 140 miles south of O’Hare International Airport (Chicago) to Champaign, knowing that we were open and could see pilots five days a week for 1st class FAA medical exams.
Benefits of Being an AME
The FAA training program is fabulous and well-organized. The FAA attracts top-notch national talent to teach and serve as consultants to the FAA system. This benefit allows the AME to develop relationships with some of the top specialists in the country, who can be called upon for consultation concerning difficult certification decisions. The quarterly FAA Surgeon’s Bulletin is another nice perk for AMEs. This online periodical outlines nice clinical pearls about determining if a pilot with a particular medical condition should fly. It supplements the online Aviation Medical Examiner Guide which is regularly updated. Serving as an AME also has a lot of crossover applications for FMCSA certification problem cases. Also, being an AME allows one the opportunity to market to new client companies, as a lot of the pilots who seek you out for FAA exams also own businesses that need occupational health services.
The Future Is Bright for AMEs
It’s an exciting time to be in aviation, and this is why an occupational health program that has an aviation medical examiner can really benefit from the growth expected in this industry. There is a need for a new generation of AMEs to take over. Currently, the majority of AMEs are older white males, and I am one of the younger AMEs, at age 66, when I attend my training programs. Due to the baby boomer pilots looming retirement, there’s a huge market for young people to become pilots. There are multiple flying schools around the United States marketing careers in aviation and offering scholarship money or some training deferral. The new generation of pilots will need a new generation of aviation medical examiners.
