Dr. Robert Sancetta is a former DC-10 captain with 11,000 flight hours. He has worked as a Senior AME since 1993 and is appointed as AME Consultant to the FAA Federal Air Surgeon.

AIN Contributor

Robert Sancetta

Pilots are often required to provide documentation to the FAA to facilitate a review of medical conditions of potential aeromedical concern. These can be for relatively minor medical treatments (but are still on the FAA radar) or for complicated, formal, and extensive “special issuance” evaluations.
The manner in which the documentation is presented to the FAA can vary, and often remains a confusing jungle of protocols—some of which can be rather nebulous—that the pilot and AME must navigate through before submitting records to the FAA.
There are, additionally, impacts to the “treating physician,” who is required to provide the medical documentation for the pilot. Without sensible direction, the physician is often left wondering exactly what the FAA wants. This can become a time-consuming hassle for physicians and/or their allied providers; nurse practitioners (NP) or physician assistants (PA), who often author many of the required “status reports.”
How does a pilot and AME know to provide data in the first place? This can be through many avenues. An AME is required to understand and review the FAA’s on-line Guide for Aviation Medical Examiners. Although an imperfect tool, it has been improved over the years and can provide reasonable initial guidance to AMEs, who can then share that information with the pilot.
The scenario above is primarily “in play” when a pilot discloses to the AME that a new medical condition has been identified during the time period between required FAA examinations. In other words, before the FAA has heard anything about the new medical diagnosis.
Once that medical condition is disclosed, and the AME has submitted any information that might be required (per the AME guide, or simply from the knowledge gleaned from years of experience), the FAA might respond with a letter. This letter will state whether the FAA is satisfied with the data as presented or whether additional data is required.
Once satisfied, the FAA may send yet another letter that states if any data will be required in the future at the time of a subsequent FAA examination or in advance of the next exam. This final letter should hopefully also be a letter of eligibility or a formal special issuance authorization, clearing the pilot to return to flying.
In spite of everyone’s best efforts, we sometimes run into problems when submitting data to the FAA. I know you’re shocked to hear that.
As already mentioned above, if the FAA isn’t satisfied with the data as presented or if a medical condition of interest was reported on the FAA exam, but the pilot and AME did not submit any data, a letter asking for additional data might be sent to the pilot. Many AMEs refer to these kinds of letters colloquially as “nastygrams.”
Unfortunately, the wording in this type of letter has become increasingly adversarial over the years. It would seem appropriate and logical instead to have a collegial, polite, and collaborative communication as a first interaction. But, as you already know, this isn’t how government agencies such as the FAA always operate.
To be fair to my hard-working and incredibly helpful colleagues at the FAA—in plain fact, the majority of the personnel, both physicians and staff, at the FAA who I interact with are actually quite motivated to be helpful—it seems that some of the adversarial nature to the letters comes from mandates from governmental legal requirements and directives. The fine FAA medical staff personnel who I interact with directly also wish the letters could be a bit less confrontational.
A “nastygram” often states that, due to the medical condition and/or dissatisfaction with any data submitted, “…we (FAA) are unable to determine your eligibility.” The letter then typically gives about 60 days to submit additional data for review and should spell out precisely what FAA wants to see in that follow-up data.
Of course, there will also be the obligatory bold-faced warnings that a pilot’s medical certificate may be denied should the requested data not be submitted in a timely manner. These letters are always initially disconcerting to the pilot, but the overwhelming majority of the time the FAA is not denying the pilot’s medical certificate with this kind of letter. They are simply stating that additional data is required, but the in-your-face wording seems to imply a sinister joy in scaring the heck out of the pilot recipient.
Once the letter is received, the pilot is forced to go back to his/her physician’s office to ask for additional data or clarifications to what has been already submitted. Again, this is a time-consuming hassle for the physician, but unfortunately, the pilot’s livelihood depends on providing that data. Most physicians are cooperative with this, although at times begrudgingly so.
If the FAA isn’t happy with any additional data submitted, another letter is sent to the pilot that states that the FAA is “still unable to determine” the pilot’s eligibility. And so, the process begins anew.
I have had a few instances over the years where a physician’s office complies but thereafter refuses to see any additional pilots due to the periodic challenges and frustrations in providing data that satisfies the FAA.
Pilots often find this process overbearing. At times, it seems that way to the AME also. However, the FAA reminds all of us that its mandate is to “protect the national airspace” and to do so sometimes requires the documentation-mania that I’ve described.
For the most part, if the pilot just takes a deep breath when a “nastygram” arrives, it will be apparent that what the FAA is asking for is usually not all that unreasonable. However, I fully understand the concern and stress these bold-face threats to a pilot’s career in a surprise letter will cause. Having been a professional pilot in the past myself, I can empathize.
Fortunately, things usually work out favorably for the pilot. It just takes some patience and determination along the way.
An important point in regard to documentation—the FAA hates it when a pilot’s physician states that the pilot is “cleared to fly.” Ask your treating physicians not to do this, please. The FAA does not want its proverbial thunder stolen.
What the FAA wants from the treating physician is a discussion about the medical condition itself, what treatments or medications were/are involved, follow-up plans, and whether the pilot is stable. Remember that word: “stable.” That’s what the FAA wants to hear from your physician.
The FAA will review this data and then state, with resounding authority, whether the pilot is cleared to fly. The FAA position here is that there are additional rigors to aviation that don’t exist for non-pilots, and that general medical training is not specific to aviation medicine.
Treating physicians shouldn’t be required to be experts in aviation medicine. Let the FAA and its internal consultants state if a pilot is cleared to fly, based on their review of the appropriate medical data. The treating physician should just discuss the medical merits of the case in any status reports provided.
An example of just such a situation is in regard to cardiology follow-up after, for example, a stent placement in a heart vessel either during a chest pain evaluation or at the time of a full-blown heart attack. A cardiologist might be tempted to state just a few weeks later that the pilot has no further activity restrictions, and is therefore “cleared to fly.” This clearance, however, doesn’t apply to pilots.
After stent placement, there is typically a minimum of a three-month wait before an extensive series of mandatory follow-up tests must be completed, after which the FAA will review that documentation before stating whether a pilot is cleared to resume flying via a special issuance authorization. The cardiologist was not wrong in stating that overall there were no activity restrictions just a few weeks after treatment–he/she simply didn’t know that FAA protocols and requirements are often different from those used in the general patient population.
Once informed of the FAA protocols, the cardiologist then understands that several months will go by before the testing can be completed. So far, so good. But what often happens next is that the required “status report” from the cardiologist simply states that the pilot seems to be doing pretty well and that the FAA-required testing will commence soon–but doesn’t discuss the actual testing results themselves.
What the FAA prefers here is that the cardiologist waits until after the testing has been completed and reviewed before making final comments. Even though the physicians at the FAA are capable of evaluating the cardiology testing results, they want to see the cardiologist’s opinion, especially if the results aren’t cut and dry.
The FAA also wants to see that follow-up plans are in agreement with both standard medical practice and, of course, ongoing FAA protocols.
To the FAA’s credit, one policy initiative seeing great initial success is the development of detailed checklists that pilots, AMEs, and the treating physicians can use to understand and potentially streamline the required documentation. A great example is how this has improved the consistency of the documentation on diabetes treatment while cutting the paperwork down considerably.
The brand-new program for insulin-dependent diabetics (who need a first- or second-class medical certificate) remains rather paper-intensive, however. It’s a program still in its infancy, but one that also has great promise. It, too, already has some checklists that will aid in standardizing certification documentation requirements.
Other programs that checklists are helping dramatically are those for both drug and alcohol treatment and separately the antidepressant special issuance cases. While these checklists haven’t significantly reduced the paperwork burden itself, they have improved the quality and relevance of the documentation submitted to the FAA.
When everyone knows exactly what the FAA wants, per the appropriate checklist, it’s easier to provide documentation that is correct on an initial application. This increases the chances that a pilot resumes flying without any unforeseen or undue additional delays.
For now, pilots must accept that the FAA will require documentation for some medical conditions. Again, the mandate is to protect the national airspace.
These documentation requirements can sometimes appear confusing and seemingly endless. Bear in mind, however, that once the FAA is satisfied that it can complete its medical review task, the pilot will usually be returned to flying.
Thankfully, most follow-up certifications after an initial semi-heroic effort are typically simpler, quicker, and less costly to the pilot.
Best of all, however, is that for many medical conditions, often all the documentation the FAA wants is a few pages of information. It is not uncommon in those circumstances that once being cleared to fly, that pilot won’t have to submit additional data again for that specific medical condition. Each FAA disposition letter is prepared on a case-by-case basis, so I recommend that all pilots discuss with their AME if (and what) additional data might be required in the future.
In my next blog, I’ll outline some helpful tips to avoid unexpected hassles when bringing documentation to the AME.

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