Prologue - The FAA's Medical Clearance System

In the coming weeks, I am going to be writing a 6-piece expose here about Pilots and Air Traffic Controllers.  Specifically, I am going to focus on how problematic the current FAA’s medical clearance system is as it tries to maintain safety in the skies.  

I started exploring this topic while I was opening my private psychiatric practice.  You see, I have a lot of experience – 25+ years of it – prescribing medications treating various mental health issues.  But, over the past several years, I have become fascinated by an interventional technology called Transcranial Magnetic Stimulation (TMS).  TMS has been around since the early 2000s and was FDA approved for the treatment of depression in 2008.  Only recently, though, it has garnered the studies and attention it deserves.  

TMS treats depression remarkably well. If you look at treatment-resistant folks, they have around a 7% chance of going into remission with a new medication.  TMS offers around a 50% chance.  And, considering that these are people that have struggled through a lot of treatments, that is very impressive.  It would stand to reason, then, that if you took people who never had any “failed” medication trials, the odds of TMS delivering success are even better.  While that statement is speculative and in need of a research trial, I’d bet on it resulting in a very robust outcome.  

Moreover, newer TMS protocols using intensive 5-day treatments are showing equal effectiveness to longer treatment cycles.  That bears repeating.  A 5 day treatment for depression.  Medications take weeks.. I’ll go on…even after stopping TMS and with no “maintenance” therapy, roughly two-thirds of “responders” remain well.  The study stopped after a year so, who knows, maybe longer.  

So, we have a treatment for our hardest patients, people for which medication after medication has failed them.  And that treatment is effective and long-lasting.  And side effects – minimal.  What’s the catch?  

It is expensive.  Well, sort of.  If you add up the money it saves the patient and the system – missed work days, ongoing medications, ongoing appointments – I think it is cheap.  But, insurers would not agree.  For them it is a large check.  Possibly 10 to 35k, in total.    

Now, don’t misunderstand me.  Medications are extremely valuable and are still my initial go-to.  It is just that TMS is an incredibly useful tool that is in short supply and hard to access.  So, I opened my own practice so that I could offer it.  

But I digress.  Pilots…  Air Traffic Controllers….  

Somewhat naively, for the reasons above, I thought TMS would be a great treatment for depressed pilots.  Well, depressed firemen, policemen, paramedics, soldiers, and, yes, pilots.  There are no ongoing medications, no sedation, minimal side effects, and minimal risks.  So simple…

But idealism is the idiot’s playground.  In life, there is bureaucracy.  I started diving into the policies that govern pilots and air traffic controllers. How is the medical care of those that fly our skies regulated?  

Wow.  What I found was a maze of complexity, all ending in dead ends and bad treatment.  It also became clear to me, as a psychiatrist, how dangerous the current system is.  

I will add there was one other ingredient that made the research fascinating.  Three times I served and deployed to combat zones with the Army.  Each deployment I had to determine if my patients – soldiers serving in the Army, Marines (love ‘em!), Navy or Air Force– needed to be sent home.  The military had strict regulations governing such decisions and I was one of those that made such calls.  So, the role of the Aviation Medical Officer, a physician that acts for and essentially represents the FAA, was a familiar thing to me.  And, along with that, I was also personally familiar with the dilemma that my patients were in – the soldiers –  when they sought my clearance or, heaven forbid, help.  So delving into this topic brought some of my past into sharper focus.  

So, with that, read my next entry in a few days on the medical care of pilots and air traffic controllers as determined by the FAA.  I do not think it will bore you.