In my last blog entry, we reviewed the FAA policy that permits the renewal of a pilot’s or ATC’s license without an extended review. It’s unlikely, but possible. There are a lot of hoops to jump through and very few people will meet the criteria. So, the great majority will get deferred. What happens then?
New FAA policy dictates precisely what the AME is to do when a pilot admits to taking a prescription antidepressant. It is fairly straightforward: They get deferred and they are offered a choice: (1) Either stop the antidepressant or (2) continue using it.
If they stop the antidepressant, they wait at least two months and then present a letter from their physician declaring them off the medication for that entire period and "cured". They give the letter to their AME and, if they concur, they are given their license. Without the letter, they remain deferred.
Of course, in all likelihood, the pilot is taking the antidepressant for a reason. So the wisdom of the FAA encouraging them to abruptly stop the medication is…shall we say, stupid.
However, the FAA’s other alternative is onerous. So much so that even a dumb idea – stopping an effective medication to satisfy bureaucrats that you actually did not need it – is, perhaps, a reasonable idea. This is because if the pilot stays on the medication, things get very complex.
How so?
First, they will need to get on the right medication. The only acceptable medications to the FAA are Prozac, Lexapro, Cymbalta, Pristiq, Wellbutrin XL or SR, Zoloft, or Celexa. Any other of the multitude of antidepressants, including “Wellbutrin IR,” will leave them without a license to fly.
Next, as soon as possible, the pilot needs to get a treating doctor and a Human Intervention Motivation Study Aviation Medical Examiner (HIMS AME). I will admit, I chuckled at this acronym. It is so much…government. And, shall we say, tone deaf: there are just HIMS AMEs. No HERS.
The HIMS AME is specially trained to deal with substance abuse issues. Given that there is separate and highly specialized training in the field of psychiatry for addiction, this makes sense. The treatment and methods used with substance use disorders is distinctly different than that seen in other areas of psychiatry. It uses very different models of care and techniques. That we have such trained HIMS AMEs to help manage pilots with substance abuse issues is a very good thing. Substance abuse needs drug testing, group treatments, confrontation, testing, etc.
However, the HIMS AME are also managing other mental illnesses, i.e., depression, anxiety, OCD, etc., and that does not make a whole lot of sense. Those same techniques used with alcohol or drug abuse – drug testing, confrontation, group therapy, 12-step – have little place in treating things like depression. But, the FAA needs somewhere to park the depressed and anxious pilots. I can just picture it: “Oh, well, they are all mental health issues….let’s assign them all to Bob. He is good with the head.”
At any rate, besides the HIMS AME, the pilot will also need an American Board of Psychiatry and Neurology (ABPN) Certified Psychiatrist. Generally, it is easiest if the treating doctor is that same psychiatrist.
Ok. Here is the key. Pay attention to the underlining. After 6-months of stability on the same dose of only one of the approved antidepressants, the pilot can then schedule a mandatory neuropsych testing. This evaluation uses a proprietary test that is required by the FAA -- the CogScreen-AE.
The contents of the screening test are "secret" which, frankly, should make you dubious. It purports to test neurologic and cognitive functioning, along with one's processing speed. Or, so I guess. The FAA will not allow unauthorized individuals to get details on the test or see it. That includes doctors. I know, as I tried.
The FAA and the private firm that makes the test claim secrecy. They do not want to make it public so as to prevent pilots from practicing the exam and defeating it. Perhaps. But, if the pilot were smart and skilled enough to overcome their impairments and still test well...then they are not really all that impaired. If someone is not thinking well, it is very hard to practice and defeat the testing.
As a side note, I think about my past when I treated many patients who were facing a competency hearing. In the hearing, the patient would be asked to explain to a judge why the doctors were wrong and give testimony that showed they were thinking clearly. I was the person they thought was “wrong.” Leading up to the hearing, our work was primarily focussed on teaching them what to say and how to contest my findings. From my experience and perspective, if they were able to learn that, then, indeed, they were competent.
Back to the CogScreen-AE. In truth, the best I can gather is that the computer-based test administers a bunch of normal and commonly used neuropsych tests like the Stroop or the Wisconsin Card Sort. These tests have been around for years.
I don’t know; the Stroop and its companions are fine tests. But, you've got to wonder: does demonstrating one’s ability to predict the next shape that will show up in a line of other shapes really track to one’s management of a plane? Does the test give credit for the pilot’s practical experience and wisdom? Regardless, what can be said is that CogScreen LLC seems to be a private company of insiders with a proprietary product that has a lock on the FAA’s credentialing process. For better or worse, they seem to have a good, lucrative, thing going. If I had my druthers, I’d redirect the FAA to a practical test, like a cockpit simulator. Call me a dreamer but I’d give the pilot a Kobayashi Maru scenario and see how well the pilot managed it.
But, back to reality. After the deferred pilot finds one of the specialists that has purchased the software and been exclusively trained by CogScreen LLC on administering their test, the pilot pays money. The CogScreen-AE costs around $800 to take. Then the neuropsych specialist charges another $2,000 to $4,000 for whatever additional tests they want and to generate a report.
So, to remind everyone, we are at this point at least 6-months into the deferral. Probably more like a year. Why? Because, remember, you had to be entirely stable on one dose of the antidepressant for at least 6-months. And you needed to schedule all these specialized appointments with a series of several hard-to-get specialists. And, give them time to do their work and collect their data.
Anyhow, after all that, the pilot schedules another AME appointment. The pilot says, essentially, "I am stable and ready". The AME agrees (or not), and generates a report.
Then the psychiatrist makes a report.
Then the Chief pilot for the commercial carrier submits a report.
All of these reports are then forwarded to the HIMS AME. They review these reports.
They also get a report from the FAA.
After reviewing all the reports, the HIMS AME schedules and sees the pilot.
Then – you guessed it – the HIMS AME makes a report.
The totality of reports is then sent up to the FAA. As I noted last blog, I think it is mailed there as the FAA’s computers are, shall we say, a bit troubled. Troubled to the tune of $20-billion or more (see part #3). So, hopefully, the recertification package arrives at the FAA and gets filed.
But, the FAA is understaffed and deferrals are at all-time highs. So it can take months to process the file. And, in the meantime, the beast must be fed. The Chief pilot must continue to file a new statement every 3 months. The psychiatrist and the HIMS AME continue to file every 6-months. And, if god-forbid someone falls behind, the whole machine grinds to a stop.
With some luck, eventually the file does get processed. It is then that the FAA determines which of the experts said too much and which said too little. Were the deadlines met? Have all the boxes been properly checked and signed off? If so, a decision is made as to the pilot's license. Otherwise a report is generated, requesting better reports.
It is exhausting. Complex, expensive, time-consuming, belittling, humiliating, and exhausting.
Stand back from the process for a moment. Imagine yourself needing to share your most shameful thoughts, your anguish, your shortcomings, your pain with one-- no, two...no, thre...four...five specialists and a massive bureaucracy looming behind them, logging it all. And that machine, grinding away, looking for that one missed data field, that one alarm bell to ring. Did someone actually write "passive suicidal thought"....oh god. And so it goes, often for several years.
Is this the best we can do?
I hate to tell you this but the story has not ended. This is just the initial round. Let’s assume you endure all that. You survive this version of hell. You manage to stay afloat and pay your bills. And, glory be, you've been recertified. You're no longer deferred. You have your license.
Temper that excitement. You are not done. There is still the "follow-up clearance" every 6 months with HIMS AME. Indeed, it is pretty much the same set of actors and same set of reports -- maybe no neuropsychologist or CogScreen-AE – but otherwise the same. Fall a signature or report short, you are deferred again.
I am exhausted just writing about it. And I still have not gotten to how the process differs for ADHD. Or, PTSD. The short answer - it is pretty much the same thing.
So, to bring us full circle: Is it really all that crazy to say, “I am just going to stop taking my medication.” That seems to be what the FAA wants.
Next time, we will review what viable options a pilot has if they wake up and find, like the other 20% of our country does at some point or another, that they are depressed. How is patient privacy managed by doctors and how is it defeated by the FAA…
No comments:
Post a Comment