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Vol.19, No.4October 2016

In this issue:

Specialized Centers Of ExcellencePresident’s Message Page 2CAMA Luncheon Program Page 3CAMA Sunday Program Page 4Executive VP Report Page 5Flu and the Elderly Host Page 6Error Management Page 8Physician Burn Out Page 10AME Question Column Page 15Robert “Bob” Hoover Obit Page 16PBRII Legal Viewpoint Page 18Blast from the Past Page 21Life, Sustaining, Corporate,and New Members Page 24CAMA Dues Form Page 26Corporate Member Form Page 27

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Civil Aviation Medical Association(CAMA) Contact Information

Mailing Address:CAMAP. O. Box 2382Peachtree City, GA 30269

Telephone: 770-487-0100Secure FAX: 770-487-0080

Email: [email protected] Site: www.civilavmed.orgFacebook : Civil Aviation

Medical Association

A publication of the Civil Aviation Medical Association

FlightPhysician

Specialized Centers of Aeromedical Excellence ConceptEvaluated by FAA Medical Leadership

The CAMA Board of Directors finalized and approved a proposalat its September meeting to forward to FAA aeromedical leadershipasking for consideration of designating Centers of SpecializedAeromedical Excellence. The purpose of these centers would be tocreate an academic platform to evaluate complex aeromedical cases,expand the bandwidth of FAA physician reviewers, and allow forincreased exposure to a variety of cases for future trainees inAerospace Medicine and potentially for any other interested FAAdesignated medical examiner.

CAMA President Clayton Cowl received word from FAA FederalAir Surgeon James Fraser that the Centers proposal was initiallyviewed favorably, and that the physician team at FAA headquartersin Washington, D.C., would be reaching out to CAMA leadership todiscuss next steps in the process of considering designating specificcenters. Determining the ability of the Federal Air Surgeon's Office todesignate such centers was to be investigated further within the FAA.Action planning may involve further face- to-face meetings withleadership of CAMA and perhaps other aerospace medicalorganizations.

“I believe we agreed that we would like to expand and explore ouracademic association with CAMA and [other academic centers],”stated Dr. Fraser in an email correspondence. “While there arelogistical challenges to handling HIPPA-related issues in a grandrounds format available to all AMEs, we discussed several ways inwhich we could develop a closer academic collaboration.”

2 Flight Physician October 2016

As the year winds down, and we as FAA-designated flight physicians look at potentialpractice improvements in the coming year orparticipate in strategic planning sessions, consideradding a checklist of items to improve yourindividual and team performances serving pilots astheir Aviation Medical Examiner (AME). Whetheryou are in solo practice or participate in a largeteam of medical providers, stepping back andscrutinizing how to best serve the aviators whopresent for evaluation should be part of a processof continuous quality improvement.

Here are some things to consider:

Are we providing the most efficient service topilots?

Efficiency and efficacy means different things todifferent people, but in general, the ability to makethe process of applying for a medical certificate aseasy as possible for the airman should be a goal ofevery practice. Use of the electronic medicalapplication form, known as FAA MedXPress, is nowrequired with the exception of certain AMEs whoare performing examinations in internationallocations without access to on-line technology.Many practices are providing on-site kiosks forpilots to enter their medical information. Theseareas should be free of commotion and offer anenvironment that will allow the pilot to keep theirinformation confidential to all except for whom areessential to completing the certification evaluation.When encountering a complex case, how are youassisting the airman? Does your practice simplydefer the medical application and tell the pilot toobtain all supporting data and forward to the FAAwhen available – or do you assist the airman incollating data and explaining the aeromedicalcertification process to them? Or do you have arelationship with a tertiary aerospace medicalpractice where these pilots with complex medicalconditions can be referred? How do you or yourstaff communicate with the pilot? Do youpre-schedule a recurrent follow up visit for the nextflight physical ahead of time?

Check on FAA training currency.As aviation medical examiners, we are required

to remain current on FAA updates. Prospective

AMEs are required to complete the MedicalCertification Standards and Procedures Training(MCSPT) and the Clinical Aerospace PhysiologyReview for AMEs (CAPAME) prior to attending aBasic AME Seminar at the Civil Aerospace MedicalInstitute in Oklahoma City. While many of us thinkof recurrency training as taking a live FAA refreshercourse every three years (which has included theannual CAMA Educational and Scientific Meetingattendance, thanks to our collaboration with theFAA), AMEs may complete the Multimedia AviationMedical Examiner Refresher Course (MAMERC)course to fulfill mandatory refresher trainingrequirements if you have attended an AME seminarwithin the last three years.

Since AME refresher training is required every36 months, MAMERC can be used to extendattendance of an AME seminar by 36 months.Attendance at an AME seminar is required everysix years (72 months), regardless of whenMAMERC was last completed. As another addedbenefit, you may complete MAMERC or CAPAMEat any time for Continuing Medical Education(CME) credit, since CME and AME refreshertraining are separate matters. In addition, AMEs areexpected to read and implement updates from thequarterly Federal Air Surgeon’s Bulletin, andcarefully review updates to the Guidebook forAviation Medical Examiners released periodicallyon line, with more frequent updates posted in thepast several years.

Implement FAA “language” into your practice.Just as pilots have specific acronyms and terms

to describe specific aspects of the flightenvironment, so do we as AMEs. Terms such as“CACIs,” “SODAs,” and “AASIs” may be part of ourdaily language but may be confusing or daunting tomost pilots. Define and share the terms with theaviators you examine – and importantly, withnurses and other allied health support staff workingon your provider team. Your medical andadministrative staffs are your outward facing brandto those who choose to come to your practice fortheir examination. Having all support staff familiarwith the certification process and specific terms willminimize confusion and may help them to “own”and champion more of your aeromedical practice.

Time for End-of-the-Year Fine TuningClayton T. Cowl, MD, MS

CAMA President

(Continued on Page 3)

Review your plans for records storage.Although the FAA Medical Application Form

8500-8 is submitted electronically, most practicesretain a record of the examination in their electronichealth record, or store a paper copy for a minimum ofthree years. Now may be a good time to review yourpractice policies for record storage and how best toretrieve sequential pilot records over time.

Reassess billing and coding strategy, and look atfee structures.

As administrators and practice managers resumethe process of closing the books on calendar year2016, many practices will begin a process ofre-evaluating required time commitments to perform-ing FAA medical certification examinations,particularly those requiring additional time forcomplex conditions requiring Special Issuance. Doyou have special codes or fees for making one ormore calls to the FAA on behalf of an airman? Willyou perform aeromedical consultations as a separateactivity from a full scale FAA flight physical when it isunclear what diagnostic testing will be required for apilot with a specific medical condition?

How will the Pilot Bill of Rights II (Public Law114-190) affect your practice?

Many AMEs are aware of legislation passed onJuly 15, 2015 involving Section 2307 of the FAAExtension, Safety, and Security Act of 2016 thatrequire an educational training course be completedby pilots electing to pursue the alternative medicalcertification pathway for airmen holding a private pilotcertificate and for airmen with medical conditions,that they undergo a comprehensive examinationsigned by a licensed physician (who is not requiredto be an AME) with an attestation statement that the

pilot is safe to fly. Final rules for this legislation areexpected to be released within the next few months.Since this document would be signed outside of thenormal role as an FAA AME, it is thought that therewould be no liability protections afforded thosedesignated AMEs who elect to sign off on thesemedical checklists. Will you and/or your practice bewilling to sign off on these attestation statements?Will you require pilots to undergo a full flight physicalor go elsewhere? How many private pilots do you oryour practice evaluate, and are you prepared for thedecline in medical examination requests if mostprivate pilots use the alternative certificationpathway?

Regardless of the size of your practice, theproportion of your total patient volume made up ofpilots, or your complexity of case load, it is importantto step back and reflect on how to maintain thehighest quality standards for each aviator weevaluate. Now is a great time of year to ensure yourstaff is educated, you are up-to-date on yourexaminer training (or make plans to refresh yourcurrency in the coming year), and that processimprovements are implemented.

Clayton T. Cowl, MD, MS is CAMA President andserves as the Chairman of the Division of Preventive,Occupational & Aerospace Medicine at Mayo Clinicin Rochester, Minnesota. He is an FAA SeniorAviation Medical Examiner, a pulmonologist, andaltitude physiology researcher.


CAMA LUNCHEON / AEROSPACE MEDICAL ASSOCIATIONROOM TBA

MONDAY, MAY 1, 2017

SHERATON DOWNTOWN DENVER HOTELDENVER, COLORADO

KEYNOTE PRESENTATION

Russell B. Rayman, MD, MPH, DAvMed, Colonel (Ret)USAF, Arlington, VA

12:00 PM to 01:30 PM “Operation New Life: Vietnam Rescue”


CAMA SUNDAY / AEROSPACE MEDICAL ASSOCIATIONROOM TBA

SUNDAY, APRIL 30, 2017

SHERATON DOWNTOWN DENVER HOTELDENVER, COLORADO

AIRCREW NEUROCOGNITIVE ASSESSMENTThe Gold Standard: Laboratory or Simulator

08:00 AM to 08:10 AM Introduction

08:10 AM to 08:50 AM Neurocognitive Assessment: FAA PerspectiveSpeakers: To be AnnouncedFederal Aviation AdministrationOffice of Aerospace MedicineUnited States

08:50 AM to 09:30 AM Neurocognitive Assessment: UK PerspectiveDr. Michael D. O’BrienConsultant Neurologist

Dr. Stuart J. MitchellHead Authority, Medical Section

Civil Aviation AuthorityUnited Kingdom

09:30 AM to 10:10 AM Neurocognitive Assessment: Neurologic PerspectiveJack D. Hastings, MDNeurology and Aerospace MedicineUnited States

10:10 AM to 10:25 AM Break

10:25 AM to 11:05 AM Laboratory-Derived Neuropsychological AssessmentMax Trenerry, PhD, LP, ABPP, CNNeuropsychology, Mayo Clinic, Rochester, MinnesotaUnited States

11:05 AM to 11:45 AM Neurocognitive Assessment: A View of Both SidesLee C. JonesAirline Transport Pilot, CaptainFAA Aircrew Program Designated ExaminerCheck Airman, Aircraft and SimulatorUnited States

11:45 AM to 12:15 PM Panel Discussion

12:15 PM Adjourn

The CAMA Sunday Program for 2017 has been put together brilliantly by Dr. Jack Hastings! Markyour calendars to attend this informative and thought-provoking event and invite others to attend.The programs are being submitted to AAFP for a CME rating. Please see the CAMA LuncheonProgram on Page 3.

A publication of the Civil AviationMedical Association (CAMA)

President:Clayton T. Cowl, MD, MS

President-Elect:Warren S. Silberman, DO, MPHImmediate Past President:Mark C. Eidson, MD.

Executive Vice-President:David P. Millett, M., MPHSecretary Treasurer:John S. Raniolo, DOVice-President for Management andPlanning:Gerald W. Saboe, DO, MPHVice-President for Communicationsand Representation:Petra Illig, MDVice-President for Education:Robert Haddon, MD

Civil AviationMedical Association

FlightPhysician

The editor of The Flight Physicianwelcomes submission of articles,letters to the Editor, news items,interesting aeromedical cases, andphotographs for publication. Pleaseemail items to:

Sherry [email protected]

I was so very sorry tohave to miss seeingeveryone during theCAMA annual scientific

meeting at the Mayo Clinic! Yourgood wishes for my health werevery much appreciated! The upperrespiratory infection has completelyresolved, and hopefully, no one elsewas exposed.

The reviews and evaluations of the2016 meeting were excellent, andwe had very interesting speakersfrom the Mayo Clinic, coveringsome new subjects and medicalspecialties! We look forward tobringing back some of thosespeakers in future years.

The 2017 annual scientific meetingwill take place at the GreensboroSheraton Hotel in Greensboro, NC,September 14-16. Save the datesand mark your calendars now forthis event! Registration will be openin late April or early May, 2017.

We are very excited to report thatwe have signed with the CaptainCook Hotel in Anchorage, Alaska,for our 2018 annual meeting. Thedates are September 27-29.

We were glad to have theopportunity to meet and work withthe FAA CAMI new InstructionalSystems Specialist, Deann King,Ed,D. Deann has been assigned tothe position previously held byJanet Wright. Janet was a mainstayof CAMA annual meetings and willbe sorely missed by all of us! Wewish her a very happy retirement!We look forward to working withDeann King for our future meetingsand find that she is very helpful andsupportive of CAMA educationalactivities. Congratulations on yournew position, Dr. King!!

At the end of each year, a new setof CAMA Trustees is elected to theCAMA Board. Often, there are

individuals who volunteer tocontinue to contribute their time andefforts to the running of CAMA andits programs, and each year thereare new individuals who volunteerto serve as Trustees and Officers.

The slate of CAMA Trustees with aterm expiring at the end of 2019are: Robert J. Gordon, DO, RichardS. Roth, MD, Sergio B Seoane, MD,Basil P. Spyropoulos, MD, and SirRodney E. L. Williams, MD. HaroldN. Walgren, MD, JD, has beenmade an Ex-Officio Board Member,and we hope that he will continue toattend Board meetings and lend hisconsiderable expertise to ourorganization!! Robert Haddon, MD,will continue as the VP of Educationfor 2017, and we look forward toanother exceptional educationalprogram in Greensboro!

All of the presentation slides fromthe annual scientific meeting havebeen made into PDF files and sentto the web master to be placed ontothe CAMA web site atwww.civilavmed.org. In themeantime, if there is a particularpresentation that you wish to haveemailed to you, please let us knowby calling or emailing the CAMAhome office. Once the slides are onthe web site, you may view and/ordownload any presentation byclicking on the tab entitled“Lectures” at the top of the webpage.

If you have any questions orcomments regarding the content ofthis publication, please email us [email protected]. We solicitarticles, photos, research, andinformation from our readers andother CAMA professionals.


Message from CAMA Executive Vice PresidentDavid P. Millett, M D, MPH:


Influenza Vaccination andthe Elderly Host—Is Age

Just A Number?

US statistics of the general population, as well asthe aviation community, confirm a continued growingconsensus that the percentage that comprises theelderly cohort has been increasing steadily over thepast two decades.

Uniformly, all of us wish to live to a fine old age;however, others argue that it’s not how long you live,but how well you live while you are living.

The Air Safety Institute performed a decade longliterature review to assist in answering questionsregarding the aging pilot population with specificattention to the age 60 rule.

My father, now aged 91, still drives and lived inthe home that I grew up in until earlier this year,when we made a decision to pursue an assistedliving environment for both him and my mother. It isclear that, although his faculties are intact, there hasbeen an age-associated decline of other aspects ofhis health.

The elderly host clearly has a diminished ability torespond to infection, as well as to mount a significantimmunologic response to preventive vaccination.

The Center for Disease Control/CDC documentsthat the older population is disproportionatelyaffected in terms of both death and hospitalizationregarding influenza associated illness. Despite thewidespread availability of seasonal flu vaccines,influenza continues to be responsible for significantmorbidity and mortality in the United States.Influenza statistics confirm close to 3 million hospital-ization days and 35 million outpatient visits as adirect medical impact of the flu each year. Last yearalone, estimated medical costs secondary toinfluenza infection exceeded $10 billion. Although itappeared last year was a relatively mild influenzaseason, over 20,000 people died from influenza orthe secondary complication of this viral pulmonarypathogen. Although the people over 65 make uponly 15% of the general population, influenzamortality is comprised of 90% from that population.

Researchers confirmed that age is definitelyassociated with objective deterioration of T cellsubsets and cytokine production profiles inquantitative immunologic studies. Regardingantibody surveys, younger patients had a much morerobust increase in their antibody levels afterinfluenza vaccination than the elderly host. Thus,new vaccine recommendations, such as high-dosevaccines and a booster recommendation, areincluded in the newest vaccine protocols. Over-whelming evidence suggests that increased antigenpresentation through the higher dose vaccine, andpossibly the booster recommendation, leads toincreased antibodies and subsequently, betterprotection.

Fluzone high-dose has been designed since 2011specifically for adults age 65 or older and retains astrong recommendation as the vaccine of choice forthe elderly host. One could also consider standarddose vaccination, but repeating a “booster dose,”one month or so after that initial seasonal shot.

New vaccine licensures have arrived into ourarmamentarium, specifically Fluad and Flucelvax.Where the first has a potent adjuvant to increase theeffectiveness of the antibody response of thatparticular product, the second is a modified cellculture-based, inactivated quadra valent formulationas a potentially stronger an acceptable alternative toother licensed vaccines.

Unfortunately, research has also proven that theduration of immunity after standard vaccinationwanes in only a few months after the initial dose.Evidence from some earlier clinical trials indicatedprotection against influenza extended 6 to 8 months;however, other literature suggests that a potentimmunologic response to the challenge of trueinfection may decline within two months after aroutine single-dose vaccination in the early fall. Thedesire to improve immune response and vaccineeffectiveness among the elderly continues to be achallenge, so this year the CDC has once againrecommended the high-dose form of the influenzavaccine, which is a trivalent formulation containing60 µg of antigen per dose compared to the 15 µg of

Richard S. Roth, MD, Infectious DiseaseSpecialist, Savannah, GA, and ProgramDirector of the Infectious Disease Training

Program, Memorial Health University Medical Center, MercerUniversity School of Medicine. Dr. Roth is a Senior AME andholds both ATP and private pilot ratings. He serves as a Trusteeon the CAMA Board of Directors

antigen in the standard dose formulation.

Large post-licensure population-based studyemphasizes the safety of these inactivated influenzavaccines. There was no increase in clinicallyimportant medically attended events during the two-week window period of observation of over 200,000individuals. Subsequent studies which reviewed mildside effect profiles determined that none of theevents in this large study appeared to be serious orwas associated with complication. Typical side effectprofiles post vaccination lasted less than 48 hoursand were typically defined as local vaccine reactionsthat were mild and rarely interfered with therecipient’s ability to conduct usual daily activities.There was no greater incidence of post vaccinationfever, malaise, myalgia or headache compared toplacebo groups studied prospectively.

Thus, I would strongly recommend in the olderpilot or any senior citizen in your practice, for thatmatter, to strongly consider Fluzone high-dose dur-ing this vaccination window that is open at the time ofthis writing, and also consider the use of Fluad as analternative option in these patients.

Years ago, some vaccine product arrived atoffices as early as July and, although it benefitedwith early delivery by being available for a greaternumber of individuals, time-associated antibody de-cline may have led to greater influenza impact laterthat season. Delaying vaccine protocols into theearly fall continues to be recommended to allow a

greater immunologic umbrella to be provided to allhosts during the peak season, around the holidays,and well into the New Year. Vaccination protocolsshould continue throughout the season due to theduration of the influenza activity, which has occurreduntil February in March in previous years. Typically,we prefer all flu vaccination to occur beforeThanksgiving. However, vaccination administered aslate as December is likely to be beneficial in themajority of influenza seasons

Regarding storage of influenza vaccines in theoffice setting, approved manufacturer packaginginformation should be consulted. In general, thevaccine should be protected from light and stored atrecommended temperatures/refrigerated near 45°Fand should not be frozen. Any frozen product shouldbe discarded, and multi-dose vials should bereturned to recommended storage conditionsbetween usage. All vaccines should be discardedafter the expiration date on the label.

It is clear that, as the research and epidemiologicdatabase evolves, the aging process will be differentfrom pilot to pilot, independent of comparable agegroups studied. Certain areas of commonality, suchas cognition, physical fitness, and performance needto objectively detailed to a greater extent than thecurrent literature outlines. We are quite fortunate tohave a clear and current understanding of theimmunologic responses in the elderly host,warranting significant emphasis on our older pilots toonce again recommend an ounce of prevention


Error Management:Lessons from Aviation

I had the pleasure of presenting this talk duringour recent annual CAMA meeting. While most talksfocus on a specific disease or specialty, error spansall of our practices. I thought focusing on error wouldbe interesting to compare and contrast my twoworlds: aviation and medicine. It seems there’s anarticle or news story nearly daily discussing medicalerror, often framing the data in terms of the numberof jetliners that would have to crash so often toaccount for the staggering numbers. Several recentstudies are estimating the number of deaths inhospitals due to medical error to be severalmultitudes higher than those put out by the Instituteof Medicine: To Err is Human report in 1999. If theseestimates are correct, medical error is now the 3rd

leading cause of death in the United States. Besidesthe sheer loss of life, this represents huge cost bothfinancially and in loss of trust in the medicalcommunity. The aviation industry, on the other hand,has demonstrated decades of improved safetystatistics.

Aviation and medicine have many similarities, butthere are important differences as well. Parallelsinclude a complex, dynamic, and high-riskenvironment that is intolerant of error. There’s oftentime pressure while interfacing with technology.Personality traits such as overconfidence, invulnera-bility, impulsivity, and anti-authority can be found inpilots and physicians. However, planes and peopleare two very different platforms to work in. Errors

can also be separate in space and time. Forexample, instead of a crash site that results from animmediately preceding error, a person may notdisplay symptoms of a cancer for decades afterbeing treated with too high a dose of radiation. Riskof litigation also influences many of the decisions wemake in medicine. While aviation is not immune,litigation is not usually one of the deciding factors inhow a pilot flies a plane or deals with weather.

With the knowledge that 85% of accidents can beattributed to pilot error, the aviation communitybecame an early adopter of focusing on humanfactors and the systems in which they work. Thehuman element is the most flexible, adaptable, andvaluable part of aviation and medicine. It is,however, also the most vulnerable. Understandinghuman factors or how we interact with theenvironment, technology, and other people was vitalin developing a culture of safety. This cultureallowed development of cognitive aids (checklists),ways to detect error producing situations(simulation), and design of error resistant systems(crew resource management). As opposed to asystems approach, medicine has been stuck in ablame-based culture termed the person approach. Inthis approach, error is due to some deficiency orcharacter flaw in the individual, exemplified in theidea that “bad things happen to bad people.” In asystems approach, errors are thought to be due tosystemic factors. Human variability is accepted andmitigated. Similarly, error management seeks to limitthe incidence of error and design systems that cantolerate and contain the effects of error. Shifting to asystems approach would allow medicine to developsafe practices and safe systems in which healthcarecould be designed to be safer at all levels.

Focusing on how we think as individuals can be ahelpful exercise. Cognitive error is an error in thethinking process. This is not deliberate or a lack of

knowledge, but more of asubconscious process thatleads to error. For example,a heuristic is a mentalshortcut that allows a personto make a decision morequickly by ignoring part of theinformation. This could bevital in an emergent situationand a positive attribute in aseasoned professional, butrelying on heuristics can be

error prone as well. Bias in medicine can alsoinfluence how and when we make certain decisions.In the Swiss Cheese Model, our thinking process cancause the holes in the cheese to line up through achain of events causing a trajectory for error. Wecan develop cognitive aids which act as forcing

Leigh Lewis Speicher, MD, MPH, isboard certified in Internal and Aero-space Medicine. She serves as aconsultant within the Section of

Executive and International Medicine. She is a licensedprivate pilot and a Senior Federal Aviation Administration(FAA) Aeromedical Examiner. She also has an interest inpreventive medicine and women’s health. Dr. Speicher isan instructor of Medicine at Mayo Clinic College ofMedicine in Jacksonville, Florida. Dr. Speicher earnedher BS degree at Eckerd College in St. Petersburg,Florida. She then obtained her medical degree from theUniversity of Miami School of Medicine in Miami, Florida.She completed a general surgery internship at theNational Navy Medical Center in Bethesda, Maryland. Shestudied internal and aerospace medicine in her residencyprogram at the University of Texas Medical Branch inGalveston, Texas, where she also completed a Master’sof Public Health degree. Dr. Speicher is a north Floridanative who has served as a flight surgeon at Naval AirStation Jacksonville. She worked in the medical appealsdepartment for the FAA prior to joining Mayo in 2012.She enjoys spending time with family, traveling,exercising, and scuba diving.



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functions to engineer out the holes in the layers ofcheese. These aids help to mitigate the effects ofhuman variability caused from stress, fatigue, orpreconceived notions about a patient or process.Just as checklists are now widely utilized in bothindustries, other similar tools may already be a partof your medical practice. Examples include alarms,automatic shut downs, non-compatible tubing sodifferent anesthesia gases aren’t confused, markinga patient prior to surgery, surgical time-outs, andbarcode scanning prior to administration of amedication.

Managing how individuals work in teams has alsobeen a successful practice. Just as this is a powerdisparity between the pilot and co-pilot, there aremany different levels in medical teams. Cockpit orcrew resource management (CRM) was developed inthe 1970s after a series of accidents that may havebeen prevented with the input of other team players.CRM is a group effort to maintain situationalawareness. Each member of the team isencouraged to have a questioning attitude andemphasis on communication. Flight briefings can beadapted to medical team huddles. Simulation canalso be used to practice CRM as a team. As webecome more comfortable discussing and learningfrom our errors, medicine too can truly develop aculture of safety.

Gluck, PA. Medical Error Theory. Obs and GynClinics 2008; 35: 11-17.

Makary MA, Daniel M. Medical error-the third leadingcause of death in the US. BMJ 2016; i2139.

Reason, J. Human error: models and management.BMJ 2000; 320: 768-70.

Singh H, Peterson LA. Thomas EJ. Understandingdiagnostic errors in medicine: a lesson from aviation.Qual Saf Health Care 2006; 15: 159-164.

Stiegler MP, Ruskin KJ. Decision-making and safetyin anesthesiology. Current Opinion 2012; 25:724-729.

To Err Is Human: Building a Safer Health System.Institute of Medicine, November 1999.

September 2016 CAMA Board of Directors Meeting

The CAMA Board of Directorsmeets at least twice a year todiscuss pertinent issues andpolicy positions, and to map thecourse of CAMA activities. Thededication of the doctors whoserve on the CAMA Board ismuch appreciated! Boardmembers donate their time andare not compensated for theirparticipation.


Burnout Syndrome ofDoctors and Other

Medical Professionals

Dr. Basil Spyropoulos, MD, is a psychiatrist withspecialties in Community Mental Health, Telepsychiatry,and Aerospace Psychiatry. He is the Medical Director ofTelemedicine at Rogers Memorial Hospital, Madison, WI.He is responsible for the overview of quality and efficiencyof technological services for provision of telepsychiatriccare, as well as performing orientation of new clinicians totelepsychiatry services. Dr. Spyropoulos is a graduate ofthe Southern Illinois University School of Medicine. He isfluent in Greek, and has volunteered with Hellenicare, anon-profit organization dedicated to providing medicalassistance to the poor of the Black Sea region. He is aTrustee on the CAMA Board of Directors.

Physicians are not immune to the stress and strainof life. In the past few years, the medical andpopular press have been reporting increasingly oftenon the under-recognized, and arguably increasinglyprevalent, issue of physician burnout. Burnout is asyndrome which affects up to one-half of the entireUS medical workforce at any one time. It has aninsidious onset and can be caused by a variety offactors.

The term "burnout" was likely coined in the early1970's. Social psychologist Herbert Freudenbergerappears to have written the first scholarly article on"Occupational Burnout" in 1974. He described it asa type of psychological stress, typically found inhuman service professionals, characterized byemotional exhaustion, lack of enthusiasm andmotivation and feelings of ineffectiveness. Thestress from which burnout results tends to be chronicand is usually associated with emotionally taxingwork and high expectations of the worker. Burnoutis a cumulative process which tends to occur over aprolonged period. Treatment hinges upon identifyingand addressing the causative factors and can bevery effective. However, once burnout has occurred,the sufferer may experience it more easily in thefuture.

At present, there are three generally recognizedhallmarks of burnout, and these resembleFreudenberger's description: Emotional Exhaustion,Depersonalization, and a Low Level of PerceivedAccomplishment. Emotional Exhaustion refers to a state of

emotional depression resulting from work factors

and can be manifested by such symptoms as lowenergy, lessened enthusiasm for work, andinability to "recharge one's batteries" after workor on weekends.

Depersonalization (also referred to as Cynicism)is manifested by withdrawal from personalinteractions or the dehumanization of thoseinvolved in one's work.

Low perceived accomplishment or Low Self-Efficacy refers to feelings of futility with respect toone's work or feeling of low personalaccomplishment, regardless of the opinions/reassurances of others.

As with some of the more common mental illnesses,the onset of burnout tends to occur slowly over time,and it tends to be present for a prolonged periodbefore it is recognized, if ever. The "Real-World"consequences of burnout are varied and range fromprimarily impacting the sufferer, without an initialovert impact on others, to having a negative impactupon a clinician's patients, loved-ones andco-workers. The manifestations tend to initiallyaffect only the clinician, but do quite often expand tothe point that other people are significantly impacted.Burned-out clinicians are more likely to developmaladaptive behaviors such as withdrawal/isolationfrom their work and social environments, substanceabuse, and compulsivity syndromes. They also aremore prone to developing frank psychiatric illnessand being involved in medical litigation.

Physicians in the United States appear to havehigher rates of burnout than those in other countries.Statistics vary, depending upon the source, butalarmingly suggest that the prevalence of burnout isincreasing rapidly. The Mayo Clinic's TateShanafelt, MD, has published a great deal onburnout and in physician surveys conductedrepeatedly over several years found an increase inreported rates from 45% in 2011 to 54% in 2014.Medscape.com has also been collecting data forseveral years and has reported somewhat lower,but significant rates of 40% in 2013 and 46% in2016. Keep in mind that these data are generatedfrom participating physicians' self-reports on aLikert-like scale. [SEE FIGURE 1 on next page]. Asthe tendency for many physicians is to minimize ornot report their own stressors, pain and suffering, itis possible the rates are higher still.

(Continued—See Figures 1 and 2 on Page 11)


FIG 1What Percentage of Physicians Are Burned-Out?

FIG 2How Severe Is Physicians’

Burnout?


Physician Lifestyle Report-2015, Medscape.comThe Medscape reports compare the incidence andseverity rates among various common medicalspecialties. The highest rates (up to 55%) arereported by specialists in critical care, urology andemergency medicine, followed closely by internists,family practitioners and pediatricians. Median scoresare reported by oncologists, nephrologists,orthopedists, neurologists, and infectious diseasespecialists. The lowest rates are reported byendocrinologists, ophthalmologists and psychiatrists.One might speculate that the rates for this lowest-impacted group are related to the office-basednature of many of these practices, but it should bequite sobering that the group reporting the lowestincidence of burnout still had a rate of 40%. Thisfact, combined with the increasing rates over just afew years, is not encouraging.

The Medscape study also examined potential causesof physician burnout cited by surveyed physicians.Among the more common complaints were:excessive bureaucratic tasks, excessive work hours,increasing computerization, income not high enough,and feeling like “a cog in a wheel”.

Also, according to the ongoing Medscape study,female physicians experience burnout at a ratealmost 20% higher than male colleagues (55% vs46% overall). The course of burnout also seems todiffer between the genders, with females tending tomanifest the 3 stages in the previously describedorder (exhaustion – depersonalization/cynicism –reduced sense of accomplishment), whereas malestend to experience the Depersonalization/Cynicismstage first, followed by emotional exhaustion and areduced sense of accomplishment.

It is tempting to think of burnout as a syndromeaffecting primarily older physicians, when in fact therates of burnout and depression in trainees aresignificant in medical students, residents/fellows andearly career physicians and higher than the generalpopulation.

With respect to affected individuals it is vitallyimportant to address not only the symptoms andcauses of burnout as soon as possible after they areidentified, but also that any barriers to treatment beaddressed. It should be no surprise to the readerthat physicians not only experience but also erectmany barriers to their personal health care.Generally, we avoid treatment for physical or mentalhealth issues. With respect to mental health, weusually seek outside help only during a personal orprofessional crisis. Physicians often fear exposureand possible repercussions or judgment from others.As high achievers with generally a strong sense of

responsibility, physicians are also likely to feel guiltyabout “letting the team down” or not “being there” fortheir colleagues and patients.

Physicians also are quite adept at using intellectualdefense mechanisms. Examples might include:Denial (“patients get sick, not me”), Minimization (“itcan’t be that bad, I can still do my job”), Rationaliza-tion (“once I take a vacation, it will be fine”). Some-what more complex and less obvious defenses caninclude: Reaction Formation (giving others all theattention we would like to get / overcompensating forour negative feelings, guilt, anger, feeling that ourpersonal needs are being neglected), andDisplacement/Sublimation. In this last example,dissatisfaction in work and personal life can lead to aphysician working even harder than usual becausephysicians are used to getting results from sustainedhigh effort. This can either temporarily boost one’sself-worth or distract the mind from upsetting issuesover which we feel we have little or no control. (It isalso socially acceptable to work harder, even thoughthe old adage, “Hard work never killed anybody” isfar from the truth.)

If you find yourself in a position to help a strugglingphysician seek appropriate help, you must respondquickly. Most physicians have already waited toolong before seeking help. Be supportive and under-standing and always be empathetic. Respect thesufferer’s confidence in you and ensureconfidentiality, though it is important to be aware ofyour jurisdiction’s reporting requirements. Forinstance, Wisconsin (one of the States in which Ipractice) mandates that physicians report colleagueswhose clinical abilities appear impaired by mental orphysical ailments.

If you are the one providing clinical care for a burned-out or otherwise struggling physician, you shouldkeep in mind certain guidelines and cautions.Doctors are typically not trained to confront otherphysicians and are generally taught to respectanother physician’s autonomy. At the beginning ofcare, you should set and maintain appropriateboundaries throughout your clinical relationship withyour physician patient. Don’t share excessivepersonal information and avoid emotional enmesh-ment in your patient’s plight. Always act like aclinician and treat your physician patient the way youwould any other intelligent patient. Ask directquestions and make thorough clinical decisions whileappropriately preserving the patient’s autonomy.Attending physicians and their physician patients canunwittingly engage in competition with one another,and this can quickly lead to friction in the therapeuticrelationship. Furthermore, sometimes the treatingphysician may feel intimidated and might assume thepatient knows more than he/she really does about


mental health or other medical care. If your patientrequires hospitalization at any point, you should doyour best to ensure the course of treatment iscompleted adequately. Keep in mind that physiciansare often reluctant to adopt the sick role and followclinical advice. 10-25% will leave the hospitalprematurely. During outpatient treatment, physicianpatients may discontinue medications prematurelyand be less than optimally compliant with follow-uptreatment.

Addressing Burnout by Fostering Resilience:

Resilience, in psychological terms, is a concept thathas been gaining significant traction in the pastdecade. As an adaptive trait, it is being studiedintently for its applicability to patient care.

The American Psychological Association definesresilience thusly: “Resilience is the process ofadapting well in the face of adversity, trauma,tragedy, threats or significant sources of stress —such as family and relationship problems, serioushealth problems or workplace and financialstressors. It means 'bouncing back' from difficultexperiences.”

Resilience is a trait which we all have to somedegree. It is not to be found only in the relatively few“super-stars” among us, and it does not imply lack ofdifficulty or distress in daily life. Resilience can andshould be cultivated by all persons during their life’sjourney. A core trait of resilient persons is self-awareness. One should be well-acquainted with his/her core values, strengths, interests or preferencesand passions as well as with any significant personalweaknesses or limitations. A resilient physicianunderstands and periodically re-evaluates what typeof work is satisfying and meaningful (e.g. providesadequate intellectual stimulation and challenge,sense of service, outlet for creativity,etc.). It iscritical to know one’s core values as these inform lifeand career choices. An adequate knowledge of one-self and one’s values helps create a sense ofpurpose in life. This sense of purpose providesmeaning and an internal sense of control.Awareness of this is invaluable in the search for/design of a self-compatible practice setting.

A resilient physician also has a sense ofconnectedness to an adequate personal andprofessional network of relationships which helpsupport the attainment of personal and professionalgoals and also serve as an important buffer againststress. The maintenance of these networks is anactive process, and all healthy relationships requireactive attention, even though at the best of timesthey may appear self-sustaining.

Active attention to one’s needs also benefits thephysician’s approach to continuous learning andadvancement of non-clinical skills (e.g. keeping upwith pertinent technology, work strategies, financialmanagement skills, interaction with the managedcare milieu). Many physicians are trapped by the“old rules” they learned in a prior era and findthemselves unable to reconcile the old with the new.

I’ve saved for last what is perhaps the mostimportant factor in developing and maintainingpsychological and emotional resilience: Life Balance.A content, non-burned out physician is more likely tohave well-developed personal relationships as wellas good work relationships. This physician alsovalues a healthy amount of solitude and leisurepursuits and takes regular vacations. It is alsoimportant to regularly remove one’s intellectual “hat”and contemplate one’s life, life goals and thesurrounding world. When it comes to spirituality,believe it or not, at least 70% of physicians (evenpsychiatrists) reports having discrete spiritual orreligious beliefs. We may not discuss them much inthe workplace, but they do affect the way we makechoices and live our lives. When I take a patient’ssocial history, I always inventory whether the patienthas (or doesn’t have) any connection with religion orspirituality so that my recommendations can be morecompatible with the patient’s world-view. We asphysicians should do the same when we address thebig issues in our own lives. Even persons with noconcept of a “deity”, “beneficent universe”, or “higherpower” can cultivate an attitude-of-gratitude andpractice spending more time thinking about the goodthings and good fortune in their lives and less timeruminating about what is painful.

I will close with a review of potential strategies toprevent and address already established burnout inyour or a colleague’s life.

The old saying, “An ounce of prevention is worth apound of cure”, applies to burnout as it does to somany other medical conditions. People who haveexperienced burnout once are more likely than theirpeers to experience it multiple times. As much asyou can, tailor your practice to your body’s needs,rather than trying to convince yourself that you reallycan do fine on 2 hours of sleep every 3rd or 4th night,or that your medically trained body doesn’t need thesame attention to nutrition and exercise that werecommend to our patients. Work a tolerablenumber of hours. Try to focus at least 10% of yourpractice on clinical or research issues that you aremost passionate about.

If your or your group’s morale is low, or if your family,friends or co-workers express concerns about yourbehavior, your schedule or the way you look, try to at

least contemplate their concerns and give them morethan lip-service.

The development of somatic symptoms (headache,GI problems, concentration difficulties, insomnia,worsened temper), while non-specific, may be anindication of excessive or prolonged stress. Theeffects of stress develop insidiously and are easilyoverlooked and can clearly contribute to the develop-ment of burnout, depression/anxiety or both.

Be aware of potentially dangerous personality traitsand intellectual behaviors such as perfectionism,selflessness, passivity/avoidance, and externalizingblame or guilting yourself.

Set realistic goals for yourself and periodically reviewand reconsider your priorities, values and work goals.Don’t be stoic, but discuss your concerns and planswith friends and loved ones. Exercise in asustainable way and take enough vacations. Keep inmind the words of Leticia de Mattos-Arruda, MD,“there is no such thing as work/life balance; there arework/life choices.” No one can “have it all.”

Once full-fledged burnout has occurred and has beenidentified, it is critical to identify contributing factorsand address the most important causes, and any

impact on patient care, first. Don’t be fooled intothinking “it will get better when….”, because itprobably won’t. Rule out the presence of a co-morbiddepressive disorder. Treating just the depressedmood with only psychotropics might (perhaps) helpthe depression for a while, but it won’t help theburnout and will ultimately be a failed strategyleading to more resistant symptoms. Don’t drinkalcohol excessively or otherwise self-medicate. Gethelp with patient coverage when possible. Do takeyour needs very seriously and don’t try to be some-thing you don’t need to be. Recognize that you havevalid limits, needs, hopes and dreams just luck anyrole model you’ve ever looked up to (but whoprobably didn’t show you many of their“weaknesses”). Finally, if your thoughtful andmethodical approach to making things better doesn’twork fairly quickly, seek the advice of someone youtrust to help you, professional or otherwise.

In a future article: “The impact on pilots of workplacestress”. There is ample human factors research onthe effect of stress on the proficiency of pilots, butrelatively little on the prolonged effects of being apilot on the pilot. I hope to provide a review of theeffects of workplace stress on the long-termwell-being of pilots.

References:

Amer. Psychol. Assn (www.apa.org)

Bianchi, R.; Schonfeld, I. S.; Laurent, E. "Is burnout adepressive disorder? A re- examination with special focuson atypical depression". International Jourznal of StressManagement 21 (4): 307–324 2014 British MedicalJournal

Art Caplan, PhD - Division of Medical Ethics, New YorkUniversity Langone Medical Center

Drummond D. TheHappyMD.com

Dyrbrye, et al. “Burnout among U.S. medical students,residents, and early career physicians relative to thegeneral U.S. population.” http://www.ncbi.nlm.nih.gov/pubmed uid=24448053

Freudenberger, H, Richelson G. Burn Out: The High Costof High Achievement. What it is and how to survive it.Bantam Books. 1980

Goldman LS, Myers M, Dickstein LJ -eds. “The Handbookof Physician Health” AMA Press 2000

ST Gregory & T Menser, Burnout Among Primary CarePhysicians: A Test of the Areas of Worklife Model, Jrnl ofHealthcare Mgmt 60:2 March/April 2015

Hester AM. “Dealing With Compassion Fatigue”. Hospital-ist News May 16, 2016

Houkes et al. “Development of burnout over time and thecausal order of the three dimensions of burnout among

male and female GPs.” BMC Public Health 2011, 11:240

Johnson, V. “Care for the Caregiver – Caregiver Burnout”.Navy Medicine Magazine Feb 24, 2014

Linzer M AMA Wire March 4, 2105

Linzer, M. 10 Bold Steps to Prevent Burnout in GeneralInternal Medicine. J Gen Intern Med. 2014; 29(1):18–20.

Maslach, Christina; Jackson, Susan E.; Leiter, P. Michael;Schaufeli, Wilmar B., 1996.

Leticia de Mattos-Arruda, MD Medscape.com Dec 14,2015 http://www.medscape.com/viewarticle/855706Medscape 2015 Annual Physician Lifestyle Report

Murphy T. “Physician Burnout: A Guide to Recognitionand Recovery” ALOHA Publishing 2015

Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes inburnout and satisfaction with work-life balance in physi-cians with the general US working population between2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613

Spitzer RL, Williams JBW, Kroenke K “Patient HealthQuestionnaire” Pfizer, Inc.

https://www.acponline.org/system/files/documents/about_acp/chapters/ut/16mtg/l opez.pdf

http://www.animatedimages.org/img-animated-doctor-image-0065- 188686.htm#linkit

https://www.presentationmagazine.com/newspaper-headlines-template-9437.htm


AVIATION CERTIFICATIONSERVICES, LLC.

Warren S. Silberman, DO, MPHPresident-Elect, CAMA

If my fellow members were unable to make theMayo Clinic Rochester, MN, Annual Meeting youmissed a great one. Drs. Cowl and Bob Haddonfrom Mayo’s Preventive Medicine/AerospaceMedicine Department put on a fantastic seminar!

An important process for all AME’s to get used to isthat the FAA Office of Aerospace Medicine isplacing more and more responsibilities on itsAMEs. (This should not be a great surprise to youall, unless you have been in a coma for the past 15years!) You all need to get used to using theFAA.gov website. There will be more and moreinformation and certification aids on this site. Youcan find out what to do about a good portion ofaeromedical conditions by going to this site. Inreality, you should be using this site ratherregularly, when your airman has a Condition AMECan Issue (=CACI) condition. (http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/certification_ws/)

They want you to navigate to the Guide for AviationMedical Examiners site and from there use theAerospace Medical Dispositions link, CACICertification Worksheets link, or Disease Protocolslink. From there, you can find what they want youto do about most aeromedical conditions.

I want you to try something. Let’s go with some-thing easy this time! How about if you had a deafpilot come in for an initial FAA medical examina-tion? What do you do? Let’s see. Go to FAA.gov,click on the link for medical certification. Under thesecond section entitled Aviation Medical Examinersyou will see the link for the Guide for AviationMedical Examiners. Click on that link and you willbe taken to a screen where you see AeromedicalDecision Considerations. Under that heading yousee the link Aerospace Medical Dispositions. Clickon that link and next you see DecisionConsiderations – Aerospace MedicalDispositions; Item(s):. There are all the links forthe items on page 2 of the 8500-8. Now click on#49. Hearing—http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/app_process/exam_tech/item49/amd/ Here is theURL address you will be taken to, and what do yousee: Bilateral Deafness. See Items 25-30. If other-

wise qualified, when the student pilot's instructorconfirms the student's eligibility for a private pilotcheckride, the applicant should submit a writtenrequest to the AMCD for an authorization for aMFT. This test will be given by an FAA inspector inconjunction with the checkride. If the applicantsuccessfully completes the test, the FAA will issuea third-class medical certificate and SODA. Pilotactivities will be restricted to areas in which radiocommunication is not required. There is what youwould do for a deaf airman!

In the next publication, I am going to test you to seeif you can find the answers to some aeromedicalconditions.

Now to answer a question from one of ourmembers: I was asked about what would an AMEdo about professional liability insurance (orMalpractice Insurance) if he is retired now and isperforming examinations and is also a HIMSAME—that is all he is doing. Look, I am not goingto preach what you should do, but I will tell you mypersonal thoughts. I know AMEs out there who go“naked” (without any insurance). I am sorry, I ampersonally too paranoid. Even though you shouldbe overly truthful to the airmen you evaluate. Youmay be wrong with your opinion. If you tell themthey “should” gain medical certification and they getdenied. Or perhaps even worse, you miss some-thing on the examination and they come after you.I had professional liability insurance. What we doas AMEs and AME advocates is not actually carefor airmen. We don’t prescribe medications. Wedon’t do procedures. We practice what I call“administrative medicine”. Trying to find an insur-ance person who “got” what I did was the mainproblem. They all quoted what an internal medicinespecialist should pay (I am also an Internist.) Evenafter I wrote my own statement that explained indetail what I did and what I didn’t do, they still quot-ed what I thought was an outlandish amount ofmoney ($7,500 to $14,000 US per year)! Aftermany attempts, I finally located someone who “gotit!” The first year I was out, I paid about $3,000 US,and this year I paid approximately $3,400 US. Stillit was much less than I was initially quoted.

NOTE: Please submit any AME-related questions youwish answered to [email protected] for Dr.Silberman. Please indicate in your emailed questionyour city and state or city and country, and statewhether or not you wish to have your real name used inthe column. Dr. Silberman will answer your question inhis column and may also contact you directly via emailto provide a timely personal answer.

AME Question Column



Robert Anderson “Bob” Hoover, a pilot whoescaped Nazi captivity in a stolen plane, testedsupersonic aircraft with his friend Chuck Yeager,barnstormed the world as a breathtaking stuntperformer and became, by wide consensus, anAmerican aviation legend, died on Tuesday in LosAngeles. He was 94.

Even General Yeager, perhaps the most famoustest pilot of his generation, was humbled by Mr.Hoover, describing him in the foreword to Mr.Hoover’s 1996 autobiography, “Forever Flying,” as“the greatest pilot I ever saw.”

The World War II hero Jimmy Doolittle, anaviation pioneer of an earlier generation, called Mr.Hoover “the greatest stick-and-rudder man that everlived.”

Tall and lanky, Mr. Hoover forged a long careerstudded with aeronautical achievements and feats ofderring-do. The subtitle of his memoir, written withMark Shaw, suggests as much: “Fifty Years of High-Flying Adventures, From Barnstorming in PropPlanes to Dogfighting Germans to TestingSupersonic Jets.”

At a World War II air base in the Mediterranean,he wrote, he terrified senior pilots who had beenlording it over him by flying a P-40 fighter under abridge while they were standing on it. At aninternational aerobatic competition in Moscow in1966, he put on a thrilling, though unauthorized,display flying upside down and executing spectacularloops in a Yakovlev-18. By his account, the stuntupset his Soviet hosts, and he escaped KGB custodyafterward only because of the intervention of a mildlyinebriated Yuri Gagarin, the first man in space. Thetwo had struck up a friendship.

Indeed, Mr. Hoover could tracethe history of aviation, to the dawnof the space age, by the men hecame to know: Orville Wright andCharles Lindbergh, GeneralDoolittle and World War I flying ace

Eddie Rickenbacker, and the astronauts WalterSchirra and Neil Armstrong, as well as GeneralYeager and Colonel Gagarin.

Mr. Hoover’s trademark maneuver on the showcircuit was a death-defying plunge with both enginescut off; he would use the hurtling momentum to pullthe plane up into a loop at the last possible moment.But his stunts were not foolhardy. Each involvedpainstaking preparation and rational calculation ofrisk. “A great many former friends of mine are nolonger with us simply because they cut their marginstoo close,” he once said.

Hoover’s favorite plane in the 1950s and ’60s was“Old Yeller,” a P-51 Mustang fighter painted brightyellow. Mr. Hoover sometimes shunned flight suits toperform in a business suit (less trouble for theundertaker in case of an accident, he once said) anda trademark Panama straw hat.

He once invited a crew from the ABC program“That’s Incredible!” to film him in action, pouring aglass of iced tea with one hand while he rolled hisplane 360 degrees with the other.

Robert Anderson Hoover was born on Jan. 24,1922, in Nashville, TN. His father, Leroy, worked fora paper company while his mother, Bessie, kepthouse. Bob started to fly as a teenager, “working 16hours in a grocery store to earn 15 minutes of flighttime,” as he told an audience of young admirers.

He soon taught himself the loops and hand rolls ofaerobatics, enlisted in the Tennessee National Guardand received orders to Army Pilot Training School.With the onset of World War II, he was sent toEngland as a flight instructor for the Royal Air Force.The Army Air Forces later assigned him toCasablanca, Morocco, where he tested newlyassembled and repaired planes and ferried them tothe front. Valued as an operations officer, he wasnevertheless hungry to fight and, through

Robert A. “Bob” Hoover Obituary

Bob Hoover with the F-100DSuper Sabre, an aircraft that hetested for North AmericanAviation. Credit Boeing, All RightsReserved

Chuck Yeager, left, and Bob Hoover in1997 at Edwards Air Force Base inCalifornia. Credit Reuters

Ron Kaplan, of the National Aviation Hall ofFame in Dayton, Ohio, where Mr. Hoover wasenshrined in 1988, said of Mr. Hoover, “You do notsurvive the life he lived without discipline andcaution.”

persistence, persuaded his commanders to granthim combat duty. “I can hit a target upside down orright side up,” he said he told a general.

As a pilot with the 52nd Fighter Group, based inCorsica, Mr. Hoover, a lieutenant, flew 58 successfulmissions before his Spitfire fighter was shot down bythe Luftwaffe in February, 1944. He spent 16 monthsin Stalag Luft I, a prisoner of war camp in Germanyreserved for Allied pilots.

Mr. Hoover and a friend escaped from the campin the chaotic final days of the war, according to hismemoir. Commandeering an aircraft from a desertedNazi base, he flew it to freedom in the newlyliberated Netherlands, only to be chased by pitchfork-wielding Dutch farmers, enraged by the plane’sGerman markings.

He remained in the military after the war as a testpilot based at Wright Field in Ohio (now part ofWright-Patterson Air Force Base). There, with jet-propulsion planes replacing propeller aircraft, he tookon the dangerous duty of working out kinks in work-horses like the F-80 and P-51 fighters. Mr. Yeagerwas also a test pilot there, and in the fall of 1945they became friends after getting into a spontaneousmock dogfight that ended in a draw. They were soonperforming in air shows around the country.

Both men were recruited to train together atMuroc Field (later named Edwards Air Force Base)in California to fly the Bell Aircraft X-1, the rocketplane that broke the sound barrier in October 1947over the Mojave Desert. Mr. Hoover might well havegotten the call to pilot the plane if his rambunctiousstreak had not undone him, Mr. Kaplan said. Earlierthat year, he had buzzed a civilian airport in Spring-field, Ohio, in an experimental military jet as a favorto a friend; the friend wanted his relatives in the areato think that he was flying the aircraft.

Commanders discovered the episode, and Mr.Hoover was relegated to flying the “chase” planeduring the X-1 test flights, making observations andtaking photographs, while Mr. Yeager made history.

After leaving the Air Force (the successor to theArmy Air Forces), Mr. Hoover became a test pilot forGeneral Motors and then North American Aviation, aLos Angeles-based military contractor that latermerged with Rockwell International. He stayed with

the company through the 1980s. But as the pace ofjet innovation slowed, he became a roving ambassa-dor and showman, flying North American planes atair shows around the world and taking part in adocumentary film, “Flying the Feathered Edge: TheBob Hoover Project.”

After leaving the aerospace business, Hooverbecame an hallmark of the air show and race circuit.He flew in more than 2,500 civilian and military airshows in the U.S. and around the world, according tothe Smithsonian, thrilling those on the ground withhis trademark routine: Shutting off one or both of theengines on his North American Rockwell ShrikeCommander 500S, while performing loops and dives.

Mr. Hoover flew well into his 80s, but not beforeclashing with the authorities when he was 72, in1994, when medical examiners from the FederalAviation Administration declared him unfit to fly,saying that his “cognitive abilities” had diminished.

Mr. Hoover quickly recertified himself in Australiaand began a legal battle back home, led by thedefense lawyer F. Lee Bailey, who had befriendedMr. Hoover through a mutual love for flyinghelicopters. Mr. Hoover emerged victorious 18months later, and his United States license wasrestored. His campaign found support among fanswho wrote thousands of letters. At the Oshkosh Fly-In and Air Show in Wisconsin, posters weredisplayed everywhere saying, “Let Bob Fly.”

A precise aviator, Hoover famously was able topour a glass of iced tea in the middle of a barrel role.Hoover's famous green and white stunt plane sitsprominently under the wing of the Concorde super-sonic airliner at the National Air and Space MuseumAnnex in Chantilly, Va.

Mr. Hoover was one of the most honored pilots inAmerican history. His military awards alone includethe Distinguished Flying Cross, the Soldier’s Medalof Valor, the Air Medal with Clusters, the PurpleHeart and the French Croix de Guerre. In 2007 hereceived the National Air and Space MuseumTrophy, the museum’s highest honor.

Mr. Hoover’s wife, Colleen, died recently. They hadlived for many years in the Los Angeles area.Survivors include a son, a daughter and severalgrandchildren. There are a number of obituaries andvideos of Bob Hoover available on the Internet, andWikipedia lists his accomplishments and projects indetail.

(The items in blue are links to articles and videos. It may benecessary to click “Control” and the link at the same time toactivate the links.)


Bob Hoover was enshrined in theNational Aviation Hall of Fame in1988. Credit Ron Kaplan/NationalAviation Hall of Fame


Ms. Kathleen Yodice has been representing aviationlegal interests for almost 30 years, beginning her careeras an FAA prosecutor and regulatory lawyer, beforemoving into private practice defending air carriers,commercial operators, repair stations, pilots, andmechanics against FAA enforcement actions andassisting entities and individuals in aviation compliancematters, medical certification concerns, and aviation-related business and transactional issues.

Ms. Yodice received her law degree from the Universityof Maryland School of Law and a Bachelor of ArtsDegree from Frostburg State University, where sheconcentrated her studies on psychology andmathematics. She is admitted to practice in Marylandand the District of Columbia, as well as the U.S. Courtsof Appeals and the U.S. Supreme Court. She is anactive member of the Maryland and D.C. BarAssociations, the Lawyer Pilots Bar Association, andthe International Air & Transportation Safety BarAssociation. Ms. Yodice is a Past President of theLawyer-Pilots Bar Association and currently sits ontheir Board, and she served on AOPA’s Board ofAviation Medical Advisors. She was appointed to, andcontinues to serve on, the Editorial Board for the ABAForum on Air and Space Law, and she is a former long-time panel member in the Transportation ResearchBoard’s Airport Cooperative Research Program.

Ms. Yodice is an instrument rated private pilot. Shelearned to fly in the family’s 1946 Piper J-3 Cub, and sheco-owns a 1968 Piper Cherokee 180 with her brother.

I Do Declare –PBRII Physician

Certification Change

As we’ve all no doubt heard by now,Congress passed legislation this past summer thatdirects the FAA to adopt rules to allow pilots tooperate aircraft without having to hold a currentmedical certificate issued by the FAA. Many refer toit as “Third Class Medical Reform”. Proponentsargue that it is a positive step toward bolstering theGeneral Aviation industry and finally eliminatingunnecessary and costly bureaucratic red tape; oth-ers have described it as compromising a tried andtrue safety system. It literally took an act ofCongress to achieve this landmark change that hasbeen the subject of debate, letter writing, petitions,meetings, draft rulemaking, and more for many,many years. Sure, a form of this has been inexistence for years for balloon and glider pilots, anda broadened application was achieved with SportPilot. But, this change goes much further, yet somewould still say not far enough. At this point, thedeliberation is done, and we’re left to see how thechanges play out.

The legislation is fairly specific, but a lot will stillneed to be sorted out in the rulemaking process,which will need to be completed by summer 2017.An area of the legislation that will likely not besubjected to much change in the rulemakingprocess will be the certification that physicians mustmake when examining a pilot who may then flyunder this new medical classification group. Let’sexamine the difference between what AME’s sayfollowing a third class medical applicationexamination, and what a doctor (maybe an AME,but not necessarily an AME) will say after theexamination required by the new law.

To be an AME, a doctor must receive adesignation from the FAA and thereby beauthorized to conduct examination of individuals ina manner that allows that AME to complete the“Report of Medical Examination” on the medicalapplication. There is a rather lengthy list of medicalchecks that need to be done and documented.After conducting the required examination, the AMEmust make a statement as to whether a medicalcertificate was issued, no certificate issued, orcertificate had been denied. And, then the AMEmust make a “Medical Examiner’s Declaration” bysigning the form saying,

“I hereby certify that I have personally reviewedthe medical history and personally examined theapplicant named on this medical examinationreport. This report with any attachment embodiesmy findings completely and correctly.”

(Continued on Page 19)


Such a declaration isevidence of the facts declared,i.e., that the AME was the onewho reviewed the individual’smedical history (Question 18 onthe application), and the AMEwas the one who conducted theexamination and is providingthe examine information to theFAA.

For the most part, the list of items contained onthe FAA’s medical application form is nearlyidentical to the checklist that is contained in thelegislation that outlines the “comprehensive medicalexamination” to be conducted by any State-licensedphysician. The physician is to check each item andaddress “as medically appropriate” every medicalcondition and any medication listed, includingdetermining whether any medical tests are warrantedand discussing the potential of any prescription ornon-prescription medication to interfere with the safeoperation of an aircraft or motor vehicle. Then, thephysician must affirmatively state,

‘‘I certify that I discussed all items on this check-list with the individual during my examination,discussed any medications the individual istaking that could interfere with their ability tosafely operate an aircraft or motor vehicle, andperformed an examination that included all of theitems on this checklist. I certify that I am notaware of any medical condition that, as presentlytreated, could interfere with the individual’s abilityto safely operate an aircraft.’’

A certification is the formal assertion of some fact,i.e., that the physician performed the examinationand discussed any conditions and medications withthe individual, and further, that the physician doesnot know of a medical reason the individual could notsafely operate an aircraft.

It appears that the role in each circumstancediffers significantly for the physician. I expect thatthe physicians will take care to fully appreciate theimport of their examinations and their signatures ineither circumstance. It’s a change, pure and simple.

It appears that the role in each circumstancediffers significantly for the physician. As an AME, thephysician is acting as a designee of the government,acting on behalf of the FAA, and any informationgathered is shared with the FAA for them to makethe ultimate medical qualifications decision. Itappears that the physician performing theexamination under the new legislation, whetherholding an AME designation or not, will be renderinghis or her own conclusion of medical qualifications to

safely operate an aircraft. A lot of questionsregarding training and experience to perform theseexams, the extent of the associated responsibilitiesthat come from signing the bottom line, theavailability of malpractice insurance coverage, andthe potential liability issues, at a minimum, all remainunanswered at this time. I expect that the physicianswill take care to fully appreciate the import of theirexaminations and their signatures in eithercircumstance. It’s a change, pure and simple.


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RAYMAN’S CLINICAL AVIATION MEDICINE5th Edition, 2013

CURRENTLY AVAILABLE FROMTHE CAMA HOME OFFICE!!

The 2013 fifth edition of “Rayman’s Clinical Aviation Medicine” is a 485 pagerewrite of the classic text. Seven physicians well experienced in aviationmedicine provide aeromedical disposition guidelines for civil and military avia-tion, making it an indispensable reference for the aviation medical examineror flight surgeon practicing in an operational or regulatory role. (The authorsreceive no royalties.)

The price for the book is $50.00, plus $7.00 postage in the U. S., $25.00 toCanada, and shipping rate to other locations outside of the U. S. is variable,payable by check, VISA, or MasterCard. Call or email CAMA for your copy!770-487-0100 or [email protected]

CAMA now has a Facebook page! In order to provide the best options for communicationwith our members and other interested parties, we have established a Facebook page. Ifyou are already on Facebook, you may find our page by entering “Civil Aviation MedicalAssociation” into the search box. We will post current events, photos, and other pertinentinformation about our organization. You are invited to ask questions or to post comments orphotos on our page (inappropriate remarks/photos or advertisements will be removed). Thepage is monitored several times daily, and we will strive to answer your questions promptly.Please contact the CAMA home office if you have any questions, suggestions, or commentsabout the Facebook page.

BLAST FROM THE PASTFrom the Fall 1988 Edition of “The Flight Physician”



BLAST FROM THE PAST (CONTINUED)


BLAST FROM THE PAST (CONTINUED)

Dr. Forrest M Bird passed away August 2, 2015, and his beloved wife Dr. Pamela Riddle Bird, joined himin the next dimension on October 8, 2015. (See the full memorial articles for each in the September 2015and November 2015 editions of “The Flight Physician” for additional information.) Both were friends andsupporters of CAMA and are very much missed.

The vision Dr. Bird had for the future of CAMA in 1988 and his perception of CAMA’s history are stillpertinent to the organization today. CAMA has remained a progressive organization dedicated to theeducation and support of the AMEs and the aeromedical community in general and a leader in promotingcommunication among the various government and aviation-related organizations. We are very proud tohave been associated with Doctors Forrest and Pamela Bird, and to have had the privilege to present theForrest and Pamela Bird Recognition Award to deserving individuals each year through 2015 during theHonors Night Banquet of the Annual Scientific Meeting. Since the Birds are no longer with us, the futureof the Bird Recognition Award will be determined by the CAMA Board of Directors in the future.

Past recipients of the Bird Recognition Award can be viewed on the CAMA web site atwww.civilavmed.org. Click the tab “About CAMA” and click the link entitled “Awards” for a description ofeach award and its recipients.

Civil Aviation Medical AssociationSustaining, Corporate, and Life Members

The financial resources of individual member dues alone cannot sustain the Association’s pursuit of its broadgoals and objectives. Its fifty-plus-year history is documented by innumerable contributions toward aviationhealth and safety that have become a daily expectation by airline passengers worldwide. Support from privateand commercial sources is essential for CAMA to provide one of its most important functions: that of education.The following support CAMA through corporate and sustaining memberships, and we recognize the support ofour lifetime members:

Allied Pilots Association14600 Trinity Boulevard

Suite 500Fort Worth, TX 76155www.alliedpilots.org

Casa Palmera, HTC, LLC14750 El Camino RealDel Mar, CA 92014www.casapalmera.com

Harvey Watt & Company, Inc,P. O. Box 20787Atlanta, GA 30320-9990www.harveywatt.com

SomnoMed, Inc.7460 Warren Pkwy, Suite 190Frisco, TX 75034somnomed.com

Talbott Recovery Campus5448 Yorktowne DriveAtlanta, GA 30349www.talbottcampus.com

Corporate Members & Sponsors

Life Members

Prof. Michael Bagshaw, MB BChMichael Boyer, MDJohn R. Capurro, MDGeorge H. Coupe, DOBill B. Curtis, MDAndrew J. Davis, MDM. Craig Delaughter, MD, PhDMark C. Eidson, MDMohammed Eisa, MDTony Evans, MDDonna Ewy, MDEdmond Feeks, MD, MPHAynalem Gebremariam, MDRobert Gordon, DODottie Hildebrand-Trembley, RNErnst J. Hollman, MDJoseph Kearns, DOAtsuo Kikuchi, MDStephen M. Kirkland, MDErnest J. Meinhardt, MDAndrew H. Miller, MDDavid P. Millett, MD

Story Musgrave, MDThomas Nguyen, MDMichael G. Nosko, MD, PhDHugh J. O’Neill, MDMilton A. Padgett, MDRob G. Parrish, MD, PhDMichael A. Pimentel, DOJeffrey P. Powell, MD, DDS.Sean Kevin Roden, MDRobert M. Roeshman, MDMark S. Rubin, MDGerald W. Saboe, DOPhilip Sidell, MDSergio B. Seoane, MDKazuhito Shimada, MDBrian Smalley, DOE. Warren Stadler, Jr., MDRuth Steward, RNShepard B. Stone, MPS, PASalil C. Tiwari, MDLars Tjensvoll, MDHarold N. Walgren, MD.

Sustaining Members

Per Johan Cappelen, MDA. Duane Catterson, MDDeWayne E. Caviness, MDGary Crump, AOPA

Harold H. Haralson, II, MDHarold N. Walgren, MDSir Rodney E. L. Williams, MD


William A. Collignon, MD203 Avalon Avenue, Suite 100Muscle Shoals, AL 35661Senior AME, Pilot, General Surgery

Herminio Cuervo, MD, MPH1601 Williamsburg SquareLakeland, FL 33803AME, Neurology/Aerospace Medicine

Marque Malan, ATPAeromedical & Human Performance SpecialistAirline Pilots’ Association535 Herndon ParkwayHerndon, VA 20170Pilot, Aeromedical & Human Performance

Soli D. Miningou, MD01 BP 4730Ouagadougou, Burkina Faso, AfricaSenior AME, Pilot, General Practice

Dean M. Olson, MD, MS309 Dellwood AvenueOakwood, OH 45419AME, Aviation Medicine/Family MedicineDirector, Aerospace Medicine Residency ProgramWright State University

Ira Rampil, MD236 Candler WayWilliamson, GA 30292Senior AME, Pilot, Anesthesiology/Aerospace Medicine

Kathleen G. Todd, MDBox 1829Valdez, AK 99686AME, Family Medicine

New Members

CAMA is very pleased to announce a number of new members to our organization since our last publication.We welcome the following physicians and organizations into CAMA, and we look forward to working witheach of them over the coming years.

PresidentClayton T. Cowl, MD, MS

President-ElectWarren S. Silberman, DO MPH

Immediate Past PresidentMark C. Eidson, MD

Secretary TreasurerJohn S. Raniolo, DO

Executive Vice PresidentDavid P. Millett, MD, MPH

Vice President for EducationRobert Haddon, MD

Vice President for CommunicationsAnd RepresentationPetra Illig, MD

Vice President for ManagementGerald W. Saboe, DO, MPH

CAMA Trustees:

Term Expiring 2017:

Edmond F. Feeks, MDFred A. Furgang, MDJohn D. Hastings, MDSean K. Roden, MDAlex Wolbrink, MD

Term Expiring 2018:

Steven Altchuler, MD, PhDMichael F. Boyer, MDRichard Ronan Murphy, MBChBGregory A. Pinnell, MDRussell B. Rayman, MD

Term Expiring 2019:

Robert J. Gordon, DORichard S. Roth, MDSergio B Seoane, MDBasil P. Spyropoulos, MDRodney E. L. Williams, MD


2016-2017 CAMA Officers:

flight physician - camacivilavmed.org/wp-content/uploads/2016/12/cama-flight...logistical challenges...

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