Spring Meeting: Saturday 23rd February 2008, London.
Theme: Recent Advances in Aviation and Medicine
Venue: The Royal College of General Practitioners, 14 Princes Gate, Hyde Park, London.
Our grateful thanks are due to Norena McAdam who undertook the general organization, and Raj Bansal who organized the lecture programme, the theme being “Recent Advances in Aviation and Medicine”.
The meeting went off very well, and was followed in the evening at the same venue by a delightful Association Dinner.
During the meeting a short EGM was held to change Article 11, carried unanimously, so that a quorum is now 10% of eligible voting members to be present within 15 minutes of a set time for a General Meeting.
Chairman Michael Bagshaw, an ex fast-jet pilot, explained that one speaker, John Thorpe, was ill with shingles and severe pain which made him too unwell to attend. Prof. Bagshaw agreed to take John Thorpe’s spot with an off-the-cuff talk, much appreciated by all.
The national private pilots licence – Dr. Ian Perry.
Dr Perry is an internationally known aviation medical specialist. He is ex-Army, and was heavily involved in setting up the Army Department of Aviation Medicine. He has a particular interest in the Army Air Corps Museum.
The NPPL ( loosely based on the USA sports licence) is attracting interest from the European authorities. Dr. Perry is not enthusiastic about the medical aspects of the NPPL, feeling that it is too much based on trust and is unhappy at the lack of mandatory record keeping. GPs can sign up NPPL medicals, but are not contractually obliged to do so and often refuse on the grounds of lack of aviation knowledge, though the criteria are little different from an HGV medical.
Dr. Perry considers cases referred to him sympathetically, but the lack of firm rulings means that he frequently has to use his own judgement, and basically he feels that there are “lots of holes in the NPPL“.
To consider some specific examples:
- Insulin-dependant Diabetes: Six in the UK, only one with passengers. Compare with 60 HGV UK drivers and 650 unrestricted flyers in the USA. The criteria are to be fit and stable.
- Bipolar disorders. Not happy with these since there is an element of unpredictable behaviour.
- Lymphoma. OK, with reservations, must be fit and well and in proven remission.
- Bowel cancer. Just uses his judgement for the individual.
- Heart valve replacement. Difficult, the JAR rules are inflexible.
- Limb prostheses. Generally not a problem.
- Warfarin and anticoagulants. Not a problem if the basic condition is stable and satisfactory.
- Positional awareness problems need very careful consideration, and demand excellent visual function and compensation ability.
- A significant UK advantage over the USA and European situations is the availability of central GP records, albeit at times with some difficulty.
Human factors in G.A. accidents – Prof. Michael Bagshaw.
As well as his impressive list of medical achievements, Michael Bagshaw is a commercial pilot, instructor and examiner. He is co-author of the standard work “Human Performance and Limitations”, a new edition is due soon.
He reminded us that G.A. “fatals” remain relatively constant at around 12 per annum, the commonest cause being “Controlled Flight into Terrain” (CFIT), usually due to continuing into bad weather. Other factors are loss of control at low level and going off the end of the runway. Though “Human Factors” has been an exam. subject since 1991, there has been no obvious decline in the accident rate. It has become just another exam. to pass.
He suspects that many basic skills have become eroded with automation and sat-nav. He doubts whether our medicals contribute much to flight safety, partly due to inaccurate self declaration. He noted the current “locked door” commercial policy, mentioning the problems of long hours alone with an opposing personality.
The partial pressure of oxygen at 15,000 feet is of no real interest to the average GA pilot, and such matters lower the credibility of the exam. It does help, however, to know that alcohol and hypoxia produce similar results, giggles or aggression, depending on make-up, along, of course with unrecognized incompetence.
Human error potential is within us all, and always will be. What really matters is our individual reaction to it. We should consider an incident or error, analyse it and learn from it. The problem arises with those who dismiss an error without thought, if indeed the error was recognized.
He illustrated this with a recent twin rating test with a rich businessman owner of a smart new twin. Having completed the required hours of training he insisted on taking the test, even though his instructor advised more training. (In commercial tests, the candidate must be signed up as competent, before the exam. can be done).
The man was all sweetness and charm in the briefing, then took an age to get the aeroplane aloft. Very soon he committed a gross and dangerous basic error of airmanship, and M.B. terminated the test and suggested further instruction. The candidate became absolutely furious and unapproachable, not taking on board the seriousness of his error. No doubt he would get his rating in due course, but would you want to be in the same airspace with such a person?
You cannot treat personalities. Fortunately the sky is a big place!
Assessing pilot medical fitness through JAA to EASA – Dr. Peter Saundby.
Peter Saundby is an ex-RAF Medical Officer, retiring in 1991 with the rank of Air Commodore. He has held a PPL since 1953, and has long been Medical Adviser to the British Gliding Association.
He has argued for simpler medical requirements for the NPPL and is negotiating with EASA for similar for the proposed European PPL. Medical fitness addresses two issues: 1) Functional fitness e.g., special senses, orthopaedic. 2) Risk of incapacity, e.g. cardiovascular, neurological, hypoglycaemia, psychiatric.
ICAO (International Civil Aviation Organisation) was founded in 1948 making international law out of US domestic law, and favouring the US commercially. The JAA (Joint Aviation Authorities) standardized national legislation, though without legal powers. It had a medical committee with good international co-operation, quantifying medical standards on a reasonably scientific basis. However, the committee was very large, regarding the PPL as a step towards a professional licence, so Class 2 standards were not perhaps applicable to recreational aviation. It quantified some risks, introduced limitations, and tried to manage changes following medical advances. Class 2, however, was never accepted in France, and Switzerland and the Netherlands produced a Sport licence, and the UK the NPPL.
EASA (European Aviation Safety Agency) is European legislation to be implemented by national authorities. It was established in European law in 2002, HQ in Cologne, 300 staff, 2 medics (one Russian, one German), is inadequately funded with low salaries and poor recruitment. It is driven by Airbus for reasons of aircraft certification.
“Medical” is a subgroup of “licencing”, producing draft laws in stages, with no national opt-out, but supposedly open consultation. Final versions are given political approval, for implementation by national authorities. There is a proposal for a “Light Aircraft Licence” allegedly giving a balance between “regulators” and “industry”, which he feels is not being achieved. Individuals are “experts” with no accountability, and communications between national authorities is poor. Documentation is confidential until late stages, with obvious risk of toxins in the small print.
There is a small medical sub-group including a CAA high-up and our speaker. Consider the pilot population as a pyramid, professionals at the top, hang gliders at the bottom. The lower down, the greater the likelihood of international controversy. Class 1 certification is not a problem, but Class 2 still has uncertainties, including frequency of examination.
The EASA group is tasked with producing a simple Light Aircraft Licence, with simple medical provisions. There is strong opposition to delegating this to General Practice.
Dr. Saundby predicts that, using the pyramid model, Class 2 will produce controversy and the licencing for the lesser mortals will be open to widespread attack. Since there is no international forum for Medical Officers, standardization may well be lost.
Retaining registration with the GMC – Dr. Stephen Brearley.
Dr. Brearley, Consultant Surgeon at Whipps Cross Hospital is an elected member of the GMC, now feeling, after over 20 years service, that he has had enough.
In the late 70s you only needed to pay your fee, register a contactable address, and keep your nose clean. The Blue book (“Do not…”) has been replaced by Good Medical Practice (“Do…”).
The Medical Register is now only available electronically, updated daily (www.gmc-uk.org). Parts are generally available, but no addresses, other parts on a “need to know” basis, and others, completely confidential, e.g. bank details. There is no intention of publishing medico-legal histories as is done in the US. At present you have no need to confess to being dead or not working, but this will change, as will the present fee exemption for the over 65s.
Various points:- Fees will rise due to increasing number of “fitness to practice” cases: To prevent identity theft, photos, passports, etc. will be needed. “Registered address” is anywhere through which contact can be made, (about 1,000 names annually are removed due to negative contact state).
Future arrangements will need a description of practice, effective insurance cover, and “revalidation”. Remember that insurance is limited, whereas indemnity is unlimited but discretionary.
Revalidation: The aviation comparison is meaningless since aviation tests are for laid down procedures, whereas doctors have a huge variation in their work. Revalidation is widely viewed as a way to weed out bad doctors, whilst the GMC says it is to encourage doctors to develop themselves. The truth is that well over 90% of doctors are being un-necessarily harassed.
Revalidation will be difficult to tailor to a doctor’s work, and will need to identify those with good knowledge and skills, but having a significant attitude problem. Some record of activity (“folders”) will be needed, along with local appraisal of clinical practice and no unresolved issues, along with declaration of health and probity. It is likely that some form of questionnaire will feature, involving the doctor, patients, colleagues and the Colleges. This of course will cause problems with perfectly good “outliers” e.g. prison doctors or those in purely private practice.
This year-end should see the issue of “licence to practice” and the end of free registration for over 65s, though this group of ancients can, for a substantial fee remain registered, a useless move, since without “the licence”, one cannot prescribe. Fret not, however, we can still call ourselves “Dr.”, and sign passport applications.
Dr. Brearley reviewed “Fitness to practice” historically, covering misconduct, persistent poor performance, criminal offences, ill-health and determination by another regulatory body. “Human Rights” now , it seems, make “in house” investigation/prosecution/adjudication all wrong. The GMC will “stream” complaints and ,we hope, dismiss many silly ones. The rest will be labeled either not serious, (refer back for local action), or potentially serious.
If the latter involves potential danger to the public, an interim order may be given. Otherwise action is immediate, the suspect is informed, comment invited and investigation begun. The decision regarding a “hearing” will be decided by a lay/medical group. Hearings will be in public, as in a court of law. A proven allegation can result in; no action, a warning, setting conditions, suspension or erasure.
It is said that there will be no chasing of honest mistakes, there must be a pattern of poor performance. The GMC will be reduced from the previous 105 (many elected), to 35 (not elected). Put this lot against round figures of 150,000 doctors, 200 hearings and 70 erasures on average p.a.
Oh, yes, your reporter nearly forgot, the change from “criminal standards”- “no doubt”, to “civil standards” – “no reasonable doubt” will be “flexibly applied” and is not expected to have much effect.
(Your reporter Anderson, FRCS ATPL age 70 and therefore untrustworthy and disposable, assures you that pigs fly, the evidence base for this being that he was overtaken by one on the 28 ILS at Blackpool recently. Or maybe he imagined it, being miffed at being deprived of the right to prescribe everyday drugs after 40+ years of honest graft in the trade. His submitted whinge about this at so-called consultation time was not even acknowledged. Anderson notes that two allegedly clever lawyers, untrained in policing or medicine, have pronounced in the manner of the word of God on the defects of, and remedies for these professions.
Anderson wonders whether the time is not ready for a senior bright doctor or policeman, fed up with the day job, to be appointed to pronounce, with equal authority on the legal profession. When this happens, pigs with PPLs will surely then become common.) One could go on… these comments meaning no disrespect to Dr. Brearley, who was simply reporting the state of affairs.
Professional issues in aviation medicine – Professor Carol Seymour.
Professor Seymour, a lady of many talents both medical and legal is Medico-Legal Advisor to The Medical Protection Society, and wrote a very useful and readable article in that Society’s recent publication circulated to members.
She reviewed the doctor–patient relationship, both traditional and in the light of more recent generally higher expectations. MPS cases have included alleged irregularities in CAA medicals, disputes over completion of forms, breach of confidentiality, failures of specific or timely warnings, and awareness of the Aerotoxic Syndrome (? due to contamination of compressor stage bleed air used for pressurisation). A single incident has the potential to cause much trouble.
An Aeromedical Examiner (AME) should be competent in clinical skills, diagnosis, legal and ethical issues, up to date with new knowledge, and aware of own limitations. The AME is applying the requirements of the JAR/FCL concerning physical and mental capability, and the prognosis for the next one or two years. The error margin should be on the side of safety, since missing early signs of disease may be considered neglectful. Pilots must not with-hold information, and should understand the role of the AME.
Professor Seymour recommended the six “C”s for a peaceful life:- Clinical skills, Consent, Communication, Confidentiality, Clinical Records and Cognizance . Case notes, as always, should be clear and accurate. Scribbled illegible notes will no do. She discussed the legal “standards” deriving from the cases of Bolitho and Bolan. Her recommendation was to keep to accepted practice, to act within one’s limitations and to know when to seek advice.
Concerning “Good Samaritan” acts, it is a sad fact that these days we are not immune to legal action, so the next time you come across someone in distress, do not omit to state your intentions, and competence and seek consent for your proposed action. See your reporter’s comments at the end of the previous summary, or perhaps more usefully read Professor Seymour’s recent MPS article.
Thanks again to our organizers and lecturers for a splendid day. If you missed it please come next time.
Rassemblement International Médecins-Pilotes.
5th-8th June 2008. A number of our members joined with our French counterparts at a meeting based in Perpignan.
Summer Visit to the Houses of Parliament.
Wednesday 11th June 2008, London.
Flying Day: 21st June 2008, Perth
We joined the Scottish Aeroclub for their Open Day and scenic flying. Perth Airport, Scotland.
Summer Meeting: 18th-20th July 2008, Shenington.
A gliding weekend in a relaxed and friendly atmosphere.
Autumn Meeting: 12th-14th September 2008, Lincolnshire.
Our annual social and flying event. This year the Autumn Meeting was based in Lincoln with a visit to East Kirkby airfield in Lincolnshire, home of the Lincolnshire Aviation Heritage Centre. There, we had lunch in the NAAFI followed by a tour of the museum and witnessed the unforgettable sight of the Lancaster bomber taxiing.