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timescale greater than that of the validity period of the Medical Assessment) improve the pilot’s health,
and as a consequence, improve flight safety.
Two aspects are particularly worthy of consideration. The first concerns the preservation of physical
health. The factors for this are well known. Aspects of diet, exercise, smoking, body weight, etc. and their
effect on health should be familiar to all medical examiners and these can be discussed with the individual
applicant in light of the particular circumstances of the individual, such as family history of illness, body
weight, exercise habits, etc. Licensing Authorities are encouraged to provide guidance to designated
medical examiners regarding these aspects of health maintenance.
ICAO Preliminary Unedited Version — October 2008 I-3-5
The second aspect concerns mental health and use of psychoactive substances. Guidance on prevention
of problematic use of substances is given in ICAO Manual on Prevention of Problematic Use of
Substances in the Aviation Workplace (Doc. 9654), but otherwise guidance in this area of aviation
medicine is not so readily available. At the request of ICAO a small group of experts has recently
reviewed the evidence that raising certain topics with applicants, by means of asking specific questions,
may be of benefit. Studies of the general population has demonstrated that some mental illnesses and
some kinds of problematic use of psychoactive substances can be reduced or prevented by early
intervention, before the situation has deteriorated to an extent where the health, or medical fitness for
flying of a licence holder, has been adversely affected. A separate section on this topic with guidance
material is provided below.
Historically, the focus of the periodic medical examination has been to detect medical conditions, and
almost exclusively the emphasis has been on detecting physical medical conditions that may pose a threat
to flight safety during the ensuing period of validity of the Medical Assessment. The medical examiner’s
primary role has therefore been to detect significant conditions that may cause incapacitation in the
relatively short term. The role of the medical examiner as educator has not played a formal part in the
process, although many examiners have taken on this task as a natural part of the role of any doctor
conducting a medical examination. Whilst the role of the medical examiner in determining the physical
fitness of pilots in all age groups will continue, an opportunity to safeguard the long-term health of the
applicant, as well as improve flight safety, presents itself because of the low level of physical pathology
encountered in the lower age group. One view, sometimes put forth by pilots or their organizations, is that
this is not the role of the regulatory medical examiner, but this attitude disregards the fact that preventive
advice is beneficial to flight safety as well as in the best interest of the individual pilot. The medical
examiner is in an excellent position to provide this service, and experience has shown that most pilots are
unlikely to seek such advice elsewhere.
By reducing the emphasis on the physical examination in those Class 1 applicants less than 40 years of
age, time is made available to focus on the non-physical aspects of health, in a non-threatening manner,
and at no additional inconvenience or cost to the applicant.
Some medical examiners may be uncomfortable in omitting parts of the physical examination in alternate
years, believing that the examination of physical systems naturally leads to a discussion of ill health
prevention associated with those systems being physically examined. Medical examiners may therefore
prefer to continue to undertake a full physical examination at all renewals, for reasons other than
detection of physical disease.
Mental Health and Behavioural Questions for Use by Medical Examiners
As there is evidence that several fatal aviation accidents have been caused by psychiatric disorders or use
of psychoactive substances, it is reasonable that as part of the periodic aviation medical examination there
should be questions that pertain to these issues. Little guidance has been provided concerning how such
aspects could be addressed in the periodic medical examination, although experienced medical examiners
have often informally and spontaneously included them in their evaluation of the applicant. Further, the
number of non-physical conditions that can affect the health of pilots and which can lead to long term
unfitness in those of middle age appears to be increasing. The conditions addressed by the proposed
questions have been shown to be amenable to preventive action before they develop into significant
health problems and before there is an impact on the pilot’s medical status for flying.
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Manual of Civil Aviation Medicine 1(19)
