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1.1.3 Clarify administrative details
1.1.3.1 Explain the licensing authority’s requirements for checking background details (eg licence,
current/previous certificate, existing limitations) and the reasons for checking these
1.1.3.2 Explain the licensing authority’s other administrative requirements (e.g. collecting a fee)
1.1.4 Verify that the regulatory context of the process has been addressed
1.1.4.1 Explain the medical examiner-applicant relationship
ICAO Preliminary Unedited Version — May 2010 V-1-11
1.1.4.2 Describe any potential/actual conflicts of interest (e.g personal relationship, airline examiner)
and how they would be managed
1.1.5 Provide applicant with information about privacy/confidentiality
1.1.5.1 Explain who owns and who has access to the medical assessment report and associated
documentation and information provided by the applicant
1.1.5.2 Outline how this is explained to the applicant
In that medical examiners are designated by the State, the responsibility of those examiners is to assist States
in fulfilling their responsibility to minimise flight safety risk. This role is different from many, or most, other
clinical roles in which the doctor’s primary responsibility is to the patient. In situations where these interests
may be in conflict, the designated medical examiner’s ultimate responsibility is to the State. In many States
this can be complicated by the fact that the applicant may pay the regulatory examiner for the medical
examination. However the lines of responsibility should be clear. An example of where a conflict may arise
is when an applicant does not want a medical condition disclosed to the Licensing Authority, but the examiner
believes the condition to have important safety implications. The examiner needs to be clear on how the
safety obligation relates to the applicant’s wishes, and what the examiner’s legal obligations are regarding the
release of this information. Any conflicts of interest must be understood by the examiner and managed
carefully. The processes for dealing with confidentiality, consent, and disclosure need to form part of medical
examiner training.
1.2 Establish rapport and encourage an open reporting environment
The use of the terms “medical examiner” and “medical examination” are relevant. The perception of many,
including aviators, legislators and even DMEs themselves is that the process of examination is an inspection
which will reveal medical conditions with potential impact upon the safety of flight. This is true for only a
few conditions; many are not detectable on physical examination and the examiner more often has to rely on
information provided by the applicant. For example, a pilot or controller who suffers seizures or frequent
fainting attacks is likely to appear normal on physical examination. In most cases, such conditions will only
come to light when declared by the applicant, and the most effective mechanism for learning about such
conditions is by encouraging open declaration by applicants.
Potential barriers to declaration by the applicant may include:
i) Not understanding the requirement to declare, or the significance of, a particular medical condition.
ii) Forgetting a medical condition or event.
iii) Fear of losing a valid Medical Assessment - of being unable to fly/work temporarily or permanently.
iv) Mistrust of the examiner or of the aviation regulatory system. If the perception is that declaration of
a problem will inevitably or unreasonably lead to cessation of flying or working, this will represent a
barrier to reporting.
v) Guilt, shame or embarrassment – particularly for conditions in which a degree of denial is a
recognised feature (such as substance dependence, psychiatric illness, eating disorder).
It is apparent that non-declaration is a common occurrence in some jurisdictions. Canfield et al (2006)
compared medications found post-mortem in pilots involved in fatal crashes with the medical conditions and
medications which they had declared to the US Federal Aviation Administration, and found evidence of
under-reporting by pilots in that jurisdiction: of 387 pilots found to be taking medications, only 26 per cent
had reported taking any medication, and only 8 per cent had reported correctly. Other studies have described
similar evidence of under-reporting (Hudson, 2002; Sen, 2007)
It is believed by ICAO that medical conditions are more likely to be communicated when an environment of
trust is achieved between the examiner and applicant. This is most easily achieved when a relationship is
ICAO Preliminary Unedited Version — May 2010 V-1-12
established over time. While some commentators have pointed to the risks of collusion between examiner
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Manual of Civil Aviation Medicine 2(151)
