In order to keep up, we'll go ahead and introduce our next unknown speaker. Our next speaker is also an old buddy of mine. God, Dan and I knew one another, I think from the Air Force, and then we knew us from this organization, and then I got the experience of a lifetime. Wasn't enough time, but it was good enough. Dan was down at Tyndall Air Force. This is a long time ago. Dan was down at Tyndall Air Force Base, and one of my RAM classmates was head of the courses in the Air Force, and I wanted to do it as a resident, but I didn't get to, and I went to what's called Top Knife, and Dan had just gotten to Tyndall, and both he and I did this. It was his first time, and then, of course, my time to get to fly in the F-15. In the military, it's called permissive TDY, meaning you get to pay for yourself, but that's all right. It was the best. I think it was a couple of hundred bucks. It was the best money ever spent. We had a blast and we did it together in the F-15. I'm going to introduce Dan Barry to talk about a topic that we probably don't talk about enough, and that is basic med. Dan is actually a PhD in biomedical engineering. Before he went to medical school, he's a board certified in a family practice of preventive medicine. That's right. He was involved with getting the osteopathic specialty of undersea and hyperbaric medicine started. Of course, he is the president of our board of preventive medicine for the college, and he is president and CEO of Optronics Incorporated, which is for medical device patents. He was a flight surgeon in the Air Force for 28.5 years, and he was a colonel. He's got over 2,000 hours of flight time and over 30 aircraft. I remember he spent some time spending a lot of the Air Force's money, and he really liked that job. Dan is going to talk about basic med, which I'm sure some of the folks don't know about. The other good thing about it is he's going to go over the latest data on basic med individuals. Dan Barry. Warren, that brings back such good memories back when I was in the Air Force. Warren mentioned that I was assigned to the 1st Fighter Squadron, which is F-15 aircraft. It's a lot of fun to fly, and one of my jobs there was to teach the top knife course. Top knife course is to teach flight surgeons what it's like to fly in high-performance aircraft, the F-15 aircraft. There was also a similar program for the F-16 aircraft, which was at Luke Air Force Base. What would happen is flight surgeons would come. Oftentimes, they had never flown in a fighter aircraft before, never flown faster than the speed of sound or anything like that. So it was a lot of fun for them. They could come and they could take the course. We'd have lectures in the morning and they'd fly in the afternoon, or else we do the opposite. They'd fly in the morning and have lectures in the afternoon, and be talking about things such as G-induced loss of consciousness, and then go out and experience G-induced loss of consciousness. It was really a lot of fun to do things like that. That's one of the exciting things about working in aerospace medicine and flying. Then I got out of the Air Force and I went to the FAA where we never fly. Now, having said that, we're working with headquarters to try to get it so that the flight surgeons who are in the FAA will be allowed to do some flying, actually get to sit in the cockpit on certain flights. I think it's very important that we're doing that because as a flight surgeon, we need to experience what our pilots are experiencing, know what the requirements are. If we see this and we understand what it is, it makes a lot more sense when we make our aeromedical decisions on who can fly and who can't fly. This is a funny one. When I die, I want to die like my grandfather who died peacefully in his sleep, not screaming and yelling in terror like all his passengers. Sleep apnea is a big problem and people do fall asleep while flying. In fact, when we take a look in the FAA at what causes accidents, you can really break it down into two categories, sudden incapacitation or subtle incapacitation. Everybody understands a sudden incapacitation. One minute you're flying along, you have a seizure, you're completely unconscious, and the next minute, you're not in control of yourself or the aircraft. That's a sudden incapacitation, but what's a subtle incapacitation? Well, a subtle incapacitation is when you're getting drowsy and you're not really right there together with everything, and pretty soon you're off to being asleep. Another example of a subtle incapacitation is you're taking medications, and medication makes it so you may be awake, but you're not as alert. You're not paying attention to the gauges in front of you, and you end up making mistakes because of that. So that's the kind of things that we're looking at. And so a few years ago, what happened is there was some accidents that involved people falling asleep while flying, and there was one big incident in which some pilots were flying, and they flew past their destination in Minneapolis And so the ground operators, the air traffic controllers, called to them and they didn't answer. So what was the matter? What was going on? Well, finally, they did wake up, turned their aircraft back around and flew to Minneapolis, landed, and discovered that what they had was everybody in the cockpit had fallen asleep. And so there was nobody there controlling the aircraft, and all the passengers in the back had no idea what was going on. But that's the kind of thing that we get concerned about. So the FAA was told by the NTSB, the National Transportation Safety Board, you must change the way you do things, and you must evaluate for sleep apnea. So the FAA immediately thought, well, okay, well, how do we do for that? Maybe we look at people who have risk factors for it, and if they have risk factors, we can ask that they get evaluated for obstructive sleep apnea. Well, one of the risk factors for it was being overweight. Another one was, you know, having a larger neck. I mean, there were several risk factors. And so the FAA started to list these things out and started to vet their policy out there. You know, the FAA doesn't like to just simply make an order and put it into effect before people know about it. It was interesting because the newspaper started picking this up and saying that the FAA is trying to get rid of fat pilots. Had nothing to do with sleep or sleep apnea. It's just that, you know, the FAA was going to be discriminating because they were going to be looking at weight. The FAA decided, okay, we're not going to go that way, but what we're going to do is we're going to look and have the EMEs do an assessment to see if a person is at risk for sleep apnea. And so there's, you know, they do like the upward scale. They can ask the individual if they snore or if the spouse complains about them snoring or anything else like that. So what ends up happening is that nowadays when you do a physical exam on pilots, there's a section to fill out on risk factors for sleep apnea. Now, if a person has a condition which we're concerned about, normally the EME would defer the exam. And then the FAA would write to the pilot and say, send in this information. Once we get the information and see that they're okay, we would issue them a medical certificate so that they could fly. Under sleep apnea, though, there was so much protests from the flying community that they decided, okay, we're going to let the aviation medical examiner issue if they report, this is first-time report, that they have sleep apnea, and then the FAA will give them 90 days to provide the information. So it comes to us. We then see that they've got sleep apnea, initial sleep apnea, not that they've had it before, and we send out information so they can continue to fly while they're providing us the information. And that's the only thing I know of where we allow somebody with a potentially disqualifying condition to fly while we're waiting for their information. Everything else, we ask for their information first. So that's basically what we're doing with sleep, and hopefully we won't have people falling asleep while flying. Now, the main thing I want to talk to you about today is basic med. And this is a new law that came about. And in that law, one of the things it said was after five years, the FAA was supposed to report back to Congress and let them know how it was. Was this new program successful, or are we having lots of accidents under the people that are flying under these conditions? So what I'd like to do today is tell you what basic med is, and then talk to you about the look back and what we found, some of the concerns and issues and some of the successes with the basic med program. But before I talk about basic med, I'd like to talk about what the FAA normally does for giving medical certification, and then when I talk about basic med, you'll understand the difference between the two. Some of you are already aviation medical examiners, so what I'm going to go over for the next three or four minutes, you probably already know. But for the rest of the people in the room, I want to make sure it's clear. So I'm going to talk about what the FAA normally does. For years, what the FAA has done is when a person wants to fly most aircraft, they have to have a medical certificate. And there's first, second, and third class medical certificates. First class medical certificate are for pilots who fly with passengers behind them. When you flew here, your pilot in the front of the plane had a first class current medical certificate. We have other people who fly and they may be flying cargo or they may be doing other things in which they charge. And those are pilots that have a second class medical certificate known as a commercial pilot medical certificate. So second class is for commercial. Third class is for your private pilots. If you want to have fun and get out there and just fly around and enjoy yourself, that's third class. As you can imagine, the requirements for third class are nowhere near what they are for first or second class. So that's basically it. And if you're first class, we really want to make sure that those people are healthy because we don't want them crashing with a large plane. There are several things that we do for that. One is that for first class, you have a couple pilots up in front. If one did get incapacitated, you still have another one up there to fly. And as you probably saw in the news this last week, we had a pilot that had a heart attack while he was flying. Fortunately, the other pilot in the plane was able to take care of it and land the plane safely. One of the other things about first class pilots, if they're under 40, they have a physical exam once a year. If they're over 40, they have physical exam every six months. So if there is a concern, we'll be able to find it soon and not have to worry about them crashing planes. For second class, they're all one year. There's none of them that are required to get it every six months. And for third class, it's only once every five years if they're under 40. If they're over 40, it's once every two years. Now, many of you have heard that if a person has a first class certificate, let's say they're over 40 and it's only good for six months, that it reverts to a second class. And then after a year, it reverts to a third class. So they can continue to fly until a third class would run out. That's almost true. It's still a first class certificate. It never reverts to a second or third. It's just that the privileges they can exercise with that certificate after it expires for a first class would be the second class privileges. In other words, they could fly commercial, but not with people behind them. At the end of that year, it would not revert to a third class, but they would be able to use that first class certificate to do third class types of flying, such as flying around for fun in a little Cessna or whatever they own or rent. So that's the difference between first, second, third class. A couple other things I wanted to mention about that. In order for a person to get a first, second, or third class medical certificate, they have to go to an aviation medical examiner. An aviation medical examiner is a physician. And that physician has to take a one week course in Oklahoma City. The FAA pays for that course, so it's no cost to an individual to become an aviation medical examiner. Of course, they'd have to pay their way to Oklahoma City and have to pay for their hotel and food and everything, but the course is free and you get free CME out of that course. Once you're an aviation medical examiner, then you're allowed to do first, second, and third class. Now, first class, you're not able to do it first. You have to become a senior SME or a senior AME before you can do first class exams. And to become a senior AME, you just have to have some experience in time. We usually require two years, but there's cases where, you know, somebody does a lot of exams and will be able to put them in faster than the two years. So that's what an aviation medical examiner does. So we have a lot of pilots out there that are flying and don't like the idea of having to go get a medical certificate. They say, look, Australia allows you to fly with just a driver's license and Canada allows people to fly with just a driver's license. Anyway, they named off some of these things and they went to Congress and said to Congress, can't you make it so that we can fly with just a driver's license? Well, Congress came and asked the FAA about this and said, what do you think? They're doing it safe in Australia. Don't you think they could be doing it safe here? And the FAA answered and said, in Australia, to get a driver's license, you have to have a physical exam. You have to have your eyes checked and a bunch of other things. And if you have certain medical conditions, you have to be able to pass, kind of like what we do here with truck drivers. So Australia isn't equivalent for having a driver's license like we do. Congress said, okay, we understand. So now they have the pilot organizations like AOPA, EEA, and everything else, asking for some way of getting around having a medical certificate and having the safety of the national airspace on the other side, saying that do we want people to be flying who may have medical conditions which could be disqualifying and endanger the airspace? Congress ended up making the law. This was not an FAA initiative. They did ask the FAA, and we gave them some issues and concerns, but they passed the law. And this is the basic med law that I'm going to be talking about. But what it does is one of the things is it allows the pilot to get an evaluation by any physician, not somebody who's been trained in aviation medicine. So all of you could be signing off on basic med, regardless of whether you've had any training in aviation or not. That's one of the reasons why I wanted to talk to everybody about this, is you may have people coming to you and asking you to sign off for them to fly under basic med. When Congress passed this law, they said that they were going to ask the FAA to come back in five years and tell them what's happening with this. Are we in trouble or is this perfectly safe? You know, we need to know. Those five years are up. The FAA did the study, showed all the statistics and everything else. Now it has to go to the NTSB. The NTSB has to approve it. Then it goes to Congress. Two years ago, we gave that to the NTSB. It's still sitting there. It has not gone back to Congress. Now, what's in that report, a lot of it is non-releasable, and I can't tell you all the information from it. From sources other than that's in that report, some of the information that's in the report I have access to. And so anything I'm showing you today did not come from that FAA report back to the NTSB that's supposed to come back to Congress. So all these are from open sources or other sources that I'm going to be sharing with you today. So what I wanted to do is give you the FAA update, which I did. I'm going to talk to you quickly about a CACI program that the FAA has had for a few years and tell you an update on that and what all we have CACIs for. And then I'm going to be spending the rest of the time on basic med. And then finally, I'm going to be able to answer questions for you. The FAA used to give out medical certificates only if everything was fine with the pilot. If they had medical problems or issues that had to be deferred and come to the FAA, the FAA had to review that information and then say to the pilot whether they could have a medical certificate or not. So we were having a lot of cases deferred, and the flight surgeons in the FAA had to review a lot of these cases. And a lot of them were simple things that weren't really serious problems for most people. It could be a problem if they had something wrong. But we felt that the aviation medical examiners would be able to look at these conditions, follow a flow chart, and if everything was OK on the flow chart, we'd be able to make a statement on item 60 of the exam stating that they meet the requirements for a CACI. CACI stands for conditions for which an AME can issue. This program has been very successful. And now between 95% and 97% of the time that a pilot comes in to get a physical exam, the AME issues in many of these cases are issuing with a CACI or condition which the AME can issue. And currently, I will read these to you. If they have arthritis, asthma, bladder cancer, breast cancer, chronic immune thrombocytopenia, chronic kidney disease, colitis, colon cancer, colorectal cancer, essential tremor, glaucoma, hepatitis C, chronic hypertension, hypothyroidism, migraines and chronic headaches, mitral valve repair, prediabetes, primary hemochromatosis, prostate cancer, renal cancer, retained kidney stones or testicular cancer, this does not have to come to the FAA for evaluation if they meet the criteria that's on the sheet. I'd like to give you an example of one of these sheets just so you kind of get an idea of how a CACI works. It's nice to say they get a CACI for this, but what does that actually mean? Well, here's one for hypothyroidism. And so when the AME says, OK, this person's got hypothyroidism, how do they know whether they can issue or not? Well, first, the treating physician finds the condition is stable or the current regime and no changes in recommendations. They say, yes, good, okay. Symptoms and signs, none of the following. They can't have fatigue, mental status impairment, symptoms related to pulmonary cardiac or visual systems. So in other words, if you found that your person that was hypothyroid had any of these symptoms, mental changes, for example, is listed on there, you wouldn't go ahead and issue under CAC. You'd still have to defer it, send that to the FAA. And here again, it says acceptable medications and it lists the medications a person can be taking and still be able to fly under the CACI. And finally, the TSH has to be within range. So in other words, there's people with hypothyroidism that are taking medications. Problem is, is that medication working for them? So they have to have a TSH test so that they can be able to see if they actually meet the requirements necessary to fly with a CACI. If they do, the AME can simply put down there that they meet the CACI requirements issuing the medical certificate, they're out the door. That medical certificate is not time limited for like one year or whatever. It's lasts as long as that medical certificate would last. For example, somebody that's under 40, their third class certificate, that CACI lasts them for five years. If they're a first class pilot, you know, over 40, it would last them for six months. But the point is, is it lasts as long as the physical exam would normally last for an individual and not shorter like our special issuances do. So that's the update on CACI. Now I wanna turn the rest of this talk to basic med. Basic med was passed in 2016 and went into effect in 2017. This is part of the law. Now let me kind of explain, when something goes into the law, where do you put the law so people can read it? Well, in the case of aviation and many other things, it goes into what's called a CFR or Code of Federal Regulations. That's a law passed by Congress, signed by the president. Well, as you know, our first, second, third class pilots fly under part 67 of the 14 CFR. Whereas with this, these people do not fall under part 67. In fact, they fall under part 68. So that means that they don't have the same requirements as what a first, second, or third class pilot would have. Now, what does it require for a pilot to fly under basic med? First of all, they have to have a valid U.S. driver's license. If their license has been suspended for alcohol, can they fly with basic med? Nope. So it's gotta be valid for them to drive a car. Also the same thing for valid for them to fly a plane. And I might wanna mention here, if you take a look at your driver's license, some of those driver's licenses may be things like you're required to wear glasses, or that you're required to fly a car that's modified for hand controls, like for instance, paralyzed people and stuff like that. Whatever restrictions are on the driver's license are also restrictions on basic med for the pilot to follow as well. The FAA medical certificate, they must've had a valid one sometime after July 14, 2006. And that's when you get a valid one. Sometime after July 14, 2006. What's interesting is when this law was passed, it said within 10 years. Well, that law was passed on a certain date, and so they went back 10 years before that. So as time goes on, that date doesn't change. It's just that they have to have a valid certificate sometime after, a valid medical certificate, first, second, or third class, sometime after July 14, 2006. In their most recent application for medical certificate may not have been denied revokes, suspended, or withdrawn. If they had, so in other words, if they applied for a medical certificate and didn't get one or had it taken away from them, they're not gonna be eligible to fly for basic med. Doesn't mean they won't ever be able to. They can apply for a new first, second, or third class medical certificate. If they pass the new one, then they'd be eligible after that to go for basic med. And if they've had certain medical conditions, they're still not allowed to fly under basic med unless they've gotten a special issuance from the FAA for that medical condition with a first, second, or third class medical certificate. Well, what are those medical conditions that would prevent an individual from flying under basic med? There's four that's listed under mental, three under neurology, and four that's mentioned under cardiac. These are specifically disqualifying conditions. You notice there are 10 specifically qualifying, disqualifying conditions for basic med. Many of you that are AMEs know that there's 15 disqualifying medical conditions for people flying with a first, second, or third class medical exam. And on here, you won't see certain things like insulin-dependent diabetes, which means if they've got insulin-dependent diabetes, they can fly under basic med. They don't even have to have any kind of special issuance or anything like that. They just fly. So you can see already that there's some holes in this system with basic med. Now, the four mental health conditions which require them to not be able to fly under basic med unless they've had a special issuance are a personality disorder, and this specifically refers to overt acts. Overt acts are things that an individual has done repeatedly that demonstrate a lack of compliance with rules and regulations, especially safety rules and regulations. Now, you might think that these are some of the worst personality disorders, Charles Manson, et cetera, but that's not what all it's talking about. If a person has speeding tickets and stop sign and running red lights and just consistently they're showing a repeated disregard for rules and regulations, and that's a real big danger for aviation safety. So the times we see the worst accidents are when somebody is doing something that they know they shouldn't be doing, they just decided, hey, I'm gonna do it anyway. Psychosis is disqualifying. Bipolar disorder is disqualifying, and substance dependence. Not substance abuse, but substance dependence. In other words, if they're an alcoholic, this falls underneath this. If they've got a single DUI, it does not. So that's one of the differences between basic med and a medical certificate. The neurological conditions that are disqualifying are epilepsy, a disturbance of consciousness without satisfactory medical explanation of cause, a transient loss of control of the nervous system function without satisfactory medical explanation of cause. And by the way, somebody is sitting there in their seat and has a loss of consciousness. Is that a vasovagal? I mean, they're not standing. There's no reason for it all. They go and they see the doctor and the doctor says, well, you know, they hadn't been feeling so good. They were a little dehydrated. That's not an adequate cause. If somebody just simply has a loss of consciousness while sitting down and that's not a vasovagal. There's no stimulating event. Like they weren't watching somebody bleed. They weren't standing at attention during a parade. You know, all the normal triggering factors for vasovagal, don't buy it. That is not a satisfactory explanation of the cause. The last four conditions are all cardiac. That's myocardial infarction. If they've had a heart attack, they are not allowed to fly under basic med unless they get a special issuance for that with the first, second or third class medical certificate. They've got coronary artery disease requiring treatment, cardiac valve replacement or a heart replacement. So if anybody has those things, they're not qualified for basic med unless they were to apply for a medical certificate and get approved by the FAA with the medical certificate and a special issuance. And it's just one time. Under an air force, I'm sorry, under an FAA special issuance, what happens is they're time limited. So in other words, after a year, they would have to come back and provide information again saying that they were still okay. Here's one of the flaws with basic med is that they can continue to fly forever and never have to put any more proof down that they're still okay after a heart attack. Let me take a break here for just a minute from the slides and give you a little bit of philosophy of how the FAA works. First of all, you know that there are a lot of old aircraft flying. You might be seeing a 1960s Beechcraft or a 1950s Cessna. How can planes that old fly and fly safely in the airspace? You don't see cars driving around that old on the road that are driving around. So how can you do that with aircraft? Well, the answer is that aircraft get inspected and they find out if there's anything wrong. And if it's wrong, they don't say that aircraft can't fly again. They say, get it fixed, show us it's fixed. Once you show us it's fixed, we're gonna go ahead and certify that aircraft to keep flying. When you think about an FAA physical exam, it's not pass, fail. Because a lot of people have medical conditions which wouldn't pass and they're still flying. So it's the same philosophy with that. You see a lot of old pilots flying and they're flying quite safely, not having aircraft accidents. What is it? Well, if the pilot has something broken, in other words, a disease or condition, you don't say that pilot can't fly again. You say, get it fixed and show the FAA that it's fixed. And once we see that everything is okay, then we issue you a medical certificate so you can fly. And that's what a special issuance is. Special issuance doesn't say, hey, we're ignoring the law, which says you can't fly with this condition. The special issuance says, okay, you provided evidence that your condition is under control and therefore we're gonna allow you to fly. I'll give you an example. If a person has the myocardial infarction that we just talked about a moment ago, they get a special issuance for that, but they have to show that it's been treated. Like for example, he may have had a stent or a cabbage. Then the second thing is that after that, we have to be able to see that they no longer have ischemia, meaning that they're getting oxygen to the heart. Now, if we see that afterwards, we know that the heart is getting good enough oxygen. We feel that they are safe to fly for the next year. The problem is that stress test isn't good enough to predict if they're gonna be safe in two years or three years or four years. Because what happens is after they've had their myocardial infarction and they've had the coronary artery disease, that coronary artery disease can continue on and start to constrict down on that artery It's not gonna happen within the first year. Normally, if they have a stress test that shows no ischemia, the longer you get out from that, the more likely it is. So we require that stress test every single year. And if it's good, we say, okay, you can fly for another year. If it's good, we say we can fly for another year. But if it's bad, we say, don't fly, go get it fixed again. And so they may go get another stent. We have pilots, interestingly enough, I should say we have people interestingly enough who aren't even pilots that end up getting a physical exam and a special issuance. Why? They want somebody to track and tell them when their heart is no longer good and they need to go back for further treatment again. Because what happens if their doctor doesn't say, hey, there's something wrong, you need to go back and get that fixed. Well, the FAA is watching it and so they do. And that's been very valuable. A lot of pilots don't like this and don't like to have somebody telling them, okay, you need to have that watched, you can have a problem with it. They figure, hey, I had my stent placed, I'm perfect from now on. And of course, as physicians, we know better than that. But that's one of the failures for basic med is saying that they're good forever. Okay, let's go on with this. What does a pilot have to do to use basic med? There's two things that they need. The requirement one is they have to get a physical exam from a state licensed physician. The law says a state licensed physician. States are allowed to decide for themselves what's a state licensed physician. You'd think that they would say it needs to be from an MD or a DO. Some states say a chiropractor is a state licensed physician. Other states will say that a nurse practitioner or a PA is a state licensed physician. There's only a few states that do that. But the point I'm getting at is the law does not prohibit that. So can you imagine that somebody who has got insulin dependent diabetes gets their chiropractor to sign off on them saying that they're safe to fly? Anyway, what ends up happening is they can go online and they can download this comprehensive medical examination checklist. This checklist is almost word for word what the FAA physical exam is. So it will ask them the same questions. And there's a few exceptions. For example, it doesn't ask them how many hours they've flown. And that was specifically removed because some of the, I gotta be careful what I say here because I don't want to say anything politically incorrect. But some of the special interest groups did not like it that the FAA could track accident data based on number of hours flown because this report was supposed to go back to Congress. And if you don't have a denominator, how can you compare it with people who have medical certification? Now I'll just leave it at that. So there are certain questions that were left off of that checklist due to lobbying at Congress. But anyway, they've got to print off this checklist and they can take it to any physician that they want, any state licensed physician they want. And then they will have the physician fill that out. And this is required every 48 months while they're flying with basic med. Now, keep in mind if somebody is under 40 with a medical certificate, they can fly for five years, which is 60 months rather than four years for 48 months. And so a lot of our younger physicians prefer to get a medical certificate because it's gonna last you longer. And there's other things too, like for instance, you don't have to do requirement two, which is, well, I'll get to that probably on the next slide. Yes. So with any of the exam, they can, if they don't start filling out and then come in and realize, oh, I'm gonna pass, then you have to turn that in. Yes. In fact, with this. Yeah. If they come in to their doctor to get this and the doctor is like, I don't know enough about this, what happens? Interestingly enough, one of those lobbyist groups, AOPA, has been advising pilots what to do. And they say, if your doctor doesn't feel comfortable in signing off this certificate, go to a second doctor or go to a third doctor, find somebody who will. However, if three or four doctors- Certificate? Yeah. If it doesn't work, they can toss the certificate? Yeah, well, they just simply keep- Well, it's not an AME. It's not an aviation medical examiner. They go to, they can go to anybody. Well, the certificate or a form that they fill out, they start- It only messes with the, it only, as soon as the AME opens your file from MedExpress or ACMS, whatever you call it, that's when they've crossed the forbidden threshold. Yeah. They can fill out the MedExpress for the rest of their lives, fill one out every day if they wanted to, and it won't ever have any impact, it doesn't count. But the second the AME opens it, an exam has started, and they're doomed. Yeah. Now, that's if they've done a medical certificate under the AME program or the first or second or third class. But what I think you're asking about is somebody that- Basic meds. Goes basic med. They show it to the doctor. They show it to the doctor. The doctor says, I'm not going to sign off on that. Right. Nothing happens. These certificates, these never go to the FAA. That was part of the law, that these things don't go to the FAA. And I'll explain all this in a minute. So anyway, AYOPA says, okay, you can look for a second physician or third physician or fourth physician, trying to find somebody who will sign off on this. They do say, however, if you've gone to three or four physicians and no one's willing to sign off on this, maybe you shouldn't be flying. So that's what the pilot community is telling people, but that's not enforceable. And we can't say, okay, you've got a medical condition. You shouldn't be flying with this. If somebody is willing to sign this off for them. One of the concerns with this program. Okay. They have to sign an attestation statement that the physician does, that they've discussed all items on the checklist and any medications that could interfere with operating an aircraft or a motor vehicle, performed examination on all items on the checklist and certify not aware of any medical condition that at present treated could interfere with the individual's ability to safely operate an aircraft. So the physician is now signed this saying that they certify that this person is basically safe to fly from a medical standpoint. Now, let me compare a medical certificate with basic med. If a pilot comes into an aviation medical examiner and has something, let's say, I've mentioned diabetes on insulin before. The aviation medical examiner is not the one to issue the medical certificate. It's deferred to the FAA. The FAA gives them the medical certificate and says you're allowed to fly under these conditions. Whereas with basic med, it's a doctor that's giving them that medical certificate. Now let's say that this person goes out, has an accident, kills himself, and there's a concern that it was caused by a medical issue. Maybe there wasn't even any concern, but the widow thinks it might've been their insulin that caused it. If they'd gotten a medical certificate from the FAA, they can't really go after the doctor. It wasn't the doctor. The AME isn't the one that issued the medical certificate. It was the FAA. So if they want to sue somebody, they can sue us. But let's say they come to you under basic med and you're the one that signed off and you just now certified them saying that they were safe to fly. Who's the widow going to be suing? I want you to think about that when it comes time for your insurance or if you decide to do basic med. Okay, requirement number two is that they have to take a free online course. And this actually is a good course. It tells all the things that are of concern with medical, gives them a lot of good information. After they take the course, they've got to answer some questions. They don't answer mine. They can take it again and again and again. They're going to finally pass this exam. They've got it. But one of the important things is that they've got to get some information on this that does go to the FAA. Remember that checklist that the physician signed off never goes to the FAA. We never see it. What the FAA does see when they've completed this course is that they have to provide the physician's name, state license number, address, and phone number of the physician. And once they do this, they also have to sign an attestation statement about their health, and they have to consent to the National Driver Registration Checklist, which checks to see if they have any DUIs. So bottom line with this is that they should get the checklist done with the physician before they take this online course, because this online course is going to ask them the name and license number of the physician. They better get all of that first so they can take it and fill in this form. So if they come to you and ask you about that, tell them to do the checklist and exam first before they take the online course. And the online course is required every two years, whereas the physical exam checklist with their doctor is required every four years. The exception to that rule is if they have mental health or neurological conditions that we mentioned before, then it's every two years they have to get an exam. So for any neurological or mental health condition, they have to get this done every two years for that checklist. And requirements also apply to neurological or mental health conditions for which they held an authorization for a special issuance medical certificate. That means even if they've got a special issuance on their previous exam, on their last FAA exam, they still need to go in every two years to be reevaluated. Now, well, this law, it's called the FISA law, which is what made basic med only specifies neurological and mental health conditions. A responsible pilot, no matter what the condition is, should be going in and keeping it under control with their physician. That's an expectation under the law that they manage themselves. Whereas with the pilots, the first, second, or third class, more of that responsibility falls to the FAA to follow and make sure that they're doing what's best for their health and the safety of the airspace. Now, I'm not going to go into some of the technical details on some of these things, so I'm going to skip over that. You're not required to complete a basic med. If somebody comes to you as a patient and says, would you fill this out for me? Well, if everything they reported on their physical exam for their health history looks good and you don't find anything bad with them physical, I wouldn't feel bad doing it. I'd sign off one of those myself. But if somebody comes to you and wants you to sign off on some kind of strange medical condition, especially if you're an aviation medical examiner and you know that condition is a disqualifying condition, you probably should not go ahead and sign off for them. Check with your insurance on that. Pilots before they fly, same thing for pilots that have first, second, or third class medical certificates as those that fly with basic med, have to go over the I am safe checklist. And that's just a checklist that pilots use to make sure that they are physically fit on the day that they're flying. If a pilot is not physically fit, even if they've got a medical certificate, let's say they've got a cold or a flu, they're taking medications that cause drowsiness or whatever. There's the FAA regulation 6153, which says that they may not fly with a known medical condition. Same thing applies that they have a heart attack between medical exams. They may have a valid medical certificate, but they've now had some kind of medical event between when they last got their medical certificate and when they want to fly, they should not fly under 6153. This basic med program started May 1st of 2017. So it's now been over the five years for the report going back to the FAA, to the Congress. And so that was up in 2022. Now, what are the restrictions for a person flying under basic med? Well, they have to fly with no more than six people. If they're the pilot, that means they can take up to five passengers with them and they cannot fly any aircraft that exceeds 6,000 pounds. So there are some restrictions, but you can see they can fly helicopters and they can fly any kind of aircraft that weighs under 6,000 pounds. So like I said, not more than five passengers or six total, including the pilot who's flying. Now they can fly with either the visual or the instrument rules. Either one is okay. In fact, they cannot fly for commercially. However, if somebody is a trainer, they're charging for training, not charging for taking them up and flying. So they can charge them while they're flying with them, but only for the training part of that flight. And they can only fly within the United States. They can't fly at speeds more than 250 knots, and they have to fly at less than 18,000 feet. What's interesting is they can fly in the Virgin Islands. They can fly in Florida, but they can't fly their plane from Florida to get to the Virgin Islands. They need to take the commercial flight over their rental plane, but they could fly it around. Some interesting rules on that. Same way if they're going from, say, Seattle up to Alaska, they can't fly over Canada or international waters for that matter. Here's where you can find more resources if you're interested. And by the way, these slides are available online. So everybody was looking so forward to getting basic med, and the first couple months we had basic med available, huge numbers of pilots went out and got it. And then less and less got it and less and less got it. And you can see that you're really dwindling off now for the number of people that are getting basic med. And keep in mind, basic med is only good for four years. So you'd think that that big spike there that happened that four years later, you'd have another big spike with people going back out and getting basic med again. That did not happen. Also, you can see that third class physical exams went down a little bit just as the number of basic meds went up a little bit. As you can imagine, most people that get basic med were somebody that was on a third class medical certificate before and just simply switched over to basic med. But you can see it really hasn't dropped our numbers off so much for third class physical exams. And by the way, I might say this last year we set a record for the total number of people getting first, second, third class medical certificates with the FAA. And it's continued to go up this year. We expect to break the record again. So we had expected that basic med would take some of the burden off of us for the number of people applying for medical certificates. It has not. The FAA experience with basic med. And here's some of the things I wanted to get into. And that is that there's no oversight or checks for falsification. What happens if a person lies? There's no way to be able to tell. Did, do you know if they actually saw a physician? Is it, are they under the care of a physician? Did they not truthfully disclose their medical history? So these checklists do not go to the FAA. They keep them with them. Now, if the flight ramp check asks them to show that they've had a, for basic med to show that they've had a certificate, they need to be pulled out. But that's not a physician that's looking and they're not looking to see what all medical conditions they said they had or anything else. They're just looking to see if they, if they have a checklist when they fly under basic med. There's no feedback notification system for the airmen found not to qualify under basic med conditions. There's no process for handling a positive NDR report. So if they've had a DUI and they didn't report it and they have basic med, what do you do about it? There's, these are just some of the problems we're finding. So go back there for a second. So how did DUI just keep on flying? No problem. Yeah. Now, if they keep, keep in mind, it says, Hey, we've got a problem. No, cause the FAA doesn't know. Well, they haven't, the FAA actually does know about it. They do an NDR check and they get a response and they know that the pilot has had a DUI, but we don't have authority to do anything about it. And that's what, you know, I'm giving you the truth about the system. This, by the way, this was not proposed by the FAA. This was proposed by lobbyists and they got a lot of what they asked for. And so you can see some of, I'm just telling you the truth about concerns with this system. Now there is one thing that is helpful and that is that if the state they're in restricts their driver's license and says they can't fly, well, they can't, I mean, they can't drive, they can't fly during that same period of time. But if we get a positive hit on NDR, nothing we can do about it. That's why they require the check and then anyway. Yeah. Even for legislation that's bad. Okay. Well, you know, when this report goes back to Congress, and by the way, these things aren't, I did not get any of this from the report that's going back to Congress. So I can't say anything about what's in that report, but these are just things that we've internally identified as concerns. Okay. Process for collecting the number of flight hours that's not required for reporting. So when we look at accident investigations and accident rates and everything like that, we don't, we can't give a rate. We can't say, okay, this is the amount of hours basic med pilot flies before likelihood of an accident or the average number before an accident where you can give exactly that number when it's for anybody for first, second, or third class mishaps. So let's take a look at some of the statistics on that. Okay. Yeah. There was something on there about five. Oh, that there's more than that right now. I'm sorry. This is this slide. When this slide was made, there was only five at that time. And I should erase that because we've got much more updated statistics than that. And that would be, that was when almost everybody that had to start with basic med, by earning it again, you couldn't get it once if it's still on your badge. So I don't, I, I think the state is, I understand money because you can decide every time you get your airplane, you decide if I'm flying to basic med or under my FAA medical. Yeah. That was the slide I skipped and thank you for bringing that up. Yeah. But, but early on, if you had to go get an FAA medical, it may have still been live, either long-term plan was flying to basic med. I think the day when you did your count, if they haven't a valid FAA medical, they were flying under that. Yeah. That's exactly right. And that's some of the flaws with the statistics, and I'm glad you pointed that out. Okay. The FAA receives a monthly list of all basic medical, medical, basic med qualified airmen. Remember I said that when they fill out the, when they take that course online, the free course online, they have to put that information in. So the FAA gets a report. We know who these people are that are claiming that they have basic med and we're able to conduct monthly review of demographics of the basic airmen. We can see what their age is, the class of prior medical certification they had, the date of their last medical certification. We can see special issuance information and we can track the fatal basic med accidents. So those are some of the things we can see. So let's take a look at this right here. How many do you think of the young people are going out and getting basic med? Not many. Those people really don't care for basic med because they have to take an extra training course with it. And they, you know, it's not good for as long, you know, they can go for five years with a medical certificate. They can only go four years with a basic med. But how many of the people that are old and sick and have lots of bad medical conditions don't want to have that reported to the FAA? Well, let's take a look at this. And I'll talk about what these statistics mean on the next slide. The average age is 64 years of age for people that are going for basic med. We have one that's 93.5 years old. The youngest was 16.3 years old. There are 28 pilots that are 90 years old or older. There are 863 pilots that are between 80 and 89 years old. There's 4,310 pilots between 70 and 79. There are 167 pilots only that are 20 to 29. And there's only eight pilots less than 20. What does that tell you? Highest airman certification, as you'd expect, it's mostly third class people that are going for basic med. And how many years ago was it that they would be able to fly 10 years? So the oldest certificate, but all the longest time since their last medical certificate should not be more than 10 years. We have people in basic med 11 years, 12 years, 13 years. And so you can see people aren't following the rules of what's to stop them. So I have a few frequently asked questions. I'm going to see how we're doing on time here. I see we only have a few minutes left, so I'm not going to run through all these. Yes. I noticed the seat map wasn't on khaki condition in basic med 4. Is that true? I'm sorry, what's that? Earlier, you didn't list seat medicine as one that they could qualify. Yeah, actually, with basic med, it doesn't matter if they have sleep apnea or not, they can still get basic med as long as they can get a doctor to sign off on it saying that they're safe. So and that's basically the way it is with all the khaki conditions. It's only 10 conditions, which the FAA specifically states that they're not qualified for unless they get a medical certificate ahead of time. Why did the FAA use the old 8,508 as the basis for basic med comprehensive medical examinations checklist and not the current MedExpress version? You know, we have a few different questions on our current 8,500, which is the physical exam form than what is used for basic med. And the reason is in the law, Congress passed said you'll use the 8,500-8 from such and such a date. Okay, I actually have about 50 frequently asked questions that I've included with your slides, so that if you have some questions on that, most likely those questions will have been answered in some of the frequently added questions that's in there for your review. But I only have a few minutes left, and I wanted to save four and a half minutes to be able to ask any questions that you would like. Yes. And this does not, the basic med does not supplant the requirements for those flying sport pilot or light sport, was it? Where are they? I'm sorry? Where they could self-certify under light pilots? Yes, that's completely different. For light sport, a person just needs a driver's license, but there they're really required to fly, you know, just very small little things. Yeah, so that's true. There's one thing more I wanted to show you that didn't come out on here, and that's some accident investigation data. Yeah, new letter of the narrative, virtual letter of the narrative, that's brand new. Yes, I'm struggling. If you're getting paid for it, it's going to charge a lot, but the $100 hamburger. The $100 when you pay, there's plenty of all you need. No, no, what we used to call a $100 hamburger, which you could fly to point A, you'd have a hamburger, you can go back, that's... Yeah, but I'm saying light and air stuff is, they only go one way, they never come back. I've got two of them that are grabbing me shots right now, from yours. There's a couple of slides that weren't on my slide presentation here that I still wanted to show them. I'll give you a couple more just real quick here, and that is 34.9% of basic med qualified pilots received a special issuance from their medical certificate. On the basic med, only 8% of pilots and 11.5% of third-class pilots require a special issuance. So you can see most of these people are getting out of getting a special issuance, not that they're a healthier group of people, but that they use the basic med to get out of having to be tracked. Let's take a look at some accident data. The blue line here... Presentation mode, boss. Pardon? We want to put you back in presentation mode. Yeah, please do. If you could do that for me, I'd appreciate that. Thank you so much, appreciate that. You bet. Okay, so I'm going to just point over here. You see this line? This is the FAA's goal, getting general aviation accidents below that. And you can see the yellow line was the actual number of accidents back in the different years, going back to 10, 13, coming up here. We were a little bit above the line, but yet it was coming down. The trend was coming down really good right until here. Basic med was introduced May 1, 2017. So here's where basic med was introduced, and here's what happened. Well, that's only a couple of years after 2017. It's now 2023. But what happened in 2020? COVID, exactly. People were not flying, so all accidents went down. So let's see what happened. Well? I thought flying hours went up during COVID. No, for private pilots, the number of flight went down. Yeah. I apologize for this because I thought... I don't have it. I'll tell you what I'm going to do is I'll just point with my finger and pretend it's a slide. What ended up happening is accident rates started going up after this was introduced. Then what ended up happening is we had COVID, and it started to come down like this, and then as people started to return to flying again, it's come back up. So you can see that other than the COVID dip, that the trend rate for mishaps since basic med has been on the rise. Okay, I have one minute left. Does anybody have any other questions? Okay. Thank you very much. It's been a pleasure talking with you all today.

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