AME Guide Grand Rounds December 2025 Session

Okay, good evening. Welcome to the December Grand Rounds. I'm going to turn this over to Dr. Susan Northrup, our Federal Air Surgeon. Dr. Northrup. Good evening, good day, good afternoon, because I see people from all over the world. Thank you very much for attending our December 2025 Grand Rounds in the first week of January. I want to start by saying thank you for all you have done over the last year. I also want to report to you that we have made incredible strides in the throughput of our deferred unissued cases since the first of January 2025. That's a large part on you folks helping your airmen become better prepared to navigate the system. So I know everybody's aware of the changes to MedExpress in January, or sorry, June of 2025 when we added the enhanced instructions. But we have reduced the backlog cases significantly over the last year. We went from nearly 13,000 to we're below 4,500 as of Monday. We've also reduced the average wait time. So the average age of cases when they're coming to us, or when we make the decision. So it's really pretty darned impressive. When we started January 1st, there were nearly 8,000 records waiting for a physician to look at on the FAA side. As of Monday, we were at 214 waiting for physicians. That is a Herculean effort. Now the other thing I've been out pounding the pavement for talking to any group that will listen to me is the importance of preflighting your medical. And I know we went over a bit of this earlier, but I'm happy to report for the general review cases that are fully populated with the records we're going to need. For nearly three months, the average deferral to decision is below 20 days. If we have to ask for additional information, you can tack three to four months on that. When you look at all cases, we've been below 50 days from deferral to decision. That's including the drug and alcohol, that's including neuropsych, that's including medical appeals. So please keep up the good work in making absolutely sure that the pilots are ready to go when you hit transmit and that they've got all the information and you've been able to upload it. So kudos. Thank you. We couldn't have done it without you. And I'm looking forward to this evening with you as well. So I'm going to kick it back over to Christy for the ground rules. Thank you so much, Dr. Northrup. Well, I'm Christy Risley. And again, this is the December Grand Rounds. Yes, I know it is January, but we are playing catch up for the holidays. Next slide, please. We have just a few rules to go over as always talk about. First off, this session is being recorded. No participants will be shown and the recording will be made available later via YouTube on our YouTube channel. So how do you find those recordings? You can go and open up a browser window and go and use your favorite search engine and just type in FAA AME Grand Rounds. And that's the best way to find the past recordings. They are a little bit behind because of the holidays, but you should see the most recent recordings up there soon. Next slide, please. The rules of engagement for Grand Rounds, if you're new to our sessions, first off, the session is locked after the first 10 minutes. So what that means to you is that if you drop out of the session, you may not be able to get back in. You may be able to send an email and one of our staff, if we see it, we can we can try to unlock the room. But the reason we do that is because we grant one hour of free CME per session. And if you miss more than 10 minutes of one hour, that's that's a significant portion. Also, your chat and your cameras are disabled because we want to capture all of your questions using the Q&A button at the bottom of the Zoom screen. So if you're new to Zoom or if you haven't used it in a while, go ahead and take a look at your screen. Look at the bottom of the screen and locate that Q&A button. And if you have a question during the session, that's where you are going to enter it. I would ask that you limit your questions to the topics being discussed. We'll just try to stay on topic, if you will, with the questions. And that allows us to get all of those questions answered within the session. Also, as part of our accreditation, we do have to disclose if any of our speakers have prohibited relationships to disclose. This is the statement for this session that nobody had anything to disclose. Next slide, please. For continuing medical education, we do offer one hour of free CME per session. The key to getting it is to make sure that your full first and last name are displayed on the Zoom screen. So if you would take a minute, find yourself in the list of participants or in the pictures, the Hollywood Square, so to speak. And if you have iPad, your phone number, Bob's office, admin, anything other than your full first and last name, go ahead and click those three ellipses to the right-hand side of your name and click on Rename because we cannot give credit to you for attending this session unless we can see that your full first and last name were displayed. Also, as a side note, if you're watching this recording at a future date, we do appreciate the time that you're giving to go in and take a look at the recordings. But please note that we cannot give credit for watching the recording. In addition to that, any of the recordings that are on our YouTube channel were current as of the time that they were recorded and may not reflect current AME guide updates. Next slide, please. Perfect. The other way. There we go. So speaking of CME, super easy process. If you have a cell phone camera or an iPad, Android camera, whatever it happens to be, you can scan the QR code that you see on your screen with your cell phone camera, or Gary is going to post a link to that same survey in the chat. So if you navigate to that link in the chat, that will take you to the request form. Fill out. I think there's seven or eight questions there. Click on submit and you should get your CME certificate and give us up to 10 business days, if you would please. Also, just as a note, don't save that link because the QR code and the link change monthly. In fact, that survey will close on Friday. Today is Wednesday, January 7th. Come Friday, that'll be closed out so that we can go in and pull all of those requests. So don't wait to request that. Next slide, please. Shameless plug, we do have an upcoming AME refresher. If you are in need of an AME refresher to stay current, or you would just like to come and attend, we do have some space available for our January refresher and it will be held in Fort Worth, Texas at the Southwest Region regional office. If you go into DMS, you should be able to register for that. We do ask that you try to register for that as soon as possible, but we do have some space left. Next slide, please. Okay, we've had lots of emails and comments over the last couple of months. Why are you holding Grand Rounds on the first Wednesday of the month? Well, that's because there's been a lot going on between federal funding shutdown and the holidays, but tonight is the last night, hopefully for a while, that we will be on our odd schedule. And starting January 28th, we should be back to our normal schedule. So the dates for upcoming Grand Rounds are January 28th, February 25th, and March 25th. Next slide, please. And with that, to introduce the topic for this evening, we in the education office periodically get questions from AMEs and also out in the field, we get lots of feedback of, hey, this is confusing, or could you maybe talk about this at a future Grand Rounds? So tonight's topic is something that was actually requested from several AMEs in the field regarding when a medical flight test is required, an MFT. And we had a lot of requests for more information on this. We know that this topic is difficult to understand and that there's no real formula for doing this. So Dr. Richard Carter is going to talk about this. And our objectives are that you can become familiar and develop some confidence with the FAA procedures for airman medical certification when a statement of demonstrated ability, a SOTA, we talk about a SOTA, may be granted. And then also we're going to discuss some case scenario examples and some certification guidelines related to the SOTA. And then towards the end of the presentation, Dr. Brett Weirich, our Deputy Federal Air Surgeon, will also weigh in on the discussion as well. So with that next slide, and I will turn that over to Dr. Carter. Well, welcome everyone. I hope you can hear me all right. We hear you good. As we mentioned, we're not going to go through a particular formula. You don't need to worry about writing a whole bunch of notes. We're going to be talking about real cases, real airmen. I'm going to give you case examples, and then I'm going to describe the process we go through when we're considering the need for a medical flight test. And the goal here is to make you more comfortable with this and also to enlist your aid as an advocate for the airmen when we're doing this or when it's needed. Dr. Northrup has said that we want to decrease turnaround time, and there's some things that you can do to help us with that when a medical flight test is needed. So let's just jump in here. The first case is specifically near and dear to me. I'm wearing my FAA field uniform. If there are times when the FAA sponsors us at meet and greets for pilots, one of those is Sun and Fun. And this was indeed a person, an airman that I actually met at Sun and Fun, approached our booth and said, I'm going to need some help. She was there with her father, and she wanted to have an in-person discussion about her issue. And it was pretty dramatic, an actual in-flight incident. She felt a crack on final approach. She thought that she'd maybe been over exercising and maybe just had a vague ache from a muscle strain. She didn't really have a sense that there was something significantly wrong. So it came as a complete surprise to her. The other pilot took over, the aircraft landed. She went to some people at a well-known institution in Minnesota. And I'm not going to describe to you how to do a reverse allograft prosthetic composite, just that they put her arm back together again, and it works. There were some complications, as sometimes are the case. And so we had to additionally address the metastatic issue. And then that required a consult to our Federal Air Station oncology consultant. The recommendation was we could consider with a special issuance, and then we needed to do a medical flight test. This is where the AME was particularly useful, this particular Airmen's AME, in helping coordinate what was needed, identifying the airline, and coordinating that effort with the Airmen. If you've not heard about a Certificate Management Office, that was one of the reasons why I wanted to discuss this particular case, is to just be aware that not everybody goes to the FSDO to do a medical flight test. So this was a complicated disposition. We need a medical flight test as well as a special issuance. In the interim, this was a very determined young lady. In the interim, while she was waiting for her special issuance, she elected on her own to go to a training facility and upgrade her pilot certificate in simulators to the A320. So she would be ready to go to take on a new job once everything was completed. Once we knew that, that this was the aircraft she intended to fly carrying passengers, then we selected the appropriate inspector for that aircraft and for that airline. So here's a description of what a CMO is. A CMO is exactly what the words say. The airline has to have a certificate to operate as an airline, and the people, the FAA officials that manage that certificate is called the Certificate Management Office. Now you'd think that sounds pretty straightforward. No one would be confused, and yet there has been some confusion. People will hear the descriptor American Airlines Certificate Management Office or Delta Airlines Certificate Management Office, and they'll say, well, that sounds like airline employees. They can't be doing a medical flight test. It has to be done by an FAA guy. So you need to go to the FISDO, rent a Cessna 150, and do your medical flight test. No, no, that's not it. They are FAA inspectors. They know how to fly that aircraft. They have the authority actually to walk on the aircraft itself, show their credentials, and say, hi, I'll be riding with you today. So they're FAA guys, and their job is to manage the safe operation of that airline. So in this case, we send a letter of authorization to sort of like a military order to the CMO for that airline and say we're going to need a medical flight test. With airline pilots, I commonly will send an email to the principal supervisory inspector and say we've identified this airline pilot. We'll need to do a medical flight test. I usually get a very polite but very short terse response saying happy to do it, doc. You got the correct address. I'm the guy. Send me the LOA. We'll take care of it for you. So again, the last bullet there, FISDO will not be, should not be conducting a medical flight test for an airline pilot. So follow up, she's still flying. She's now 33. Here's a comment from her doctors. She's doing real well. So this was a heartwarming success for us to get this pilot flying again. And she's indeed followed up, come to Sun and Fun again, said hi to me and Dr. Wyrick, and was obviously happy with her outcome. Case two is amblyopia. Amblyopia is, of course, a genetic disorder, essentially, congenital. They've always had a vision weakness, and typically it's relatively mild. We have some dramatic cases, but usually it's 20-30, 20-40 vision. And so the question came up, do we need to have a medical flight test for that in a relatively low hour applicant who is 14, 15, 18 years old? In this particular case example, I've added some additional complexities that you don't normally encounter. So I'm talking about a rarer, a little rarer case. There was some intermittent diplopia and strabismus that improved with PRISM. If they need a PRISM to fly, they can have a PRISM. Of course, you're going to be getting an 85007 eye report, and the doctor is going to tell you, yep, that's what the eye doctor is going to tell you. That's amblyopia. It's not going to get any better. If they had to do a PRISM, we gave them a PRISM and their diplopia is resolved. So what to do about that? For a mild amblyopia, zero hour or low hour applicant seeking a class one certificate, and we've evolved to deciding we're going to give them a soda based on physiologic experience. We can't base it on operational experience because usually they have none or very little. Our decision point is that the medical flight test conducted under these circumstances by AFISTO would be a low yield for aviation safety concerns. And so we warn for vision changes and we issue a physiologic soda and we coordinate that with the fine folks that are writing the AME guide. So they have case examples to eventually be able to update the AME guide with this disposition. So sometime in the future, I think you'll see a disposition table for this, but there's still something new that we're doing. This is relatively rare, but you were prepared in advance. You were told I'm a medical officer in the certification division. In the certification division, if you hear the sound of hoof beats, it is a herd of zebras. That's what we deal with. So a person like this or another congenital condition may be walking in your office and saying, I want a class one certificate too. I'm going to be an airline pilot. So significant birth defects. He did do a medical flight test for class three and got a class three soda. And now guess what? He wants to upgrade. So what do we do about that? That's been discussed among various medical officers and you'll see, well, how should we proceed? And so this will be a typical question AME will call and ask about. Our determination is that for a significant physical deficiency, we're going to want another medical flight test to class one standards and in a more complex aircraft than the single engine aircraft that he originally did his medical flight test on. So the take home message here is sometimes we do do a second medical flight test in a more complex aircraft. And there have been rare circumstances where the end of it is rare, but there have been rare circumstances when the individual could not adapt to say flying a twin engine jet. So here's another circumstance. The airman goes in to see his AME. The AME says, I have a favorable report from his neurologist. The AME was kind to write something down on block 60, what the AME's impression is. And we value your input. Do you think this guy needs a medical flight test? Or is there something of concern regarding a case where we wouldn't be giving a soda, but there might be concern on your part? In this case, the AME didn't have concerns. He said, the hand tremor is basically the only thing that's really noticeable. And to the AME's assessment, it seemed pretty benign. He said, I don't, his almost exact words were, I don't think a passenger would notice. So there's nothing that's really dramatic about that. However, for aviation safety purposes, our neurology consultant felt he wanted to have a medical flight test by the CMO to observe actual flight operational capability, to reassure us that the special instruments that we were given, for which all the reports said he's good to go, was validated. So if, do we have our neurologist, Dr. Murphy available? Yeah. Can you hear me okay? We can hear you okay, sir. So go ahead. Okay, great. There's a couple of caveats to these types of cases. So normally when we're doing a medical flight test, it's very often for a condition that's fixed and stable, like a permanent injury to a limb or loss of limb. But when we get a case where from a neurological condition here, there is a loss of function, it may be relatively mild, but we need to assure safety and we just want to check that the airman is able to safely perform everything that they need to perform. The medical flight test can be very useful. One thing about Parkinson's, it's a progressive neurodegenerative disease. It's likely to get worse over time. So this is not going to result in soda, a statement of demonstrated ability, but rather a special issuance. But it opens the door and allows us to consider time-limited certification. Of course, if there was a change in the condition, if things get worse, we might need to reconsider. But this would be for a situation, there's a lot of cases of Parkinson's where it may be very mild and although it's progressive, it may progress slowly. And so it still gives us a period of time when we can certify. And this is very helpful for looking at the mild motor manifestations and just making sure that that is indeed safe. Now, one other caveat I think this brings up is that medical flight tests are not intended or validated to look at cognitive issues. It's not really for that purpose. So usually before we would authorize a medical flight test in someone with Parkinson's, we would conduct a neuropsychology evaluation. So we get that out of the way first. And then the sort of final step would be the medical flight test. So that's really how we'd use it there. There'd be other conditions where there are progressive neurological conditions and we'd use a medical flight test. One example might be muscular dystrophy, very slowly progressive. But again, we wanted to make sure that at least at the time we're considering a special issuance that that airman still has sufficient strength and is able to safely control the airplane. And any change or any progression would need a reevaluation. In fact, over to you, Richard. Thank you, sir. So you're our eyes and ears, as we've said many times before, we need you to comment. There are cases where I've seen where there was no comment by the A&E, just said the neurologist said everything was fine. We'd like to have your impression of what the airman looks like. If you have concerns, then by all means, write that down. Or if you say, well, there's maybe just been a little subtle change. I'm not so sure about this one. Should we consider doing a medical flight test? A medical flight test is not a checkride. They're not going to have an exhaustive review like a checkride. It is specifically for our request to have them observed in terms of their operational capability to safely manipulate aircraft controls. We give specific instructions to the CMO, the FAA inspector to say, this is what we're looking for. Can you please comment on that? And they give us a report. It's almost invariably favorable. It's rare that somebody really fails a medical flight test. So again, it's not a checkride. There are some individuals that maybe as they get older, will have a little more trouble persuading the inspector that they really are okay to fly. But it may not actually relate to the actual reason why we're doing the medical flight test. But that's extraordinarily rare. So it's not something to really be feared, I guess is what I want to convey. So an airman like this will walk into your office, or they'll have some other relatively minor genetic abnormality. And the question may come up, well, how short are those fingers? And do they really need a medical flight test? And he's a zero hour applicant that needs his certificate typically, and you've all heard this, the same story, I need a class one certificate for matriculation to whatever school they're going to, the school has a requirement. So do they need a medical flight test or not? An option that we have explored and have been generally satisfied with is that we will ask for a report from instructor. And in many cases, it's a guy that really hasn't had much of any flight experience at all. So yeah, they have to go out and rent a plane with a flight instructor and do a few hours of flight training. And then we asked the instructor, what was your impression regarding his ability to safely manipulate the aircraft controls? And usually, certified flight instructors write a pretty detailed report, not unlike what we get from the FISDO. And if that report looks favorable, and we're satisfied with that, then we may say, well, we'll just eligibility warrant for this. We don't think it's sufficient that it actually requires a medical flight test and a SOTA. So the severity of the issue is something that we value your opinion on. Another example I'll share is an individual with a hearing aid. Well, we don't do medical flight tests for, if you will, one-eared pilots. However, what if they had a cochlear implant in both ears? And so they're dependent on those two cochlear implants working. That was another circumstance where we had the individual go to a flight instructor, and they practiced with the batteries and so on. They practiced procedures regarding loss of radio, which would be the equivalent of losing function in both the cochlear implants. So these unique situations come up, and invariably, the AME is involved, and a big asset to the airman in expediting the certification. Remember that Dr. Northup said we want to minimize delay in certification. So if the determination is made in your office that you need to do, this airman needs a medical flight test, then the other thing we need to have you put in Block 60 is, and this may require some research with the airman, is where do you want and who do you want to have that, where's that medical flight test going to be done? If he's a pilot in Phoenix, and he wants to go by a recreational aircraft, well, then that's going to be the Scottsdale FISDO. And so you put that down Block 60, he's going to need a medical flight test, the airman requests the Scottsdale FISDO. If you don't put that down, then the letter that goes out is going to say we need to have you tell us where you want to do the medical flight test. If he's an airline pilot, that's pretty easy. He's going to be done by the CMO for that airline. Some of the tricky ones are net jets, flex jet, they have certificate management offices too. And there you ask the airman to do a little research with the compliance officer for that airman and have him identify who the FAA inspector is that's managing their certificate. Once I get that name, I'll send the email to that inspector and say, can you do a medical flight test for us? Corporate pilots flying for large oil companies, for example, they have certificate management also, but in a different sort of way. They get their certificates through flight training facilities. And those flight training facilities are in turn managed by a certificate management office. They don't just hand out certificates and say, here, you're good to go. You're qualified to fly a twin engine corporate jet. There are people that are monitoring, like the FISDO monitor DPEs, designated pilot examiners. So for corporate jets, essentially they have their DPEs as well, but tracking those guys down is a little bit more of a challenge. So ask the airman, do a little research. Typically you say, find the person in your corporate office that does compliance for the FAA and then tell us who that FAA guy is. Now we're ready for Dr. Wyrick. All right. So, hey, and again, everybody, good evening and happy new year to everybody. We wish you peace, prosperity, and good health this year. And thank you again for your interest in aviation safety. And thank you for being here tonight. There's a couple of things that we just wanted to emphasize because it seems that every once in a while we do take an AME by surprise. And when a medical flight test is necessary, there's a couple of things that you need to be aware of. And first of all, is when we're asking for a medical flight test, we are trying to get to yes. We're trying to get to a yes answer where we can issue a special issuance or a soda of some sort for the individual who is the applicant. And so when we ask for a medical flight test, sometimes it'll be surprising that the first thing we do is deny the application. And we can't conduct a medical flight test unless the application is denied first. And so you'll call up the regional flight surgeon or you'll talk to somebody at AMCD. We're talking about, okay, we're going to go down the route of a medical flight test. And then the next thing you know, the applicant has a denial letter. Standard procedure. So we deny the application and we advise the airman that a medical flight test is required for reconsideration. By definition, if we're considering a medical flight test, the condition is disqualifying. So we have to deny the application. But at the same time, we go ahead and we issue the authorization for the medical flight test. It's just they have to read down further in the letter to understand. And we've had cases where some airmen just read the top and they say, hey, you know, I'm denied. That's it. No, that's not what it is. So please advise the airman that when we authorize a medical flight test, they first have to be denied. The other thing is no medical certificate shall be prior to the successful completion of the medical flight test. And applicants with medical conditions that require in-flight assessment do not meet medical standards. We will deny, for example, no usable vision, bright eye or residual corneal scar. And that's different from what it was when I first became an AME 35 years ago. Now, 35 years ago, we would issue a certificate and it was valid for the medical flight test only. All right. So these are three things that came out as and it's in the one July 2020 memo from Dr. Northrup. And again, just to just to go over it. First step is when we when we're authorizing medical flight test, we deny the application to advise airmen that a medical flight test is required for reconsideration. And we do not issue a medical. Oh, I'm sorry. I'm being corrected by Dr. Northrup. She says, actually, that memo came out. It came out from Dr. Berry, not her. So, OK, sorry about that, boss. All right. So and then the and so the and so no medical certificate shall be issued prior to the successful completion of the medical flight test. And applicants with medical conditions that require in-flight assessment do not meet medical standards. We will deny and then we'll authorize a medical flight test. OK, so with that, with that, let me turn it back over to Dr. Carter. OK, thank you, sir. Miss Risley, we're ready for you. OK, thank you so much, Dr. Carter. Next slide, please. Or well, before you do, our next scheduled guide update will be at the end of this month, which is also the same day that we'll have our January Grand Rounds sessions. Thank you. Next slide. And next slide again. So shameless plug, if you ever have suggestions for a guide improvement, I will tell you that Dr. Fraser and her group have been doing a lot of work on the guide over the past year. You can send those suggestions to a guide, all caps at FAA dot gov. Keep in mind that that email address does not answer any case questions. Next slide, please. And again, upcoming grand round dates are January twenty twenty six grand round session will be held January twenty eighth of this year and then we'll be back to our normal schedule of being on the last Wednesday of the month. So February will be February twenty fifth and March will be March twenty fifth. Next slide, please. It was asked in the Q&A if we would flash the QR code again to get CME credit at the end of the session. And thank you for asking that. Here we are. So if you had your full first and last name displayed throughout the Zoom session, you can scan that QR code with your cell phone camera or your tablet camera or whatever you'd like and answer the questions in that survey and click submit. And that's how you will request your CME. Also, Gary has posted in the chat the URL. If you'd rather just copy that URL and go to that website address in in whatever browser you prefer. So with that, this concludes this session of grand rounds. I personally want to thank you again, first off, for attending and for your interest in aviation safety as Dr. Northrup and Dr. Weirich always say, we couldn't do this without you. Thank you for being here. Thank you for watching Grand Rounds. If you're watching this as a recording in the future and as we dismiss, if you will please go ahead and log yourself out of the session. FAA staff, we will go into the breakout room for a debrief. Thank you so much for attending. Have a good evening and happy new year.