AME Guide Grand Rounds March 2026 Session

Okay, good evening, good afternoon, good morning, whatever it happens to be where you're joining us from. Welcome to this month's episode of AME Grand Rounds. Dr. Northrup, would you like to say anything to welcome them and kick this off? Sure. Thank you very much everyone for coming. We really appreciate you taking the time to spend an hour with us because we've got lots of information to pass on to you and I'll have a bit more of a speaking role at the end so I'm gonna turn it back to Christy and I'll look forward to interacting with everyone. Thank you. Thank you so much Dr. Northrup. Next slide please. As always we have a little bit of housekeeping that we need to do up front. The session is being recorded. What this means to you is that the session will be made available later on our FAA AME Guide Grand Rounds YouTube playlist. No participants will be shown as part of the recording. The best way to find that particular site is just open up your favorite web browser, go to the search engine and search for FAA AME Grand Rounds and then that should take you to our YouTube playlist. Keep in mind that all of those recordings are current as of the month that they were recorded. Next slide please. Rules of engagement. First off, this session is going to be locked after the first 10 minutes. What that means is that if you drop out of the Zoom and try to get back in, you may be able to unable to rejoin. Your chat, your cameras, all of that is disabled. If you haven't used Zoom at all or maybe if it's been a while, take a minute and take a look at your screen. Across the bottom of your screen you should have a Q&A button and we want to capture all of your questions using that Q&A button. We have several doctors, FAA doctors that are on the call and they will be periodically answering some of the questions in the in the chat, well not chat, but in the Q&A and then we'll also have a time at the end of the session for questions as well. We do ask though that you would please keep your questions to the topics being discussed. We know that there are lots and lots of questions out there and you may have a really good question but if it's not related to the specific topic, we may not have time to answer all of those questions. Also, as part of our accreditation where we grant the one hour of free CME each month, we do have some rules that we have to follow and one of those is to give a disclosure or state if we have any disclosures and this is our statement for the session that no speakers have any prohibited relationships to disclose. Next slide please. So what you're all here for, here are our objectives for the evening and as Dr. Northrup alluded to, we have quite a bit of information to talk about. We're going to discuss the AME guide updates that were released today, condition not listed, GERD, retinal dystrophies, polycystic ovarian syndrome, we've got an update to that CACI, the SYNC-A-B decision tool, the six-minute walk test, FAA results sheet. Next slide please. Protocol for coronary heart disease for first and second class medical as well as air traffic control specialists, coronary heart disease and coronary artery disease recertification status summary changes, and a correction to the AFib, AFlutter disposition table. Finally, at the end of all of the updates, we're also going to talk about a new resource that we have available on the website, which is the most common medical conditions by age group. Dr. Northrup is going to talk about that as well as some new links that are available to both you and the pilots on the web page. And then she's also going to discuss the Airmen Medical Certification Operational Metrics. So without further ado, I'm going to turn this over to Dr. Judith Frazier. Dr. Frazier. Thanks Christy. All right, thanks everybody for joining us tonight. We're going to talk about the updates that were released in the AME guide today. So the first one we're going to talk about is a condition not listed table. We have requests from AMEs to have a table for when the condition isn't listed, what's the general actions. We know you're taught this in the AME basic seminar. You see it again in the refresher seminar. This was a way to put that paragraph that we have after every body system just in one place for easy reference. So the first thing is, you know that there are thousands and thousands of medical conditions. There's less than 400 in the AME guide. So you're going to run into pilots who have medical conditions and you're going to go there's no guidance what do I do. The first thing is you want to figure out are they at increased risk for sudden or subtle incapacitation. If they're not at increased risk, that's something that you as an AME should be able to issue from the field. If the condition is not in the AME guide, this is the table that you would reference. Now even if you think a condition may not be of high risk or may not be of increased risk, if there's a DISCO table for it, you need to follow the DISCO table. This is specifically for conditions that aren't listed. So you as the AME, you have a good sense of this pilot is safe, this pilot is unsafe. Remember in the AME seminar, you probably heard this the line about if you would not put someone you love in the cockpit with this pilot, you shouldn't give them a medical certificate. So kind of keep that thought process going as you do the physical exam and ask them appropriate questions. But if the condition is not listed, if it's low risk, if it's stable, if they're not on any treatment that would make them have potentially sudden or subtle incapacitation, that's when you should go ahead and issue. When you do, you'll get a pop-up box that on our end is item 60. When you get that pop-up box, just list the condition, whatever documentation you had, some kind of short summary, and tell us why you weren't concerned about this. So that's row A, condition not listed, not of air medical concern. Sometimes you'll need documentation to back it up, sometimes it's based on your history and physical. So then like the rest of the disposition tables, we have a row B. If they don't qualify for row A, they drop down to row B. This is where it may be a concern. So if you as the AME determine this pilot may be at increased risk, you're obviously going to defer. If there's a disposition table, you follow the disposition table for that condition. But if it's not listed anywhere in the AME guide and you're not comfortable putting this pilot into pilot and command functions because of the condition of the treatment, you're going to defer. Tell us why in item 60. Give us a short little paragraph. And then to help the pilot and to help us speed up the process, if they have any of the information, we'll take a progress note. We actually prefer progress notes. Anybody who's on the MyChart system can now get their own progress notes out of MyChart. Make sure your pilots, if they're bringing you progress notes, it's progress notes and not after visit summaries. After visit summaries don't help us at all. It's got blood pressure and meds, but it doesn't say anything about the exam, the history, the decision tool, the decision portion. So if your pilot brings in a progress note from their MyChart, read through whatever the condition is and then any other testing that was done for this condition. So those are the big pieces of information that you as an AME want to help your pilot obtain before they come and see you. Dr. Northrop talks all the time to pilots about pre-flight your medical. This is a way you can help them pre-flight their medical by letting them know when they come to see you. At a minimum, they're going to need a progress note from whoever's taking care of them and the condition. A medication list helps if it's not on the progress note. And then any other testing that was done. When you see the pilot, you're just going to defer and tell us what information you have and what your sense is of this pilot. Remember, we're looking for safe versus not safe. It can be from the condition, it can be from the medication or the treatment that they're using. So to sum up the condition not listed page, it's just what it describes. If there is not a disposition table in the AME guide for whatever condition this pilot has, you want to go ahead and use this table and follow the guidelines. So pretty easy. I know you guys have heard that in the basic seminar. You hear it in the Refresh Your Summer seminar. We just had a request to put in a table to kind of go through that table scenario like we're doing on all the other conditions that we have. All right, so our next condition, another simple one. You should be able to issue most pilots with GERD. GERD is very common. There's a lot of good treatments for it. There's H2 blockers and PPIs and Carafate and a couple of other meds. Uncomplicated treated GERD, we're not concerned about. Again, it goes back to risk. Are they at high risk of causing sudden or sudden subtle incapacitation? GERD by itself shouldn't. If it's treated with lifestyle or diet, the pilot's doing fine, we want you to issue. Put that information in item 60, they get a medical certificate if they're otherwise qualified. Now, if they've got a more advanced stage of disease, they've had surgery for some reason, they have to be at least two months out from surgery. But if they're two months out from surgery and they're doing fine, if the progress note from their treating doctor says they're doing great, they're not having symptoms, they don't have anything that could cause sudden or subtle incapacitation, again, you can issue that. Tell us that information in item 60. Specifically, note if there's any complications from the surgeries. And then just like all the other DISCO tables in the AAMI Guide, row A is least concerning. If they don't fall under row A, you drop down to row B. A little bit more mid-level concern, if they don't follow row B, drop them down to row C. Row C, we know when we have one, takes up a lot of real estate in the guide pages. But the number of pilots on row C is usually smaller than what's in A and B for most conditions. When you get to a row C condition, for GERD, it would be somebody who's severe, somebody who has, you know, esophagitis, somebody who's got recurrent surgeries for something, someone who's at risk for a bleed or a perf, somebody who would be high risk of sudden incapacitation. So if you see a pilot with any of those characteristics, you'll just need to defer. We need the most recent progress note, usually from the GI doctor that's taking care of them. Specifically, the GI doc needs to tell us, what's the etiology? Are there any expected surgery coming up? Are there any complications? And what's the prognosis? We know a lot of physicians based on your training may or may not put prognosis in your progress notes. For something like this, that piece from the specialist is important. If they've had any other testing for this condition, we want to know that as well. You as the A and B, you'll go ahead and defer. You'll upload any documents that you have, and those will be reviewed on a case-by-case basis. So again, most GERD, you're going to be able to issue. One of the things we're doing is pointing the pilots also to the A and B guide so they can see what they need to bring when they come and see you. So we're trying to put more even common conditions in the A and B guide so they'll have that information as well. All right, next one. This is a little more complicated. These are the retinal dystrophies. So there's cone dystrophies, there's rod dystrophies, there's cone rod dystrophies, there's rod cone dystrophies. And the one you've heard about probably most frequently is retinal retinitis pigmentosa. It's the most common. Remember, retinal dystrophies follow this spectrum from not as concerning to more concerning. There are some treatments for them. For FAA purposes, the concern with retinal dystrophies is that a pilot could have 20-20 vision. They could meet all the standards that are required, but they can still lose their peripheral vision, and they can still lose their night vision. So anyone who has any pilot that comes to see you who has a retinal dystrophy or any air traffic controller, you're going to have to defer. When you look at the A and B guide, there's only one row. It's a row A. It lists the information that we're going to need, and you're going to have to defer. Because in most cases, if somebody has a retinal dystrophy, especially like a retinitis pigmentosa, it's progressive. It's a safety concern, because they can pass a lot of our tests, but they still do not have adequate vision to fly. Or it will progress, and we're not sure at what rate it will progress. So retinitis pigmentosa or retinal dystrophy, if you see a pilot or an air traffic controller who has this condition, make sure they bring in the most recent progress note from a retinal specialist. That's who they should probably be seeing anyway. It should tell us an interpretation of any of the testing that was done. If it's associated with a different medical syndrome and whatever treatment is proposed, if any. The other thing that you should upload is copies of any recent testing that was done, and then visual acuity. What we don't want is for a pilot or an air traffic controller who has a progressive condition like retinal retinitis pigmentosa or retinal dystrophy, we don't want them to have to go spend a lot of money on brand new testing. If their condition is progressive and concerning, have them send in the most recent progress note and testing so that we can review that. In most cases, this is going to be a denial or a DQ. In the rare case that this is an unusual type that can be treated, isn't progressing, those will be reviewed, usually by our fast ophthalmologists. And at that point, if they need newer testing or newer evaluations, we'll ask for that in the letter. So retinitis pigmentosa, retinal dystrophies, there is a new DISCO table in the guide. Use the AME, help your pilot collect just their most recent information and upload it. All right, so now we're going to go over just a couple of the changes that we put in this month. So one is we've had a PCOS khaki for a couple of years, PCOS polycystic ovarian syndrome. When we rolled PCOS out, we did not put that if they have a prolactinoma, that will knock them off the PCOS khaki. Remember khakis, we talk about two fiber rule. If you have two doctors have to discuss a case for five minutes, it's not a khaki. Khakis are simple. They're straightforward. We know what the pathology is. We know how they progress. And they're, for the most part, conditions or levels of conditions that are safe. So if somebody has PCOS and it's due to a prolactinoma, they could still qualify for special issuance. We'll need to look the prolactinoma information. You just don't want to put them on a khaki. So that's PCOS. Next was the syncope decision tool. So our neurologist helped us come up with the syncope decision tool a couple of years ago. On item number five, we asked, do they have any history of neurogenic or cardiac syncope? Neurogenic, we didn't, we just recently, somebody said, Hey, neurogenic kicks anybody off who's dehydrated or stressed or prolonged standing. We're not concerned about a pilot who has a single episode of a faint caused by a decrease in heart rate, a decrease in blood pressure, you know, they had an emotional stress, they would stood up for too long. So that type of neurogenic syncope, we're not concerned about. We pulled that off the decision tool. If they have a cardiac type of syncope that you would need to defer across the board, kind of run of the mill neurogenic, they got stressed, they got dehydrated, they stood up for too long. As long as it's not a repetitive condition, then you can go ahead and issue as long as the other decision tools items are all in that left hand column. So remember, we're looking for simple, uncomplicated, not repetitive, but we do want to make sure you know that if they have cardiac syncope, different cast category of risk and those you should defer. All right, next one, six minute walk test. So again, we've had a page in the AME guide for a six minute walk test. We use it on multiple cardiac and pulmonary conditions. You as the AME need to know that a minimum distance that we require for a good six minute walk test is 400 meters. So pilots or air traffic controllers, if they're unable to make 400 meters in a six minute walk test, that makes us be concerned about their functional status. So tell your pilots, air traffic controllers, we need 400 meters when they go and do this six minute walk test. The other change is that number one, we rewrote that question because we were getting a lot of pilots who use a mobility aid, a cane, a walker, something like that. If that's the reason that they're unable to get the 400 meters, we need to know that information so we can take that into account. So two simple changes on the six minute walk test page. One is if they have a mobility device or mobility impairment, just make sure you put that in question number one. And then number two, make sure that they know we need 400 meters in their six minute walk test. All right, a couple other things. For as long as I've been at the FAA, there has been a six month recovery period after a left main stent or a cabbage. The medical appeals physicians and the cardiologists, cardiology panel all got together and looked at left main stent specifically. And they unanimously said, we've been doing these for a long time. We haven't had big negative outcomes. Left main stent specifically are now put into the same time frame as any other stent. So a left main stent is now a three month recovery period, just like any other stent. Cabbage will remain in six months. So that's for pilots only. So a pilot who's had a cabbage still stays at a six month recovery time. But any other type of cardiac stent, they only need a three month recovery. Air traffic controllers have been on three months for everything. So they will stay at three months. And your next question is, what did the cardiac panel say about could we decrease the cabbage to three months? And that was no. So not at this time. We'll look at it again at some point and see if that has changed. But right now, left main stent is now eligible after a three month recovery period. All right. And then on this coronary heart disease recertification status summary. Remember, this takes the place of when pilots had a C.A.D. or they had a stent or they had an M.I. and they had to get stress test or stress nukes every year. Now it's based on risk factors. So if your pilot or air traffic controller is placed on a special issuance for coronary heart disease and they're sent this recertification status summary, it's about risk factors. So the only thing that we wanted to highlight is we need to know if they're diabetic or not. It changes the risk. So we need an A1C on any pilot who uses this recertification status summary or if they're not using the status summary but they're on a recert for coronary heart disease, we need an A1C. Diabetic or not, we need an A1C because if they become diabetic, it changes their risk. So that's the change that you'll see here. And then the last update that we have is AFib, AFlutter. There's a row D in the AME guide and it talks about the Watchman device or a LAA left atrial appendage surgery. If a pilot has had LAA surgery like a Watchman type device, it usually was a six-month recovery. Again, the cardiac panel discussed it and they've had enough experience with it now that a Watchman device, LAA-Aflutter type device has now been decreased to a three-month recovery period. So that's the final change that we and with that I will turn it back over to you, Christy. All right, so again welcome everybody. We have added a couple of other items to the AME guide that we hope will encourage your pilots to pre-flight their own medicals. So the first thing that we are going to go over real quick this evening is the top 10 diagnoses by age group, by certificate requested. Now the first thing to let you know, this is a simple numerator account. These are not rates. We looked at two years worth of information and just started counting path codes and this is what we came up with. So this currently being shown is the first class medical conditions page and let me move this bit over here so I can scroll down. And you can see for the younger folks, it's an awful lot of mental health diagnoses. You see some asthma thrown in there, ADHD. As you progress through, we begin to see alcohol offenses starting to show up and as you go into the more mature ages where I now find myself residing, you can really begin to see the disease patterns show that we expect to see with age. Now what's really cool is if you hover over one of these, it will take you straight to one of the AME guide pages. So we're hoping that when pilots go look at this or we go look at it as providers, it's a quick reference to get to where the instructions are. The other thing that we think is going to be really helpful with this is as we're developing education for different pilot groups, we can aim the education based on the disease processes or conditions that we see in that age group. So if you were dealing with a flight school and you were going to do a presentation, you probably wouldn't pay attention to diseases at age 60. You would be looking at somewhere here in the 20 to 25 range so that we would educate them on how to interact with our system. And we've got it broken down by second class. So here's the second class ones and here's the third. Again, it's really important to understand that these are simple counts. These are not rates. So when we look at disease burden in the younger ages, it's not as high a percentage as it is as we go through the more mature and we begin to see the conditions that you get when you're in your 50s, 60s, and 70s. Broad off the press, this was not even in this earlier today's session at noon central. Jana Williams and her crowd have uploaded some of the same information into the frequently asked question files. So if you're in MedExpress, under the help menu, there's a frequently asked questions. Go ahead, Judy. And it will lead you to some of these on how to preflight your medical and how to use MedExpress next. Again, there's hyperlinks under the pilot information. You can find those at www.faa.gov slash go slash medcert under pilot information. Go ahead, Judy. And they're also broken out like this. And we're going to continue to populate this with more information about the most common diagnoses. Someday, maybe we'll even have QR codes because my kids tell me that's the way they do things these days. But it's really pretty awesome as we're trying to push the education. All right, next slide. I wanted to show you a couple of charts to tell you just how much I value what each of you are doing and why it's so important to have the pilots preflight the medicals. And yeah, we're every month we do improvements in the guide for aviation medical examiners. We work on checklists. We understand that it's the 90% solution. And there's always that one out of 10 that we don't have all the right answers. But Judy and her team have been doing amazing work. And as we continue to push the one guide outward facing, you'll get even more information. All right, so let's take a look at what we've been doing. It's a bit of an eye chart. When we started working on our backlog in January of 2025, the average age of the cases at this position was up over 160 to 180 days. And those are for deferred unissued cases. If you look, we have a goal by the end of FY 26 to be under 117 days on average. And as of this week, we were below 90. We still have room to go. But that's the average age of all cases at final disposition. Now one thing I want to impress on everybody, these are not funny cami days where we only count the days that we had control over the case. These are case days from the day you deferred till we made a decision across the board. And then when you look at the average age of the unissued cases pending, we're below 60 days at this point. Still room to move, but we're getting closer and closer to our goal of 60 days from deferral to decision. Next slide. All right, this particular chart shows you where the cases are by workflow type. So 61% of all cases that come into the FAA are general review or GR. That's the dark blue line. The next big bunch is drug and alcohol, and that's the orange line. Medical appeals is not appeals at the federal air surgeons level. Those are the cases that are mandatory deniable that are handled by that branch at the Airmen Medical Certification Division. Then the little tiny blue line up top is the neurology and psychology and psychiatry. You can see since we started tracking this the 1st of January 2025, they're all down 68.7% in total. That's been a huge effort. We really appreciate all of you making the packages as complete as you can, and we are trying to get them moved through the system just as quick. Next slide. So this chart shows you where the cases are by type. So who quote owns them? I'm going to start with the salmon line in the middle, and I didn't think to start tracking it this way until the 1st of April of 2025, but that salmon line is the cases that are waiting for physicians at the FAA to look at them. If we had started this on January 1st, that would have been 8,000 cases. We are now holding pretty consistently between 300 and 400 cases waiting for a physician to look at it. The blue line, those are our legal instrument examiners and program analysts, and they have been doing yeoman's work trying to get that down. So when you send a case in and everything's there, the LIA has to touch it or the program analyst, then it comes to a physician, then it goes back to the LIA. So they get to touch everything twice, even when it's a first pass case. So they're doing incredible work. The green line, that's where we're waiting for something from the airmen. They still account for over 50% of all the cases we're waiting, so they're deferred on issue. But I want you to pay particular attention to the June timeframe in 2025, and there were just under 4,000 cases sitting out with the airmen waiting for them to send something back to us. That has gone down nearly 50%, and 95% of that is since June of 2025. So what happened in June of 2025? That's when we updated the instructions in MedExpress. So we really are seeing more and more cases that the airmen and you are getting to us the first time so that we really only have to touch it once as opposed to asking for additional information. Next slide. So we started tracking this, and this is all cases that we receive at the FAA. You want to be on that green line. That means you have pre-flighted your medical, we make a decision the first time. And we are almost below 30 days at this point for first touch dispositions for all cases, including the cardiac cases, including the psychiatry cases, including the neuro cases. But if we don't have everything we need the first time, you can add 60 to 90 days to the processing time. Again, these are not funny gammy days. These are no kidding. Deferral to decision. So what about the biggest block? Next slide. This is general review first pass. So that's the 61% that don't go to medical appeals, to drug and alcohol, or to neurology and psychology and psychiatry. 8.1 days average disposition time as of Monday. Now I expect that's going to hover. But if you look, the last time we were above 20 days was right after Christmas. Pre-flighting works. Next slide. In case you were interested, here's the charts for the four groups. Drug and alcohol has been consistently below 30 for about three months at this point. Medical appeals, those are a little more challenging. The numbers are smaller and the neuropsych and psychology ones are also smaller numbers. So you get a lot of perturbations with single cases. All right, next slide. So we get a lot of questions. In fact, when I met the administrator the first time, our new one, Mr. Brian Bedford, he looked at me and said, I'm not going to talk to you about your backlogs right now. And he said that the next three times he talked to me. So this is the number of cases over 365 days. We've been under 10 since December, Christmas. We have three right now. I know who all three are and they're all serving their country overseas, so they can't get the documents to us. So we're not going to deny them. We're going to let them float until they get back from serving their country. What about over 180 days? When we started this process, there were over 4,000 over 180 days. We are down to 142. And a large part of that's because of how hard you work for us and the fact we have better manpower and it's easier to get to when we get the numbers much smaller. But we're going to keep right on moving. We're still aiming for 60 days. And I think that may be my last slide. Okay. Thank you so much, Dr. Northrup. And thank you to Dr. Fraser for presenting as well. It's good to have these sessions and we got a lot of questions answered this evening. Next slide, please. I'm going to go ahead and close this out. First and foremost, I'll throw in a shameless plug for suggestions for the AME guide improvements. We have gotten a lot of suggestions over the last year, year and a half. And if you have any for improving the AME guide, you can send those to AMEguide at FAA.gov. Keep in mind that this email inbox does not answer any case questions. And that is all we have for you this evening. I'd like to take a minute to just thank everyone who attended. We really appreciate what you do as an AME. And I think hearing from Dr. Northrup tonight, you can see how passionate she is about getting these cases turned around. If you are not an FAA employee, we ask at this time if you would go ahead and sign out of the Zoom. And FAA staff members, please stand by and you'll be going into the breakout room for a debrief. Thank you again and have a good evening.