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Discussion in 'Medical Topics' started by JB1842, Jul 10, 2020.
Does anybody know if a Nurse Practitioner can conduct the physical for Basicmed?
No. Must be MD or DO. State licensed physician.
They also have a handy FAQ that addresses that very question:
Q46: Can a physician extender (such as a nurse practitioner or physician assistant) conduct the medical exam? A: A physician extender is a health care provider who is not a physician but who performs some medical activities typically done by a physician. Physician extender practice privileges and requirements for physician supervision vary by state. Physician extenders are generally nurse practitioners or physician assistants. Registered nurses, medical technicians, and medical support personnel also assist with certain elements of an examination but are not considered physician extenders. Section 2307 of FESSA did not specifically exclude participation of a physician extender. However, under BasicMed the physician is responsible for conducting the medical examination and must be the signatory on the CMEC.
A nurse practicioner (NP, CRNP, FNP, DNP etc.) typically practices under the authority of their own license which is issued by the board of nursing. A physican assistant (PA, PA-C) has their own license issued by the board of medicine but typically works in a cooperative setup with a supervising licensed physician (MD/DO). In some professional environments, there is a close cooperation between PA/NPs and physicicians in the same practice and from the sound of this, the FAA would be ok with the NP/PA performing the evaluation as long as a supervising physician signs it and assumes responsibility. Most primary care practices that use PA/NP are already set up to do this as medicare requires certain services to be ordered by a physician.
Note that in some states chiropractors may also conduct the physical exam...
Not allowing a NP to perform something as basic as the basicmed exam is akin to limitations in the certified world.
DCs managed to write their licensing rules in some states in a way that prints the word 'chiropractic physician' on the license.
I know several chiropractors...licensing aside, I don't know any that I'd trust to take a history or do a physical exam on me. I'd be vastly more comfortable with a history and physical exam from a Nurse Practitioner or Physician Assistant.
I have made it a habit not to comment on the abilities of DCs.
That tractor trailer coming the other direction on a two lane road may be driven by someone who obtained his DOT card from a chiropractor at the truck stop. Just something to think about.
OK, I'll bite... Why?
Lack of training, knowledge, and experience with General Medicine. Perhaps the most obvious example, the patient's medications must be reviewed for nature and dosage. Among other deficits in General Medical topics, and unlike Nurse Practitioners and PA's, chiropractors have no pharmacology training and no license to prescribe. That alone should disqualify them from performing a Basic Med exam, or any exam relative to operation of a motor vehicle, including aircraft.
They do have a powerful lobby, however....
The Mirriam-Webster dictionary definition of chiropractic is pretty limited in terms of their training and expertise. There's a lot more to the human body than bones, muscles, and the nervous system.
OK, I thought that may have been your angle...
In the 28 years I have been jumping through the FAA Aeromedical hoops I have never gone to an AME for anything other than a medical certificate. My experience has always been that the nurse in the practice performs about 90% of the required tests and the remaining 10% is followed up by the AME which generally took 5 min. or less. No questions were ever asked about previous medical appts in the last 3 years, etc. Checked the boxes, signed the cert and off I went.
My point is that I don't think I would classify the above as a comprehensive physical exam. I jumped through the hoops and the AME jumped through the hoops to satisfy the FAR's. BasicMed is no different. As long as you don't have a disqualifying condition, which is only a list of 11 items, you're good to go. Nothing pertaining to the physical ever goes to the FAA other than the date of the exam and the name and license of the medical professional performing the exam.
So does it really matter that a chiropractor can perform these exams?
Probably not, if one views Basic Med as kind of a joke....the extreme other end of the spectrum from an AME's exam and the FAA's arcane and rather arbitrary AME exam process. But if the FAA takes the validity of the BM exam at all seriously and is going to let chiropractors do the exam, they should at least do away with the part where they're asking a chiropractor to actually practice medicine and do evaluations and make decisions outside of their education/training and for which they are unqualified. If chiropractors can do it, no reason you shouldn't be able to just have the lady at the DMV do your Basic Med exam when you get your driver's license.
What is the purpose of a BasicMed exam?
The exam is used to discuss with the individual if any medications he or she is taking could interfere with his or her ability to safely operate a motor vehicle or aircraft and perform an exam of each of the items on the checklist (a chiropractor has NO education or training for making this kind of judgement) . Based upon this discussion and exam, you as the physician then determine whether, in your medical opinion, you are aware of any medical condition that, as presently treated, could interfere with the individual’s ability to safely operate an aircraft. It is like assessing if an individual can safely operate a motor vehicle such as a car, truck, motorcycle, or boat.
When a pilot visits his or her physician for the BasicMed examination, the pilot information and medical history portion of medical exam checklist completed by the pilot will list any prescription or non-prescription medication that the pilot currently uses, as well as information such as the medication name and dosage. The physician will then address, as medically appropriate, any medications the individual is taking and discuss the medication’s potential to interfere with the safe operation of an aircraft or motor vehicle (again... a chiropractor has no business pretending to actually be practicing medicine--they have zero training in pharmacology and have no license to prescribe medication). While there is no list of specific medications that are prohibited for pilots flying under BasicMed rules, certain medications are not safe to be used at all while flying and others require a reasonable waiting period after use. Physicians should be mindful of prescription and over-the-counter drugs that may impact the safe operation of a motor vehicle, in this case a private recreational aircraft. This can include, but is not necessarily limited to, the use of sedatives, psychotropic drugs, antihistamines, narcotics or any other medication that can impair cognition if used while the pilot is operating an aircraft
I view the whole FAA Aeromedical process as a joke. By their own admission if you have the patience, tenacity AND $ then you too may obtain a Special Issuance. So why have the disqualifying condition in the first place?
Except that's not in the law passed by congress...
I would say they can perform the exam, but the attending doctor must sign off on it. The law uses two terms at different times, “state licensed physician” and the lesser “physician”, implying a difference in role.
Nope. The state-licensed physician must perform the exam. Others may assist, but the doc can’t sign off on it without physically interacting with the person.
FWIW- I don’t think congress had intended on allowing chiropractors to perform BasicMed examinations. I suspect if they had it would have been explicit in the statute. The law said state-licensed physician, so the FAA went with state-licensed physician and left it to the state to sort it out.
Also, while, chiropractors are classified in some states as physicians, each state defines their scope of practice, which may or may not include physician examinations. So it’s possible for states to intentionally limit the scope of practice from being able to conduct pilot exams. It wouldn’t make such an exam invalid in the eyes of the FAA, but the licensee could risk loosing ones license for operating outside their scope of practice.
it is up to the doctor to decide what they sign off. They have two specific points that they must legally do personally.
It sounds like you are assuming Congress meant the same thing, but the law uses two different terms with two different definitions. In the legal world, that implies an intent to differentiate.
Once my mother’s doctor went to a concierge practice, the doctor almost never saw patients, with most work being done by PAs. That form of medical practice has been around for decades, so I think we cannot assume Congress was ignorant of it. If they had intended that the state licensed physician was required to personally perform exams, they would have stated that explicitly.
There is also a long history in regards to the use of the term 'physician' when it comes to the interaction with federal benefit programs. So I agree, I doubt the people who drafted the basicmed language were ignorant to the meaning of the words. They just decided that excluding chiros would stir up too much potential resistance and they wanted to get this passed.
There are other areas where federal law requires a 'physicians order', e.g. for some short term rehab services. In the setting of a cooperative practice where PAs or NPs directly work with a physician, that is not a problem. NP conducts the visit, doc pops in, says 'Hi' and puts his signature under the order. Its an issue where either NPs work autonomously or where the supervision of a PA is in a indirect fashion, e.g. through monthly chart reviews. Many rural health clinics are staffed that way. For the rehab orders for example, CMS has issued some state by state exemptions that allow NPs to sign those without a physician co-signer, but that has to be done under some flexibility provisions as the law itself says 'physicians order'.
I guess it would depend what your STATE considers a "physician." I can tell you in North Carolina that the "state licensed physicians" only apply to MDs and DOs and possibly some Canadian equivalents.
Specifically on the state medical board site: podiatrists, dentists, oral surgeons or chiropractors are not included.
I guess it's possible that some state might consider a chrioquacktor a physician, but it's far from universal.
If an investigation determined that the physician signing the CMEC never actually examined the applicant, the FAA would consider that signature to not be valid. Whether that would result enforcement action would depend on the facts of the case.
Chiropractors generally practice their trade without the encumbrance of having to adhere to tricky little problems like "standards of care". Their "treatments" don't require randomized, prospective, peer-reviewed validation...they can just make stuff up. Some of them...the good ones...stick with spinal manipulation, and maybe nutrition and a bunch of holistic mumbo-jumbo. Mostly harmless. Others branch out into some really whacky ****. I find the fact that they can review a pilot's medications and approve him/her to fly an airplane to be indicative of the arbitrariness of the entire FAA medical certification process.
I don’t believe you know that, it is an opinion.
Again, you are assuming that Congress used words carelessly.
Good point. You could send an email to the FAA if you would like clarification. That said, as noted in the FAQ quote above, the physician must conduct the examination, and it's hard to conduct an examination if you've never seen the patient.
I am a PA. I have had ppl bring basic med stuff and and I just have my attending see them. I know could do the whole thing and get it signed off but as a pilot knowing the rules I don’t feel comfortable with it. I do agree with you that it would be worth a letter to FAA requesting opinion/clarification. As a pilot and a PA it’s a fair question.
In this state, they make a statutory distinction between Medicine and Chiropractic. AFAIK, chiropractors aren’t defined as physicians around here.
At last count there were approximately 18 states that license chiropractors as physicians.
I don't think clarification from the FAA is necessary. Whether or not someone's doctor uses a PA to do some of the work is between them and their doctor and we have no business in that relationship.
The only two chief counsel opinions on BasicMed that I'm aware of (Williams less so, Domingo) are relatively favorable toward pilots, let's not push our luck
FTR, my doctor does not use PAs.
Please, for the love of God, don't ask the FAA to 'clarify'. Nothing good can come from it.
If you are a PA, you can 'participate' by doing anything state law and your doc allow. Just schedule the basicmed customers on a day he is in the office, have him pop into the room, look at the form over his doctoral bifocals, do that thing with the stethoscope and conclude with 'well, if Ben thinks you are ok to fly, who am I to disagree', sign the form and leave. Patient happy, FAA happy.