Cardiac issues - Basicmed

[Healthy but worried]

I am on Basicmed - 58 year old male, previous second and third class medicals since 2001. No adverse health history except for high cholesterol, which I had managed to reduce through diet to an acceptable level. A year ago, I felt a little lightheaded and had some tightness on my left side. Out of paranoia, I went to urgent care, where the doctor did a full exam, including EKG. Everything was normal - blood pressure, heart rate, EKG, etc. He recommended that I follow up with a cardiologist.

Since then I have had no similar symptoms. Best we could figure was that I was feeling the effects of pushing my cross-training workout the previous day harder than usual - with hot weather, humidity, not enough sleep and not eating yet that day, it made sense.

The cardiologist did several tests, including EKG and calcium score, which came in at 80th percentile. The diagnosis code is “I 25.84 - coronary atherosclerosis due to calcified coronary artery”. He prescribed a calcium channel blocker and a statin. No other treatment was recommended, beyond diet and exercise.

I had a six-month followup with him a month ago. He was satisfied with everything. I asked if I needed further tests, such as a treadmill EKG. The cardiologist said no, and added that he hopes he’s in as good shape when he is my age.

Two weeks after that, I had an annual physical with my primary care physician’s office. Instead of the doctor, they had me seeing a nurse practitioner. It started out weird in that she introduced herself as “Dr. Jones - I am a doctor APRN”, and repeated a couple minutes later that she is a doctor of nursing.

The physical was fine - nothing new found, everything normal. She was concerned about my cardiologist visit, and said that I needed a treadmill stress test and another calcium score. I told her that the cardiologist (who has 10 years in his specialty) said specifically that those tests were not needed. The NP got a little short and insisted that they were, but let it go.

I did ask for a PSA lab test, as her bloodwork order had not included it (and interestingly enough, she didn’t say one word about prostate cancer screening to this 58 year old man). The order lists diagnosis code R97.20 (elevated PSA).

A few days later, I get a call from a radiology center to set an appointment for tests she has ordered - whole body CT scan, and calcium score. I declined to have those done, as she had not told me they were going to happen, and the specialist said that the calcium score was not needed.

So - how screwed am I with the FAA if I want to get a second class? Will it be a Special Issuance because of the diagnosis codes? What about the NP recommending tests that I chose not to take, based on the cardiologist’s determination that they were unnecessary? Will that be a problem?

 

[bbchien]

That depends. What was the actual numeric coronary calcium score? sounds like it was above 100. And if so, you won't be getting any sort of even third class certification without what you told the ARNP "isn't necessary".

C'mon Fella, attempt to do the right thing and save your life. You want to know. And it sounds like you now have the diagnosis of CAD so you need a third class. How much flying you gonna do when you're disabled by CAD or even worse?

Betcha the ARNP's record shows you declined std, recommended medical care. That'll go over BIG @ FAA.

 

[danhagan]

It started out weird in that she introduced herself as “Dr. Jones - I am a doctor APRN”, and repeated a couple minutes later that she is a doctor of nursing.

This event would be so much cooler if it was a male doctor and his first name was Indiana

 

[DaleB]

This event would be so much cooler if it was a male doctor and his first name was Indiana

My son went to college and played football with a kid named Indiana Jones. No BS. Great guy.

For the OP, my advice is to take care of the cardio stuff without undue regard for the medical cert. Dr. Chien’s advice is kind of the gold standard. There’s always Sport Pilot, which may or may not get somewhat less restricted at some as yet unspecified future date. Your heart and arteries can kill you (or worse) just as surely as the airplane can.

 

[Stewartb]

For matters of my heart? I trust my cardiologist.

 

[geezer]

Dr Chien says he needs the actual calcium number, and that is reasonable.

Stewartb says "For matters of my heart? I trust my cardiologist."

The OP said his cardiologist, on second visit, said he was fine.

The trouble report is a Nurse practitioner, not a doctor. These are much in the news as pushing extra tests to increase billing of medical plans, increasing doctor income.

I would give Dr Chien my calcium score, and stick with my cardiologist for the heart health questions.

I had a similar event more than a decade ago. Sitting very relaxed in a hot room, stood up quickly, got dizzy, and sat back down, blacked out for a few seconds. Somebody called 911, I went to the hospital, all fine. Went to a highly respected cardiologist, full set of tests, no trouble. I am 91 now, and still active, no further issues, and annual doctor visits find no heart or other problems.

Last year my longest distance walked in one day was 2.7 miles. This year, longest is 1.7 miles, but weather has not been good for outdoors walking, either raining, windy, or cold.

 

[geezer]

Further thought on the original post.

If I made an appointment with MY doctor, and a nurse practitioner was substituted, I would return to the desk, and make a new appointment with MY doctor.

My appointments are with a specific doctor, he would no doubt be upset if I sent a substitute patient to fill my appointment.

If I am happy with whoever comes through the door, I will go to a walk in clinic and save money (I have used them for right now service).

 

[Rockymountain]

The doctorate of nursing is interesting. In its basic form you can do a 2 year RN certificate course, followed by a 12 month accelerated course to become a BSN. At which point you can enter a DNP program and complete that in as little as 24 months. Most of this can be accomplished online with very little clinical requirements, hang a shingle and in many states start practicing independently. That is 5 years of education after high school. There are longer, more structured and better programs that don't allow such short cuts, but the short cuts are there.

A cardiologist after high school required 4 years of college, 4 years of medical school, 3 years of internal medicine residency, pass the internal medicine boards, and then at least 5 years of cardiology fellowship, pass the cardiology boards, interventional boards and echo boards, if you want to be able to be a basic cardiologist and do more than simple heart caths. So 16 years of formal training after HS, and none of that can be done online.

I feel like big medicine wants to replace we physicians with ACP’s like PA’s and NP’s now DNP’s, but it is really, to put it in airplane terms, comparing a 50 hour Private Pilot with a 10,000+ hour airline pilot. But we all wear long white coats, and apparently all now call ourselves “doctor”. ;-)

Notwithstanding, ACP’s do a great job and are necessary in medicine these days. I work with many PA’s and NP’s DNP’s. Some truly are amazing, and don’t mean to come across as denigrating the occupation, but there is a big difference. Big medicine doesn’t care. They just want a cheap labor force.

 

[TCABM]

…

The trouble report is a Nurse practitioner, not a doctor. These are much in the news as pushing extra tests to increase billing of medical plans, increasing doctor income.….

The same could be said for PAs. It’s a business decision by the supervising physician to employ NPs and PAs in their practice. For all we know the supervising physician’s business plan may include techniques to maximize income.

 

[Healthy but worried]

My calcium score was 151. Is that synomous with 50% or higher stenosis? I did not have an MI, nor have had a bypass or stent. Neither were recommended. The only treatment I am on is a calcium channel blocker and a statin. I am following proper diet and exercise recommendations, and am symptom-free. Looking at the FAA documents, unless the calcium score is a diagnosis of blockage, I’m not seeing where it’s a bar.

The cardiologist - two weeks before the APRN - said he didn’t need another calcium score, nor any other additional tests. Does a general practice APRN’s recommendation outweigh a cardiologist in the eyes of the FAA?

To be clear, I am taking care of myself - daily exercise including cardio, proper diet, taking the prescribed medication.

 

[catmandu]

“Second opinions are helpful, especially when the first two differ.” - Yogi Berra (or maybe me)

 

[bbchien]

Not synonymous but the risk of one is over 80%. Policy requires the stress TMT and tracings, interp. I'd get a Stress tm echo....to avoid the 7% false positives. Two chances to pass in one test.

What part of "I 25.84 - coronary atherosclerosis due to calcified coronary artery" isn't clear?

 

[Half Fast]

But we all wear long white coats, and apparently all now call ourselves “doctor”. ;-)

Sorry, no sympathy. You physicians set yourselves up for this when you elected to use an academic designation as a job title, a designation for which you held no monopoly. Now you're stuck with it.

Big medicine doesn’t care. They just want a cheap labor force.

I'm sorta curious about this, as I'm sure it must have been studied over and over by now. Has using this "cheap labor force" resulted in a statistically significant decline in the population's health?

 

[172andyou]

I'm sorta curious about this, as I'm sure it must have been studied over and over by now. Has using this "cheap labor force" resulted in a statistically significant decline in the population's health?

No. There is no meaningful difference in outcomes.

Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care - PMC

To examine whether nurse practitioner (NP)‐assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)‐assigned patients. Veterans Affairs (VA) administrative data capturing characteristics, ...

pmc.ncbi.nlm.nih.gov

 

[Mark K]

No. There is no meaningful difference in outcomes.

Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care - PMC

To examine whether nurse practitioner (NP)‐assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)‐assigned patients. Veterans Affairs (VA) administrative data capturing characteristics, ...

pmc.ncbi.nlm.nih.gov

Did you read the actual article? All it shows are two things.

1-the utilization cost of MD's and NP's are not substantially different.
2-the quality of MD and NP care isn't different. BUT, they defined quality as 8 measures looking only at BP, glucose and cholesterol control.

2.3.2. Clinical quality​

We examined eight process and outcome measures routinely used by VA to measure the quality of primary care.26, 27 Four measures were assessed for the diabetes cohort: (a) receipt of any hemoglobin A1c (HbA1c) test, (b) normal HbA1c defined as HbA1c < 9 percent, (c) receipt of any low‐density lipoprotein (LDL) measure, and (e) normal LDL defined as LDL <100 mg/dL. For HbA1c or LDL, we used the value of the last measure if there were multiple measures in a given year. Two measures were assessed for the IHD cohort: (a) receipt of any LDL test and (b) normal LDL defined as LDL <100 mg/dL. Two measures were assessed for the hypertension cohort: (a) record of any blood pressure (BP) measurement and (b) normal BP defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg.26




If all you want out of a doctor is to control bp, cholesterol, and blood sugar, yes, by all means, an NP is fine. And they do this at the same cost as physicians.

You can't draw anymore out of this study...

 

[172andyou]

If all you want out of a doctor is to control bp, cholesterol, and blood sugar, yes, by all means, an NP is fine. And they do this at the same cost as physicians.

You can't draw anymore out of this study...

If you've got a study that shows that these findings are only valid for the care examined, share it.

 

[2-Bit Speed]

If you've got a study that shows that these findings are only valid for the care examined, share it.

How can a finding be valid for care it did not examine?

 

[Mark K]

If you've got a study that shows that these findings are only valid for the care examined, share it.

Sigh, this isn't how scientific studies, specifically, medical studies work. The conclusion may be correct, but it only applies to the findings it looked at. Asking me to prove that it is not generalizable to all of medical quality isn't how science, or, well, logic, works.

The study shows that, in terms of bp, cholesterol and a1c control measures, NP are equivalent to doctors. Nothing else can be inferred or generalized.

At my institution they use pharmacists to manage diabetes, cholesterol and HTN, and, at least internal data shows they are as good as the docs at doing this. The study really doesn't prove much except that, in straightforward management of a limited subset of medical issues, NP's at the VA did as well as the docs at the VA. Which most of us will acknowledge.

It's a free market system. If you want to save a few bucks and go with a health care system that aggressively leverages ancillary providers, and you think that's good enough, I won't stop you...

 

[172andyou]

How can a finding be valid for care it did not examine?

I assume you don't have a study contradicting it either? In the absence of that, every data point we actually have says that the quality of care is similar. Speculation that it might not be true in other areas is an interesting hypothesis that hopefully has been studied and I'd love to see the results from. But I didn't see anything when I looked.

 

[2-Bit Speed]

Speculation that it might be true in other areas is just as interesting a hypothesis that hopefully has been studied...

 

[bbchien]

A study defines outcomes only for the spectrum intended.
"Please state the nature of the medical emergency"....

 

[GBear286]

I am on Basicmed - 58 year old male, previous second and third class medicals since 2001. No adverse health history except for high cholesterol, which I had managed to reduce through diet to an acceptable level. A year ago, I felt a little lightheaded and had some tightness on my left side. Out of paranoia, I went to urgent care, where the doctor did a full exam, including EKG. Everything was normal - blood pressure, heart rate, EKG, etc. He recommended that I follow up with a cardiologist.

Since then I have had no similar symptoms. Best we could figure was that I was feeling the effects of pushing my cross-training workout the previous day harder than usual - with hot weather, humidity, not enough sleep and not eating yet that day, it made sense.

The cardiologist did several tests, including EKG and calcium score, which came in at 80th percentile. The diagnosis code is “I 25.84 - coronary atherosclerosis due to calcified coronary artery”. He prescribed a calcium channel blocker and a statin. No other treatment was recommended, beyond diet and exercise.

I had a six-month followup with him a month ago. He was satisfied with everything. I asked if I needed further tests, such as a treadmill EKG. The cardiologist said no, and added that he hopes he’s in as good shape when he is my age.

Two weeks after that, I had an annual physical with my primary care physician’s office. Instead of the doctor, they had me seeing a nurse practitioner. It started out weird in that she introduced herself as “Dr. Jones - I am a doctor APRN”, and repeated a couple minutes later that she is a doctor of nursing.

The physical was fine - nothing new found, everything normal. She was concerned about my cardiologist visit, and said that I needed a treadmill stress test and another calcium score. I told her that the cardiologist (who has 10 years in his specialty) said specifically that those tests were not needed. The NP got a little short and insisted that they were, but let it go.

I did ask for a PSA lab test, as her bloodwork order had not included it (and interestingly enough, she didn’t say one word about prostate cancer screening to this 58 year old man). The order lists diagnosis code R97.20 (elevated PSA).

A few days later, I get a call from a radiology center to set an appointment for tests she has ordered - whole body CT scan, and calcium score. I declined to have those done, as she had not told me they were going to happen, and the specialist said that the calcium score was not needed.

So - how screwed am I with the FAA if I want to get a second class? Will it be a Special Issuance because of the diagnosis codes? What about the NP recommending tests that I chose not to take, based on the cardiologist’s determination that they were unnecessary? Will that be a problem?

Please excuse the late response. I was a member of this forum many years ago and just came back to try to find information on a malfunctioning autopilot. But I stumbled across this thread and it got my attention. This issue is something I deal on a regular basis.

You definitely have diseased coronary arteries. You don't see calcium in healthy coronary arteries. But this test does not prove you have flow limiting coronary artery disease. The most important thing is to aggressively manage coronary artery disease risk factors such as lipids, glucose, blood pressure, diet and exercise and most importantly no use of tobacco or nicotine. If you have good exercise tolerance and are not having any ischemic symptoms, some cardiologists may conclude no additional cardiac testing is required. I would at least offer you a simple treadmill stress test. If you have symptoms which could represent cardiac ischemia then it's more complicated.

Now the FAA medical department works a little differently. I'm not an AME but have a pretty good idea of how they think. If there's any evidence of a medical condition you may have to prove you are low risk with additional testing. Pilots may deny or minimize symptoms in order to keep a medical certificate so they may not believe you are asymptomatic. A stress echo (if properly performed and interpreted) is a great choice. Not terribly expensive, low risk of false positives. If they get a full resting echo before the stress echo there is a chance they might see something that is reported as abnormal and that can trigger additional testing. Another option is to get a full cardiac CT with CT coronary angiography. The problem is these tests are often non diagnostic. Coronary artery calcification can cause a lot of problems depending on size and distribution of calcium which causes a blooming artifact. I don't know if the FAA would accept a cardiac CTs as adequate test even if negative.

I'm confused by the tests you reported. Whole body CT scan? PSA test? But I wasn't there so can't really comment.

My last bit of health advice is that we should all work on improving diet. The typical western diet with a lot of ultra processed food is more harmful than people realize. The Mediterranean diet is probably the most healthful. Regular exercise is important but don't overdo it if there is concern about coronary artery disease or if you are reconditioned. Start slow and gradually increase to at least an hour of brisk walking or biking 5 days a week.

Midlevels such as nurse practitioners and PA are a valuable asset but I have a problem when they exceed their competence. Many midlevels want to be physicians without the rigorous training and that's a problem.

 

[bbchien]

NB Full CT coronary angiography with CT FFR is accepted by FAA. It's tough to get, however.
And I agree that in this once great nation we are now creating doctors by legislation, not by education.