So, to not screw over my pilot/aspiring pilot patients...

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Mark K

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So, I'm a general internist in group practice and long time mostly lurker. Reading all of these threads has been pretty revealing. I can say that, in years past, major depression was diagnosed quite loosely and SSRI's, SNRI's and atypical antidepressants were used perhaps more, ahem, aggressively than they should have been.

But the etoh threads make me wonder. We now have government/quality organization mandated alcohol screening questionnaires. The problem is that, the screening questions are very vague and open to interpretation. For example. one of the questions is, "have you ever drank a lot more than you wanted to," Sigh, if truthful, how many college age folks would answer yes? And sadly, someone who was planning on having one drink, had 2 or three and might answer yes.

Anyway, the point is you can loosely answer the questions in a way that your doctor, ahem, me, codes "unhealthy drinking behavior" in your chart. We purposely use this because, well, it's not seen by us as a diagnosis of alcohol use, abuse or dependence. But how does the FAA see all of this? The alternate code is "alcohol counseling." Is that any better?

Am I dooming that college age aspiring pilot by coding "unhealthy drinking behavior?" Based all on a single somewhat dubious screening question set... I'm all for keeping alcoholics from flying an airplane. But medicine tends to over diagnose...

The code "unhealthy drinking behavior" sure sounds disqualifying...
 
Mark K said:
So, I'm a general internist in group practice and long time mostly lurker. Reading all of these threads has been pretty revealing. I can say that, in years past, major depression was diagnosed quite loosely and SSRI's, SNRI's and atypical antidepressants were used perhaps more, ahem, aggressively than they should have been.

But the etoh threads make me wonder. We now have government/quality organization mandated alcohol screening questionnaires. The problem is that, the screening questions are very vague and open to interpretation. For example. one of the questions is, "have you ever drank a lot more than you wanted to," Sigh, if truthful, how many college age folks would answer yes? And sadly, someone who was planning on having one drink, had 2 or three and might answer yes.

Anyway, the point is you can loosely answer the questions in a way that your doctor, ahem, me, codes "unhealthy drinking behavior" in your chart. We purposely use this because, well, it's not seen by us as a diagnosis of alcohol use, abuse or dependence. But how does the FAA see all of this? The alternate code is "alcohol counseling." Is that any better?

Am I dooming that college age aspiring pilot by coding "unhealthy drinking behavior?" Based all on a single somewhat dubious screening question set... I'm all for keeping alcoholics from flying an airplane. But medicine tends to over diagnose...

The code "unhealthy drinking behavior" sure sounds disqualifying...
Click to expand...
"Ever" is a really long time... And the real question is, did you learn from it? Or did you do it again?

It seems like the questionnaire needs to have some actual standards for what is "more than you wanted to". Leaving it open to interpretation both by the person filling it out and the evaluating doctor has the potential to open several cans of worms.
 
As @flyingcheesehead said, the problem is those screening questions. I realize you may have to ask them, but are you informing your patients they don’t have to answer them?

It was years ago. My PCP pulled out a psychological evaluation questionnaire. I simply said, if I were worried about my psychological health, I’d see a psychologist, and would not answer it.
 
I got these questions every year for my .mil flight physical. Standard answer is 1-2 drinks, once or twice a week.

What’s your criteria and motivation to issue a an ICD in response to the screening question? Are you qualified to unequivocally diagnose that condition based on the screening or should a a specialist be referred to provide that diagnosis?
 
"have you ever drank a lot more than you wanted to,"

—
College student: “I am going to get SOOO drunk tonight!”

I guess the answer is “no”.

College student the next day: “That was stupid.”

Repeat weekly.

—

People forget that an FAA medical exam isn’t a personal physical for medical diagnoses, it’s to determine if the individual meets certain standards. But they do base those decisions on diagnoses made by other physicians for very different reasons. I think it’s good to consider the long term consequences of how something is coded.
 
Mark, in 2009, charged with "no medical accidents" by Congress, the PBOR act gave the FAS the authority to make defintions of disease that "make sense for that mission". So they did and they are not using DSM5; they have a tougher subset and the history of "ever in your life, " not just the past 2 years. The aerospace defintions are much "tougher" and require evaluation for almost any "substance use comment" UNLESS the practitioner specifically sez, "no substance use disorder". And if a practice uses "how many drinks per session" and "how many days per week" software, anything that approaches SAMSHA defintions of heavy drining, gets inqured.

I know of no software that forces that eval (just the checkboxes) and as a fellow ABIM diplomate (1983), I just don't see our colleagues taking the time to do the history eval in detail, to support a 99205. Just not happening.

Good you are concerned. But becoming "HIMS trained" (for an AME) is like a second fellowship in intensity and detail.

I do agree that Major Depressive disorder is diangosed too often. But really, for us internists (and PCPs), just like the radiologists, we are incentivized to err on the side of caution. We really "don't want any of ours" to fall through the cracks. It was not until relatively recently that POWER of CBT and focused counseling by a Ph.D pscyhologist and/or an MA level LPC...became obvious.
 
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Mark K said:
So, I'm a general internist in group practice and long time mostly lurker. Reading all of these threads has been pretty revealing. I can say that, in years past, major depression was diagnosed quite loosely and SSRI's, SNRI's and atypical antidepressants were used perhaps more, ahem, aggressively than they should have been.

But the etoh threads make me wonder. We now have government/quality organization mandated alcohol screening questionnaires. The problem is that, the screening questions are very vague and open to interpretation. For example. one of the questions is, "have you ever drank a lot more than you wanted to," Sigh, if truthful, how many college age folks would answer yes? And sadly, someone who was planning on having one drink, had 2 or three and might answer yes.

Anyway, the point is you can loosely answer the questions in a way that your doctor, ahem, me, codes "unhealthy drinking behavior" in your chart. We purposely use this because, well, it's not seen by us as a diagnosis of alcohol use, abuse or dependence. But how does the FAA see all of this? The alternate code is "alcohol counseling." Is that any better?

Am I dooming that college age aspiring pilot by coding "unhealthy drinking behavior?" Based all on a single somewhat dubious screening question set... I'm all for keeping alcoholics from flying an airplane. But medicine tends to over diagnose...

The code "unhealthy drinking behavior" sure sounds disqualifying...
Click to expand...
Isn’t abnormal drinking behavior by college students normal? It was when I was that age.
 
TCABM said:
I got these questions every year for my .mil flight physical. Standard answer is 1-2 drinks, once or twice a week.
Click to expand...
As a flight surgeon, I love those standard responses.

Pilot: "Yeah doc, 1-2 drinks, a couple times a week."
Me: "Brother, I was with you at the bar in Guam and saw you dancing on the table. Fine, we'll say rare social drinker"

This is why the Navy embeds flight surgeons into the squadrons. It's easier to figure out who actually has a problem vs people who just want to tear it up for a weekend but otherwise have no problematic drinking issues.
 
AvNavCom said:
As a flight surgeon, I love those standard responses.

Pilot: "Yeah doc, 1-2 drinks, a couple times a week."
Me: "Brother, I was with you at the bar in Guam and saw you dancing on the table. Fine, we'll say rare social drinker"

This is why the Navy embeds flight surgeons into the squadrons. It's easier to figure out who actually has a problem vs people who just want to tear it up for a weekend but otherwise have no problematic drinking issues.
Click to expand...

AF flight surgeons were aligned to squadrons when I was active, but there desire to fly and hang out was variable.

The best ones were in the squadron as much as possible.
 
One pitfall is prescribing more than one psychoactive med at a time. A common approach to situational anxiety/depression is to give an SSRI, along with XANAX for the first two weeks to get some relief while the SSRI kicks in. Dr Bruce has said that makes you ineligible for regular issuance under severity criteria. Just an SSRI for less than 6 months results in a much easier path. Recommend you look at the FAA decision tools for depression and anxiety to get a feel for the criteria for issuance without deferral.
 
Actually for anxiety disorder as Xanax is a different category of agent (not an SS/SnRI) they'll accept that often as an acceptable 2 drug history. But mix say, Sertraline with Trazodone for sleep, and that's the big "redX" above Simon Cowell's head.
 
bbchien said:
Actually for anxiety disorder as Xanax is a different category of agent (not an SS/SnRI) they'll accept that often as an acceptable 2 drug history. But mix say, Sertraline with Trazodone for sleep, and that's the big "redX" above Simon Cowell's head.
Click to expand...
Well, that is interesting. The current recommendation (well, besides NOT using sleep medicines but CBT) is to use something like trazodone as its potential for dependence is lower. Good to know giving someone an SSRI plus a small dose of trazodone makes life really difficult from an aviation standpoint. Doesn't make giving them Xanax any better though from a nonaviation standpoint! ;))))

I do find all of this very interesting. The problem is, docs serve different masters. We generally have good intentions, but everything can still fall apart for a pilot if we are not careful what we write and code.

I get the not wanting to go to see us. But, well, you don't want to die of something preventable as well...a bit of a conundrum...
 
midlifeflyer said:
As @flyingcheesehead said, the problem is those screening questions. I realize you may have to ask them, but are you informing your patients they don’t have to answer them?

It was years ago. My PCP pulled out a psychological evaluation questionnaire. I simply said, if I were worried about my psychological health, I’d see a psychologist, and would not answer it.
Click to expand...
Well, there is no Miranda warning in medicine. But you bring up a great point. These questions that are asked are often asked routinely as part of "system generated quality initiatives" driven by external government and quality organizations. Well meaning, I suppose, but NOT something I or the patient think is pertinent to their reason for the visit.

You are completely right that it may be entirely reasonable to politely decline any questions like this if you are a pilot. I don't hold it against folks who decline to answer the depression question set, alcohol question set, etc. etc. that are not the reason why the patient is there. Saves me time to have to review. There is no ICD10 code for declining to answer survey questions.

But, I will say, if you want brownie points with the doc, don't spend 15 minutes of your 20 minute appt railing about the "stupid questions." Just talk about your specific concern that brought you in, politely decline to answer anything you think is not pertinent, and leave it at that.

I can generally try to take care of my patients with good medical care and also not accidentally cause them to lose their medical. The two are not entirely opposed...
 
Mark K said:
So, I'm a general internist in group practice and long time mostly lurker. Reading all of these threads has been pretty revealing. I can say that, in years past, major depression was diagnosed quite loosely and SSRI's, SNRI's and atypical antidepressants were used perhaps more, ahem, aggressively than they should have been.

But the etoh threads make me wonder. We now have government/quality organization mandated alcohol screening questionnaires. The problem is that, the screening questions are very vague and open to interpretation. For example. one of the questions is, "have you ever drank a lot more than you wanted to," Sigh, if truthful, how many college age folks would answer yes? And sadly, someone who was planning on having one drink, had 2 or three and might answer yes.

Anyway, the point is you can loosely answer the questions in a way that your doctor, ahem, me, codes "unhealthy drinking behavior" in your chart. We purposely use this because, well, it's not seen by us as a diagnosis of alcohol use, abuse or dependence. But how does the FAA see all of this? The alternate code is "alcohol counseling." Is that any better?

Am I dooming that college age aspiring pilot by coding "unhealthy drinking behavior?" Based all on a single somewhat dubious screening question set... I'm all for keeping alcoholics from flying an airplane. But medicine tends to over diagnose...

The code "unhealthy drinking behavior" sure sounds disqualifying...
Click to expand...

Well done sir

As someone who worked this industry and has seen the destruction based on “drive though diagnosis”, my hat is off to you

Thank you
 
It's shocking how much of the pre-appointment jumping-through-hoops is not driven at all by clinicians. The various metrics, quality-assurance instruments, mandates, and other data-gathering efforts are increasingly impinging on the ever-shorter time we get with our patients. Turns out that if you fill a 20 minute appointment with 15 minutes of mandatory screeners, it's hard to get to the reason why folks are there. And then the "patient satisfaction" metric starts turning red...
 
Yeah. My General Internist graduated the same year I did from the other large medical complex across town. He rarely touches me, he has so many metrics to satisfy. When I see him, I mostly feel sad for him....
 
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