A Washington Post last month titled,"5,000 pilots suspected of hiding major health issues. Most are still flying," spurred discussions in our department. While we too are like the millions of Americans who trust and depend on our exceptionally safe aerospace system, we have a slightly different perspective on this story. While the article was compelling, we, as researchers of pilot healthcare-seeking behavior, know that there is more to the story.
Aircraft pilots are required to meet certain mandated medical standards in order to maintain an active flying status. If a pilot develops a new mental health symptom or condition -- and discloses it during their periodic medical assessment by a Federal Aviation Administration (FAA) designated physician -- they can risk their certification, usually temporarily, to fly. For this reason, many argue that pilots face a to seeking mental health care due to fear of what this might mean for their ability to work. Interestingly, airline pilots are only one of a few professionals who must disclose all their health information (often including speaking to a mental health therapist) in order to work.
This has real world implications. If you are a high-earning commercial airline pilot with a mortgage, a car payment, and two kids in school, how bad does your mild anxiety need to be to potentially walk away from flying for months or even years to seek care? For many pilots, pretty significant.
Research conducted by me and several colleagues reveals the vast scope of this issue. In our sample of 3,765 U.S. pilots, a history of healthcare avoidance (for example, not seeking healthcare for a new symptom or seeking informal healthcare outside the traditional system) due to fear for loss of their certification to fly. This problem is not unique to the U.S. We found similar rates of pilot healthcare avoidance due to fear for loss of flying status in . Interestingly, pilots not fitting typical workforce demographics -- male, white, and straight -- may be more likely to report healthcare avoidance than their colleagues. This is a pervasive problem in the U.S. and beyond.
While the Washington Post article identified one important manifestation of this gap, the broader issue was missed. The Post article compared the rates of Veterans Administration (VA) disability benefits to the health information disclosed to the FAA and found that over 5,000 former military pilots claimed VA disability for conditions not disclosed to the FAA. First off, it is problematic that some pilots intentionally broke the rules. The safety and efficiency of our aerospace system is contingent upon the personnel working within it and this type of behavior cannot be tolerated. However, this is not really a story about safety. Aviation is exceptionally safe, made so through redundancies and measures within system-wide safety programs. We, as clinicians caring for pilots, see this story as far larger than the 5,000 pilots identified by the Washington Post. To us, this is a story about the many thousands of pilots who are potentially suffering in silence and avoiding mental health care because it could compromise their ability to fly. This is a story about an unintended barrier that this unique population -- a population that U.S. passengers relied on last year -- faces in getting the care they need.
Currently, we approach mental health in aviation in a clinical way. We identify pilots diagnosed with a mental health condition or using mental health care services and assume they may pose an undue risk to safety. On the surface, pulling these pilots from duty seems to make sense. Advocates for such an approach will point to high-profile disasters attributed to suicidal pilots (for example, the or the crashes) as evidence for aggressive aeromedical screening programs. While logical and with some truth in the extremes, the reality may not be so straightforward and our clinical approach may inadvertently leave many pilots struggling. It is important to acknowledge the remarkable diversity of mental health symptoms and their many manifestations. We're not talking about pilots with severe mental health symptoms -- certainly this population should likely not be flying. Instead, we're interested in finding a way to help pilots with mild symptoms -- perhaps those on the spectrum of life's usual challenges -- to get the support they need easily and quickly.
Certainly, every step must be taken to prevent another aviation tragedy related to mental health, but we must ask whether our current clinical approach is the right one. Importantly, it is unclear if periodic clinical assessments are the best way to identify pilots of undue risk to safety. Unfortunately, they're not foolproof: after all, high-profile disasters have occurred while using such an approach. Further, there is insufficient research to determine whether meeting the diagnostic criteria for a mental health condition is correlated with a decrement in pilot performance in the majority of circumstances and outside of the extremes. In fact, the large population of flying pilots who are quietly self-managing their life-stress, mild anxiety, or occasional depression may agree it doesn't affect their professional performance. The time is now to rethink how we might build a system that minimizes barriers to mental wellness while maintaining aviation's exceptional safety record.
So, what do we do now? Doubling down on an imperfect system is not the right answer. While the minority of pilots clearly breaking the law for their personal gain should be held accountable, broad and harsh enforcement is unlikely to bring about the change we want to see. Such an approach will only further propagate stigma about mental health and will further drive this population into secrecy. Instead, the Washington Post story is an opportunity for us to rethink how we approach mental health aviation and how we might achieve mental wellness in the aerospace system of the future.
How might we achieve this aim? We should investigate ways to transition away from our current clinical approach -- one focused on mental health diagnoses and healthcare usage -- to one focused on performance. Can the pilot perform their duties regardless of the mental health labels in their medical record? Such an approach would focus on pilot peer assessments and recurrent cognitive testing focused on performance. The science of this approach is evolving and is already being used in other parts of the transportation industry and within healthcare. One study of emergency medicine physicians showed that a similar performance-based assessment was able to identify alertness in physicians at risk of fatigue, a finding thought to potentially mirror some types of mental health symptoms in the workplace. These types of technologies have the potential to identify risk within a system and allow for targeted safety measures. Such a paradigm shift may promote early presentation to mental health care services when needed, decrease cost burdens to airlines and pilots related to flying status, and further support existing safety programs within the U.S. aerospace system.
Despite its challenges, the FAA is certainly due credit. Efforts including a robust mental health outreach program, new accelerated protocols to review pilot medical applications, and the authorization of several new medications for the treatment of mental health conditions are positive steps forward. U.S. Federal Air Surgeon Susan Northrup, MD, MPH, and her team should be applauded. That said, there is still work to do.
is a movement disorders fellow at Columbia University Medical Center and an affiliated assistant professor of aviation at the University of North Dakota John D. Odegard School of Aerospace Science. His research interests center around pilot brain health and healthcare-seeking behavior. Follow on Instagram at .
The views expressed herein are those of the author's and do not necessarily reflect the official policy or position of the Defense Health Agency, Brooke Army Medical Center, U.S. Air Force Institute of Technology, the Uniformed Services University of the Health Sciences, the Department of Defense, the Federal Aviation Administration nor any agencies under the U.S. Government.