Building Trust Between Military Pilots and Flight Surgeons

I read with great interest the article titled, “Self-Reported healthcare avoidance behavior in U.S. military pilots related to fear for loss of flying status” by Dr. Hoffman et al. I truly applaud their research to provide supporting data that healthcare avoidance behavior exists within U.S. military pilots. Unsurprisingly, this study reveals that a large percentage of military pilots reported a history of healthcare avoidance behavior.

Military flight surgeons annually perform flight physical exams to protect the health and safety of pilots. Flight surgeons work to ensure pilots are healthy enough to operate military aircraft, carry passengers, and perform other military missions. Also, flight surgeons are responsible for keeping pilots healthy from a holistic, longitudinal perspective. It is paramount that a trusting relationship is developed between pilots and their flight surgeons in order to overcome a natural tendency to minimize health issues. Indeed, the annual physical exam can be an anxiety-provoking event for pilots with a medical condition. If found medically unfit to perform military pilot duties, the pilot might be grounded and not be able to perform flying duties for a specified period or even permanently. Being grounded impacts one’s career progression, unit and personal morale, and possibly one’s financial situation. For such reasons, the anxiety associated with annual physicals is somewhat understandable.

Being grounded is not as simple as taking a break from flying. Military pilots are highly motivated to preserve their flight status. The occupational specialty is considered prestigious. Military pilots form an occupational identity and seek to differentiate themselves from other groups to sustain the occupational identity.¹ If a military pilot is medically grounded, their occupational identity could be threatened. Many medical conditions that require temporary grounding could be viewed as minor medical conditions by the pilots. However, these conditions could have a major impact on aviation safety or on the pilots’ long-term health. Because medical conditions may pose a threat to their career, occupational identity, and military mission, pilots might consider withholding the medical issue or downplaying it to avoid grounding.

Military aviation units are organized with certain equipment and personnel to accomplish a given mission set. If a pilot is medically grounded, the unit cannot get a replacement immediately. Hence, other pilots in the unit need to fly more to accomplish the mission given to the unit. Feelings of not being part of a team or a burden on the team could be associated with such incidence and can lead to depression or frustration. This is akin to an athlete who feels depressed and frustrated about not being able to play with the team or compete due to an injury.²

Aviation incentive pay, an additional pay for military pilots who are on flight status, may also be compromised by temporary or permanent grounding. This flight pay could be as high as $1,000 per month.³ Not all medical groundings directly result in the flight pay seizing. However, serious medical conditions or prolonged medical grounding may cause flight pay to stop. When a pilot is grounded, not only is mental wellness jeopardized but so may be their finances.

Perhaps, it is easier to understand the military pilots’ healthcare avoidance when we think of the coronavirus disease 2019 (COVID-19) pandemic. Many people who were having symptoms or diagnosed with COVID-19 wanted to keep such information from friends, families, and employers.⁴ They did not want to be the social outcast or be blamed for spreading the disease. Many reported that they lost their jobs when they reported the positive COVID-19 diagnosis.⁴ Some had to use personal vacation time to complete the isolation period or take a pay cut during the isolation. Healthcare avoidance behavior seems to arise when the medical condition has negative implications on social life, work life, or financial status.

Healthcare avoidance in pilots can also have a negative impact on their long-term health. For example, obstructive sleep apnea (OSA) has been linked with short-term symptoms of excessive daytime sleepiness and difficulty concentrating. In long term, OSA has been associated with heart issues like atrial fibrillation and cognitive decline.^5,6 Having excessive sleepiness or not being able to concentrate while flying a military mission could be detrimental. If the medical condition is hidden and not treated, the pilot could end up with serious long-term complications. OSA, like many other conditions, can be waived with proper workup and treatment. However, a pilot might opt to just drink more coffee or energy drinks to stay awake and not report their early symptoms of OSA to continue flying and avoid going through the hassle of a medical waiver process. That could delay treatment of the condition, which could eventually lead to further complications.

For any medical condition, early detection and treatment is the key in preventing further damage to one’s body. Thus, the military pilots are doing themselves a disservice by not disclosing medical issues to their healthcare team. This would seem to indicate that the value of their vocation overrides their own well-being and fuels their rationale of healthcare avoidance which has been suggested by this study. A previous study on pilot–flight surgeon relationships showed that many military pilots are reluctant to discuss medical issues with their flight surgeons and recommended that we find the factors causing the behavior and look for ways to improve the relationship.⁷

I believe the pilot–flight surgeon relationship can be improved by several methods. We, as flight surgeons, have the potential to be part of the integral team of pilots. Flight surgeons in the U.S. Army, U.S. Navy, and U.S Air Force are all trained to be crewmembers on military aircraft. Military flight surgeons are also required to perform flight duties regularly to maintain proficiency and currency and receive flight pay. Flying with the pilots that you take care of is a great way to build trusting relationships with them. When you fly with them, you can see how they perform, have a better understanding of their occupational stressors, and have time to get to know them as a person and not only as a patient. When you fly regularly with the pilots, they will start recognizing you as part of the flying team, not an adversary who is looking to medically ground them. You can have some shared occupational identity with them, which can enhance the trust relationship.

Flight surgeons can also put discussion of medical conditions in the perspective of aviation. All pilots are trained to identify risks in their mission and mitigate them as much as possible. Safety culture is embedded into all aviation operations. A pilot might have a better understanding of the necessity of medical processes if a trusted flight surgeon explains how a medical condition could affect aviation safety. Clearly explaining the plan to evaluate and treat the condition and the timeline could further help the discussion.

Just like a pilot will not fly an aircraft with a known issue that could cause mission failure and risk lives, flight surgeons can urge pilots to do the same for their body.⁸ As discussed above, early detection and treatment is much better than pushing off the diagnosis and treatment while letting a medical condition worsen.

All these can be done by building a better relationship with the pilots. Making time to fly with them and visiting them at the hanger will pay dividends when they feel more comfortable coming to you and discussing their medical conditions. When the pilots are comfortable with you, you will have more opportunities to provide accurate information about the medical condition, how it affects flight status, what needs to be done for a waiver, and how long it would take for a waiver and other details to lower their stress and anxiety.

Despite the limitations listed by the authors, this study is important in shedding light into healthcare avoidance behaviors in military pilots. Due to the nature of the topic, data collection had to rely on anonymous surveys. However, the results are quite valuable in motivating flight surgeons to build trust to reduce the healthcare avoidance culture within military pilots.

ACKNOWLEDGMENTS

None declared.

FUNDING

No funding was received to complete this work.

CONFLICT OF INTEREST STATMENT

I have no conflict of interest to declare.

DATA AVAILABILITY

Not applicable.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

Not applicable.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

The author wrote the manuscript.

INSTITUTIONAL CLEARANCE

Institutional clearance approved.

REFERENCES

Author notes