DAME/DAO Newsletter - June 2000
Contents
Acknowledgment
Distribution
New Medical Records System (Nu-MRS) developments
Colour vision testing
ECGs
Still more on ECGs
hdl & ldl cholesterol readings
Taxation and eligibility of services for Medicare benefits
New opportunities in aviation medicine
General updates
Continuing difficulties affecting medical examination
forms
Advertisement and poster advocating timely medical appointments
Aviation Reference Numbers (ARN)
AMSANZ membership
Other matters of interest
Feedback
Acknowledgment
DAMEs / DAOs should confirm receipt of this Newsletter per return email to <urban_ma @casa.gov.au> Alternatively, please fax confirmation of its receipt to CASA AvMed at (02) 6217 1640.
Distribution
DAMEs / DAOs should read and digest the contents of this Newsletter, retain it for future reference, and make relevant sections of it available to locums or to other staff members who have dealings with CASA on behalf of practice principals.
New Medical Records System (Nu-MRS) developments
CASA has expended very considerable financial, technical and staff resources on introducing Nu-MRS, which still requires much more development before it will be as user-friendly as required even for in-house use. At this stage, it is nowhere near ready for DAMEs / DAOs to access it in order to check an applicant’s previous medical history, an intended principal benefit of its introduction. Similarly, further extended delay appears inevitable before electronic lodgement of medical forms becomes a reality. CASA intends to let a new contract for this purpose shortly, but it now appears unlikely that this feature will be deployed until the second half of FY 00/01. Seemingly, such problems are endemic in attempts to deploy widely new, interactive systems of the type which Nu-MRS is intended to become once it is fully deployed.
Apart from its own difficulties in getting even phase 2 of Nu-MRS to work as desired, CASA is conscious of the great difficulties being experienced by examiners in the USA because of the FAA’s new electronic lodgement system. This has been reported in Aviation, Space and Environmental Medicine 71:3; March 2000. See abstract 60 at page 281. Alternatively, abstract text is available on the AsMA website at <http://pelican.webfirst.com/asma/convabs00/60.htm>
Colour vision testing
DAMEs are reminded of the routine sequence of testing, specified in the DAME Handbook: Ishihara Plates; Farnsworth Lantern; Aviation Signal Light Gun Test. Because of its labour intensive nature, applicants will NOT be permitted to undertake the aviation signal light gun test unless they have already failed both of the other screening tests for assessment of colour perception.
ECGs
Because of unresolved difficulties with the poor clarity (~illegibility) of some test-scanned ECG images, it will be necessary for Aviation Medicine Section to continue to require DAMEs to send any required tracings by mail, at least for the near term. However, the previously advised requirement for all required ECGs to be generated by a self-reading machine or to be interpreted by a cardiologist / physician / other medical specialist approved by the Director of Aviation Medicine will take effect on 1 January 2001. After that date, any other ECGs received will be returned to DAMEs for appropriate interpretation / reporting. In all cases, reports must accompany ECG tracings submitted.
Still more on ECGs
DAMEs are reminded of the need to ensure old-style self-read ECGs submitted to CASA are correctly mounted. DAMEs should personally check the mounting and reporting of ECGs to be sent to CASA, particularly where the clerical component of the work has been undertaken by a new staff member or by one who is unfamiliar with the Authority’s requirements. It is frustrating and time wasting for all involved when inadequate ECGs have to be returned to DAMEs for correction of mechanical faults in their preparation.
hdl & ldl cholesterol readings
As advised in the DAME Handbook, estimations of total fasting cholesterol and of hdl / ldl components ARE REQUIRED for initial and some renewal class 1 and 3 assessments, as shown in the flow chart in the DAME Handbook for class 1 and 3 medical certificates - particular age requirements . DAMEs should enter all three values in the relevant fields for applicants who require them, also use the HDL and total cholesterol values in calculating the applicant’s cardiovascular risk status. See the Coronary Heart Disease Risk Factor Prediction Chart in part 6 of the DAME Handbook. To iterate advice from the DAME/ DAO Newsletter from October 1999:
For applicants required to submit serum lipid results, an ldl figure is required. CASA realises that many / most pathology laboratories do not routinely supply ldl results when total cholesterol is within normal limits. This is a result of Medicare funding arrangements. Accordingly, DAMEs should endorse request forms with advice that the examination is OCCUPATIONALLY REQUIRED FOR SCREENING PURPOSES AND IS NOT MEDICARE REBATABLE. Pathology laboratories rarely object to performing the additional estimation when informed that they can bill for it privately.
Taxation and eligibility of services for Medicare benefits
The Australian Taxation Office has ruled that examinations for CASA medical certification will generally attract GST. The relevant advice now follows.
For a medical service to be GST-free, it must be a treatment. In ATO rulings, "appropriate treatment" is defined as assessment of the patient’s state of health and a process to pursue an attempt to preserve, restore or improve the patient’s physical or psychological well-being. Thus, appropriate treatment encompasses preventive services, ongoing management and cure. Services which are not regarded as treatments include medico-legal services, services which involve the preparation of reports for third parties, provision of training to other health professionals, services of an administrative nature and autopsies. (Examples cited include: insurance medicals, pre-employment medicals, professional driving or flying licence checks undertaken to meet the requirements of a regulatory authority).
CASA, like many DAMEs, DAOs and applicants, continues to be confused over the eligibility of certain aviation medical examinations, investigations and reports for Medicare benefits. In January 2000, the Health Insurance Commission provided the following advice in order to explain these matters.
Medicare benefits are not payable for health screening services. Section 13.3 of the Medicare Benefits Schedule outlines the definition of a health screening service as ‘a medical examination or test that is not reasonably required for the management of the medical condition of the patient’.
Medicare benefits are payable, however, for health screening services where a patient has a medical condition that requires monitoring or treating to maintain the patient’s state of health. In such cases medical examinations and tests are considered necessary according to the circumstances of the patient.
Further information may be obtained from the Medicare Claims Section by telephoning (02) 6124 7707.
The HIC and CASA will hold further meetings in coming months in an attempt to reach consensus and to clarify the matter so far as possible. Inevitably, some ‘grey areas’ may remain, but CASA will attempt thereafter to provide more useful advice to DAMEs and DAOs.
New opportunities in aviation medicine
As advised in the March 2000 DAME / DAO Newsletter, Australia’s major airlines now direct some applicants for flight attendant positions in the company and also existing staff employed in those positions to DAMEs for company-required examinations re fitness to resume duties rather than continuing to perform such examinations ‘in house’. The airlines provide detailed advice on standards required (this will normally be brought by the examinee), as well as their own examination forms. The airlines consider DAMEs’ experience in aviation medicine and in performing CASA medicals should suit them well to undertake these new examinations on existing employees and potential employees of the company.
Note that payment for these examinations is usually the responsibility of examinees, not of the airlines. Consequently, DAMEs should establish their own fees for such services.
General updates
The CASA website contains an index of contents for this Newsletter and for those of August 1999, October 1999, December 1999 and March 2000. This feature is provided to assist DAMEs / DAOs to locate specific notes / other information more readily.
Publication of the foreshadowed March revision of the DAME Handbook was delayed for reasons beyond the control of AvMed. The new text, now designated June 2000 revision, should be available through the CASA webpage within the next few weeks- just follow this path: http://www.casa.gov.au/manuals/regulate/dame/index.htm
Changes have been made to the DAME Handbook which reduce ambiguity, eliminate misspellings and align CASA’s procedures with ICAO Standards and Recommended Practices wherever appropriate. Significant changes have been made to the following sections of the Handbook, which should be reviewed by all DAMEs and DAOs:
1.1.4
1.3.1
1.3.4
1.3.5
1.3.6
1.4.1
1.4.4
1.4.6
2.1.2
2.1.3
2.1.15
2.7.7
2.8.3
2.12.6
2.14 (new section).
Continuing difficulties affecting medical examination forms
The March 2000 Newsletter emphasised that that DAMEs should revalidate medical certificates ONLY where applicants clearly meet the required medical standard(s). Question 6.3 (‘Has the temporary certificate been issued / certificate been revalidated?’) evidently still causes difficulty to some DAMEs, who return forms without marking either of the possible responses. This requires personal follow up telephone calls to DAMEs, particularly where there is some doubt over an applicant’s fitness for certification. When (eventually) deployed, interactive Nu-MRS lodgement will largely overcome this problem as it will prompt examining DAMEs to provide additional data before permitting form lodgement, as well as greatly reducing the requirement for revalidation of existing medical certificates.
Meanwhile, DAMEs are requested to provide full details of a positive response to Question 6.1 (Do you consider there are any areas of concern in the applicant’s assessment which require specialist assessment or counselling?) by means of an appropriate notation in the ‘Examiner’s Comments’ section. CASA will be greatly assisted by advice that an applicant (a) has been referred to (specialty) - CASA’s preference; (b) has been sent back to the usual GP to request a referral to (specialty) - next best; or (c) has been advised to consult a (specialty) - which often requires CASA to contact the applicant about the matter.
When a DAME wishes to appoint a locum to undertake CASA medical examinations during a period of absence, prior permission from CASA is essential (see Conditions of Appointment). Furthermore, to facilitate later contact with locums and to reduce potential medico-legal problems, it is important that locums identify themselves on medical forms, both on page 1 and at the signature block on the final page. At both locations, those concerned should print ‘LOCUM’ after their names.
Numerous forms STILL have to be returned to DAMEs who neglect formally to identify applicants examined. This long-standing requirement should not have to be emphasised to experienced and careful DAMEs.
Their are no pharmacists employed by CASA AvMed. PLEASE PRINT YOUR COMMENTS CLEARLY, OR HAVE THAT PART OF THE FORM TYPED!
Please remember the request contained in the March 2000 Newsletter: DAMEs are requested to enter each applicant’s nationality in the ‘Comments’ section of the existing examination forms. (This is an ICAO requirement which will be formally introduced together with electronic lodgement of medicals).
Advertisement and poster advocating timely medical appointments
CASA recognises that some applicants allow insufficient time for routine processing of their medical assessments, then harass DAMEs / DAOs involved, as well as CASA staff, to deal with them out of turn or as special cases so issues of their medical certificates is not delayed. To remind applicants of their responsibilities in the matter, AvMed has sponsored a graphic advertisement (‘You’ll be ropeable’) for the current edition of Flight Safety Australia which exhorts applicants to think ahead and to make timely arrangements for their medical examinations and any associated tests / reports required. (NB The deviant orthography went unnoticed by the proofreader - perhaps it will stimulate literate examinees to raise the issue with their DAMEs). This has also been produced as a poster and circulated widely within the aviation community. AvMed hopes that this high profile exercise will bear fruit!
Aviation Reference Numbers (ARN)
Despite repeated requests by AvMed, there is still not available any simple means for DAMEs / DAOs who do not already have an ARN to obtain one. At this stage, it is still possible to obtain an ARN by mailing or faxing a written request on your letterhead to Ms Margaret Urban, DAME Liaison Officer.
While it is still possible for medical examination and report forms to be lodged for applicants who do not possess an ARN and for AvMed to arrange for allocation of an Aviation Reference Number to these applicants, this will change when all medical forms are lodged electronically. DAMEs and DAOs will be notified well in advance of the introduction of the mandatory requirement for applicants to possess ARNs prior to examination.
Aviation Medicine Section acknowledges that a number of DAMEs have submitted requests for issue of ARN but have still not been notified of an allocation. This delay has arisen from the press of other business and from the ‘slippage’ of full deployment of interactive Nu-MRS. Rest assured: all DAMEs who have lodged an application will be allocated an ARN in due course and well ahead of needing it to lodge Nu-MRS medicals electronically.
At this stage (and until the introduction of electronic lodgement of medicals), DAMEs and DAOs are still required to insert their DAME / DAO stamp numbers on medical forms, NOT their ARNs. (Where ARN is requested on the present forms, only that of the APPLICANT should be inserted).
AMSANZ membership
DAMEs / DAOs who practise in Australia and New Zealand are expected to join and to maintain their membership in the Aviation Medical Society of Australia and New Zealand (AMSANZ). In recent years, the Society has been CASA’s only forum for continuation training in aviation medicine for our medical delegates. Even when CASA has funds available to organise its own DAME seminars, it will usually accept an AMSANZ scientific meeting as an acceptable substitute for a DAME’s attendance at one of its own periodically required seminars.
DAMEs / DAOs wishing to (re-)join AMSANZ should contact Ms Ann Fleming c/-
the Society Secretariat <fleminga@ozemail.com.au>
or write to :
AMSANZ
PO Box 4022
BALWYN EAST VIC 3129
Other matters of interest
Dr Russ Rayman, AsMA Executive Director, wrote an interesting philosophical piece on the proper role of aviation medical examinations in Aviation, Space and Environmental Medicine 71:4; April 2000 (p. 463).
Dr David Newman, former Chief Instructor at RAAF Institute of Aviation Medicine, received a PhD from the University of Newcastle in March in recognition of his work on cardiovascular adaptation to high +Gz acceleration in pilots of high performance aircraft. He was honoured by AsMA in May by award of the Arnold D.Tuttle prize for significant original aerospace medicine research. He has an academic appointment at RMIT, where he has established Australia’s first gravitational physiology laboratory. He is available for consultation on relevant applicants’ problems (tel 0407 320 748) and has a webpage under construction - see <www.flightmed.com.au>
Dr C.D.Davant wrote convincingly on the need for FAA examiners to charge higher fees for pilot medicals in The Federal Air Surgeon’s Medical Bulletin Spring 2000 <http://www.cami.jccbi.gov/AAM-400a/FASMB/FAS2001/davant.htm> Could have some resonances for our DAMEs...
From the Davant article, follow the links back to the Bulletin’s contents list for interesting accounts of FAA’s dealings so far with pilots who have diabetes mellitus.
Feedback
Aviation Medicine Section has received many constructive suggestions arising from the last few Newsletters. Some have already been implemented and others are under consideration or delayed pending the full deployment of Nu-MRS. As always, suggestions and comments from DAMEs and DAOs are welcome: all will be considered and acknowledged.
Best wishes to readers for the winter solstice - summer cannot be far behind.
(Dr) Peter Wilkins
Director of Aviation Medicine / Principal Medical Officer