 Our next presenter is the FAA's Deputy Federal Air Surgeon. He's retired from the Navy as a Captain after 30 years of service. He holds several degrees, including one Doctor of Medicine. He is also the Emeritus Member of the Society of U.S. Naval Flight Surgeons. And he was also President of the Naval Flight Surgeons from 2002 to 2003. His topic today is maintaining that important document for us, maintaining your medical. Well, let's welcome Dr. James Frazer. Well, good morning. Today I would like to talk about a couple of things. First of all, I'll start off by just briefly telling you a little bit about my background just so you know where I'm coming from. And then I want to talk a little bit about what the FAA's Office of Aerospace Medicine is all about. And lastly, and of course most importantly, I want to talk about some of the current issues regarding maintenance of your medical and of course leave time for questions at the end. As Walt said, I am indeed former Navy. I was a happy sailor some four and a half years ago when the Navy sent me one of those letters telling me that 30 years was all the fun a sailor was allowed to have. So I was very fortunate to be able to apply for a position with the FAA and came aboard four years ago and I really enjoy my job. I really enjoy what I'm doing. My background in the Navy did not start as a flight surgeon. I started as a family physician and after doing residency training in Charleston, South Carolina and sticking around as family practice teaching staff, I went overseas with my family and served as a Navy family physician in first the Philippines and then in Scotland. I had some wonderful times overseas and certainly I enjoyed family medicine but I had always wanted to learn to fly an airplane and to be a naval flight surgeon. So I came to Pensacola, Florida and Pensacola is the birthplace of all things involving naval aviation and naval flight surgeons. So just before I turned 40 and got too old, I reported for flight surgeon school and they taught me how to fly an airplane. I no longer had call every second or third night because I got flight pay. I got a pay raise. So that was my start into aerospace medicine and that's where I finished my naval career. I did a second residency in aerospace medicine there at Pensacola and if you do an aerospace medicine residency in the Navy, it's basically a one-way ticket to one of our national treasurers, one of our nuclear aircraft carriers. So I was proud to serve as the senior medical officer on board the USS Theodore Roosevelt as such was in charge of a 67-bed hospital and a 50-man department but truly looked back with great honor at that time as the senior medical officer on a carrier. Following that, I joined the Commander Naval Air Force's Atlantic Fleet where I had oversight of what were then eight carriers on the East Coast and all the flight surgeons and physicians that were a part of Naval Air Force's Atlantic Fleet. That was a wonderful job and I finished my career in the Navy at the Naval Safety Center in Norfolk where I had the opportunity to teach all naval flight surgeons. I had the opportunity to be involved at the very highest level of naval aviation in terms of mitigating some of the mishaps that we would have and I was in the chop chain and became intimately familiar with all the Navy Marine Corps accidents that finally got closed out at the Safety Center. And then I just in the last couple of months when you're supposed to be gearing down and figuring out what you do after you retire, the last thing I did in the Navy was serve on the Columbia Accident Investigation Board for a couple of three months. So that's my background and that's what I did before joining the FAA. Let me tell you a bit now about the Office of Aerospace Medicine. Aerospace Medicine is comprised of some 330 people spread out across nine regions and of course, CAMI, the Civil Aerospace Medical Institute in Oklahoma City that probably all of you are familiar with. We reside within aviation safety. We are the third largest service, a distant third behind flight standards and aircraft certification. However, we do have the largest number of designees because we have some 3,500 aviation medical examiners that we have trained and that we keep up to date. In the Office of Aerospace Medicine, our main job is the development of policy and standards, not only for airmen but for air traffic controllers. The FAA is basically the world's gold standard in terms of medical certification and I think most of the world's certificating authorities look to the FAA for guidance in terms of what we allow and don't allow with medical standards. We at the FAA are certainly in the forefront of looking at new conditions, looking at new procedures, looking at new medications and I'm very proud of the fact that we use the very best of evidence-based medicine to look at these new changes in medicine and we are willing to certificate those things that we feel an airmen can safely fly with. We certainly don't say no, that would certainly be the easiest thing to do in the interest of fairness to the airmen. At the same time we keep the national airspace safe, we certainly lead the way. There's very few countries in the world where a diabetic could fly while taking insulin and yet we the FAA allow that for our third class pilots. Whereas our primary interest in aerospace medicine is keeping the national airspace safe, a secondary mission of ours is really getting every airman up that we think can safely fly and I'm proud of the fact that of those airmen that work with this and give us the procedures or the consultations or testing that we require, ultimately only about one-tenth of one percent of all the airmen that we certificate are finally denied. So we'll talk a little bit later about reasons you should never falsify on your medical, but first and foremost the best reason is only one-tenth of one percent of all airmen that one medical are ultimately denied and of course the way we're able to do this for people that have had heart attacks or cancer or one thing and another is through special issuances and special issuances are just our way of giving airmen that have conditions that would formerly be disqualifying, they give them a time-limited certificate and we specify what kind of follow-up and what kind of testing they need and by working with the airmen in this manner we're able to certificate just about everybody that's interested in a medical. So at headquarters in aerospace medicine we oversee the issuance of 450,000 medicals every year at headquarters we serve as the appellate level or the last level of appeal for airmen that have been denied first perhaps by their AME or by the Aeromedical Certification Department at CAMI. So by the time the cases get to headquarters they're usually about that thick and they're typically very interesting medical or psychiatric issues that I certainly enjoy getting involved with. The Office of Aerospace Medicine has a role in occupational health. We work with NIH and CDC and Department of Homeland Security. We meet with those folks and we talk about how we the FAA would collaborate in cases of communicable disease like TB or SARS, certainly both very topical issues of late. We talk to these other agencies in terms of how we would interact with emerging diseases like avian flu and we also work with them in terms of what we would do for a biological agent such as anthrax. We also have roles in occupational health doing more mundane things like figuring out how big of commercial aircraft an automatic external defibrillator should be on what should go into a medical kit, how big a plane needs, how many medical kits and occupational medicine issues of that nature. The Substance Abuse Substance Abatement Division resides within Aerospace Medicine. We have a very robust division made up for the most part of our industry substance abatement folks who regularly test our 121 and our 135 pilots to make sure that they're not using drugs or under the influence of alcohol. But we also have our own internal program whereby we test our own FAA employees that are involved in safety or security sensitive positions and for the most part that's the air traffic controllers. One of the things that I'm really proud of is that we at the FAA are very active in what's known as the HEMS program and HEMS is Human Intervention Motivational Study but basically it's a program that's been around for 20 years now whereby air transport pilots that are substance dependent have a method to be identified, treated, rehabilitated and brought back into the professional world as meaningful contributors to society. We work very closely with the unions and the air carriers to be able to treat these air transport pilots and to bring them back to be a useful member of society. We have trained enough aviation medical examiners and their role as a medical sponsor in this process that we're now able to also work with 135 pilots and Part 91 private pilots in terms of getting pilots that have been successfully treated and successfully rehabilitated back into the cockpit sooner rather than later. Substance dependence is not a kiss of death for a medical certificate. We have a very robust role in air medical education. One of the primary reasons we exist is to train aviation medical examiners and as I mentioned there's some 3,500 aviation medical examiners that are spread throughout the world. We not only do basic training but all of these AMEs are required to go through recurrent training. So many of us in the FAA take a very active part in training these AMEs. And of course we also train pilots, if you step outside you can go through the spin and puke which we typically take to the air shows to show all the allusions to airmen but we also bring airmen to CAMI and are able to put them in the hypobaric chamber or are able to put them in the pool to deal with evacuation issues and things of that nature. Aerospace medicine is also very much involved in research. We do research throughout aerospace medicine. CAMI is the biggest place we do research and there we have sleds and we have hypobaric chambers and we have pools to drop people into. We look into things like emergency evacuation. We do testing to determine how you could better survive an airplane crash. We have a big human factors division. We look at things like airmen, flight attendant and air traffic controller fatigue. We look at how you select and how you train air traffic controllers. We look at color vision and other aspects of certificating both air traffic controllers and airmen and do a number of research activities involving the toxicology laboratory that we have at CAMI in Oklahoma City. We also do airliner cabin research. We are doing active research to look into how you decontaminate an aircraft following a communicable disease, emerging disease or even a bioterrorism agent. We look at airliner cabin issues such as the petroleum products that come out of bleed air that may or may not cause health problems for people in commercial aircraft that they work in those aircraft for many years. We also look at the effect of pesticides and what effect pesticides might have on these people. And we look at the more natural environmental issues that all airmen are subject to. Hypoxia, low humidity, low barometric pressure, ozone and radiation. So we have a very active role in research in aerospace medicine. So let me move on to some recent decisions and some current issues that will start to get into the maintenance of your medical issues. In terms of the headquarters FAA perspective, the biggest recent change was the Fair Treatment for Experience Pilots Act. And many people know this as the age 60 rule or the age 65 rule and basically it's the rule that goes back to 1959 whereby the FAA declared that for an air transport pilot the day they turned age 60 they could no longer transport ticket-paying passengers. And of course there was great controversy regarding the age 60 rule and our last administrator Marion Blakey basically went online and said we were starting rulemaking. But fortunately the president on the 13th of December of 2007 with the stroke of a pin can do what presidents do and change the law so that now air transport pilots can fly up until the age of 65. That was great news, welcomed by most of us that I know of in the FAA. Those that are involved in rulemaking know that rulemaking is a long, arduous process and it would have been probably two years to go through all of the rulemaking that would be involved in changing that by the typical procedure. But thank goodness we have people like the president that can just do that with a stroke of a pin. So certainly that has made my life a little bit easier and I look forward to following this process because we, the FAA and Aerospace Medicine and CAMI are going to be responsible to make sure that we are equally safe or safer with a pilot that's between the age of 60 and 65. In Aerospace Medicine we heard from pilots like you at venues like this and at venues like Oshkosh and via Congressional and other means of communication. Several years ago we were hearing that many airmen were dissatisfied that their special issuances took so long and once again most of you know that typically when you go to your aviation medical examiner 95% of you walk out with your medical certificate in hand and you're pretty happy. But for those of you that have had a health issue that need a special issuance a couple of years back there was a delay. There were times that it took several months to get an airman authorized for a special issuance and you weren't particularly happy about that. So we did a lot of things that I won't go into to speed the process up. In particular we made the process electronic so that all of our regional flight surgeons and deputy regional flight surgeons could play in the airman certification process. But one of the biggest things we did was create this class of AME assisted special issuances. We now have 35 medical conditions such as myocardial infarction, heart attacks, cancer, atrial fibrillation, I could go on. But basically 35 of the most common medical conditions whereby after a first time issuance by either AMCD at CAME or by the regional flight surgeon we then specify given a current status report on usually an annual basis and specified testing depending on what the medical condition is that you go to your AME and your AME can give you your medical every year usually and that doesn't have to get sent to CAME. Right now the average processing time for a special issuance is 16 days. And I'm very proud of the fact that we've been able to whittle that time down and no longer have the several month delay that we had a couple of years ago. As I mentioned I like to think we're on the cutting edge of allowing different medical conditions as opposed to our certificating authorities throughout the rest of the world and a good case in point is heart transplants. We now have certificated to heart transplants and when we do something of this nature we typically have to look at a subset of heart transplants and basically you can look at heart transplants and if you have angiographic evidence that there's no allograph basculopathy or left systolic ventricular dysfunction you can certifcate someone and you guys know all that so I won't go on. But the important thing is we have used the evidence based medicine and we take something as serious as a heart transplant and we identify that subset of those that we can safely certifcate and then we do so through the special issuance process. FAA MedExpress. Some of you in here have probably used FAA MedExpress. FAA MedExpress is our internet process whereby those of you that want to complete the front of your 8500-TAC-8 at 2 in the morning while in your pajamas can now do so. It's our effort to be more efficient and basically all you need is an internet address. You get onto FAA MedExpress, you fill out the front of the 8500-TAC-8 if you need to find out information or if you don't complete it in one sitting it will save whatever information that you've put in thus far. You then get a confirmation number, you go to your AME, your AME pulls your exam down on his computer, completes the back of the 8500-TAC-8 and issues you your medical certificate. So some 25,000 airmen have now used FAA MedExpress and I encourage all of you to give it a try if you are so interested. It's not required for airmen and it's not required that AMEs participate but certainly you can ask your AME if he does participate or is willing to participate in FAA MedExpress and we're always seeking to make the application process more customer friendly. Oops, finger finger. Alright, some more good news. We are currently in the very last couple of weeks of what's called team concurrence for final rule on changing the periodicity for medical certificates for airmen under the age of 40. There is ample medical evidence that if you're younger, particularly if you're under 40, you don't need to have physicals as frequently as those of us that are over 40. So we have proposed and soon will have finalized the rule whereby if you are first class and you're under 40, you'll need a medical once a year by six months and if you are third class under the age of 40, you will need your physical every five years and I haven't found too many airmen that are disappointed about the fact that they can have physicals a little less frequently. Now we did, when we published our notice for proposed rulemaking, we did discover one small hiccup and I'll bring that up just to be complete. Many of you are aware that when you fill out that 8500 TAC-8, you sign a statement that gives the FAA the authority to go to the National Driver Registry and look and see if you have DUIs. When we created this new rule, we didn't realize that this was based on a statute that we tag on to that belongs to the Federal Highway Administration that basically says we only have the authority to look back three years. So even though we are going ahead with the final rule, we are going to have to work on getting our own statute whereby we have the authority when you sign that 8500 TAC-8 to look back five years just to close that potential crack that an airman could potentially slip through. And of course I know most airmen dutifully report their DUIs. We occasionally find some that forget they've had a DUI. So we want to close that crack and we have five years to do so so I feel very confident that this is good news for all of those airmen under the age of 40. I also want to mention the antidepressant working group. We have, I talked about this last year. I've talked about this at meetings for the last four years. But I can tell you we are no kidding very serious and very close to identifying a subset of airmen that are on antidepressants that we're willing to special issue and follow very closely. 10% of all of us are going to be clinically depressed at some time in our lives and that pertains to airmen just like the rest of the general population. Right now if you have a diagnosis of clinical depression or you're taking an antidepressant that's disqualifying, certainly depression in and of itself has some disqualifying features that are not compatible with being a pilot and then the medicine, the selective serotonin reuptake inhibitors, SSRIs those have been shown to have cognitive effects such that you're not as sharp as you otherwise would be. However, we have identified some of the SSRIs that are less sedating than others and we have a cadre of psychiatrists that are willing to follow airmen on a probably a biannual basis and we are probably going to be using the neuropsychological testing which is just a very sensitive test that can determine that you have the appropriate cognition, memory and attention that you need to be a pilot. So very soon you will be hearing more if you are interested about how you can be a pilot and fly on antidepressants. Before I get off this topic I will just state categorically because every meeting I go to someone comes to me and says, you know, I have a friend who has a friend that has taken an antidepressant and guess what, he's not telling you guys. Well, we know that. We know there are airmen out there that are taking antidepressants that aren't being forthright and truthful and even worse than that, we know that there are airmen that realize that antidepressants are disqualifying so they're going untreated and that's probably even worse. So we look forward to being able to certificate this subset of depressed pilots that are appropriately treated. Our lives in Washington have been interesting of late. If you've watched the news you know that my boss Nick Sabatini has had more fun than any one man should be allowed to have. First the house beat him up last week and the Senate beat him up yesterday quite soundly. According to the paper. But we have these, I shouldn't say nasty things, that's part of our democratic process. We have hearings in Washington D.C. which are not always fun to go to. And the hearings that have affected aerospace medicine of late in a specific sense have been Mr. Oberstarr's house transportation and infrastructure subcommittee. And this is regarding airmen falsification and it affects you guys just like it affects me. And it all stems out of a project that was initiated by the Social Security IG a couple of years ago that got in cahoots with the FAA IG and they looked at a group of pilots in Northern California with over 60,000 odd pilots in a database match called Operation Safe Pilot. And the premise was if you're on Social Security disability unlike military disability, Social Security disability pretty much means that you're not supposed to be able to do any kind of work. You're unemployable. And as the IGs from our various agencies match the database, lo and behold, there were a number of folks that held both the pilot medical as well as collected Social Security disability. So the IGs found the 60 odd most agrarious cases, those that had told Social Security they couldn't work because of cardiac or neurological or psychiatric reasons and yet they had not told us the FAA that they had any such problem and these people were all taken to trial and some of those are ongoing but certainly the airmen had anything between loss of medical certificate, significant penalties or even face potential prison times. So Congressman Oberstarr picking up on Operation Safe Pilot has called Mr. Sabatini and my boss, the federal air surgeon Dr. Fred Tilton up to the hill and has basically told them that we, the FAA and specifically Aerospace Medicine must have majors in place to nip this airmen falsification problem in the bud. So what we have done, what we have been required to do by Congress, our boss, is first of all, redouble our efforts of education with folks like you and with our AMEs. We've told them that there are serious consequences to falsification. Every time you fill out that 8500-TAC-8 I don't know how many of you read that little bitty small print but there's some small print on the front of that page that says if you willingly falsify you can be fined $250,000 or spend five years in jail or both. And those of you that follow the news know that last month there was a pilot that was sentenced in Massachusetts for falsifying. This was a diabetic pilot flying a 135 operation when he went into a diabetic coma. Fortunately there was a young lady on board that had had some 10 hours of flight time or something of that nature that was able to safely land the airplane. I think it was a wheels-up landing but everyone walked away so she was a hero. But nonetheless the diabetic 135 pilot has now been sentenced to a couple of years in jail. So it's my job to tell airmen like you and to tell AMEs that there's very good reasons that you should be honest and forthright on your medical. Not the least of which is the fact that less than one tenth of one percent of you would fail to get your medical if you would just work with us and get the specified follow-up and testing that we agreed to. It's also fair to point out that there can be serious consequences with falsification if you were so unfortunate as to be the pilot in the fatal mishap. You know all of our fatalities in aviation mishaps get investigated by the NTSB and by law we, the FAA, Aerospace Medicine have a world-class toxicology laboratory at CAMI and part of the post-mortem findings involves shipping specimens to CAMI where you are tested by very sophisticated equipment that looks for any unusual drugs and unfortunately there have been cases where there have been antidepressants or cardiac medicines or other post-mortem findings that indicate something different than what the airman reported in his 8,500 TAC-8 and when that turns out to be the case insurance companies not uncommonly refuse to pay life insurance so it's important, another important reason that airmen should be honest and forthright when they fill out that 8,500 TAC-8. As a result of these hearings a couple other changes that you'll be seeing is a new box on the front of the 8,500 TAC-8 whereby you will be asked if you receive medical disability and also if you turn the front page of the 8,500 TAC-8 over and actually read the instructions there will be a new line that will make you aware that by filling out the medical certificate or by the application your information could be matched with other federal databases in much the way that Operation Safe Pilot was operated in Northern California. So as long as you're honest and forthright there's nothing to worry about but certainly Congressman Oberstar is interested in this falsification issue and we are working with him to do what we can to educate and tell airmen and AMEs to be honest and forthright. I want to close before I open it up to questions just talking about current issues with Sport Pilot because in a venue like this Sport Pilot is certainly topical. These are some of the operational limits that many of you that fly Sport Pilot are aware of basically low and slow. The most important part from my perspective is the medical issue regarding Sport Pilot. All of you probably know that you can fly a light sport aircraft with a valid driver's license unless for any reason you ever applied well not ever, if for any reason you applied for an FAA medical certificate and you did not receive that on your last application or if you were revoked, suspended or denied or if you held a special issuance and that was withdrawn. If for any reason on your last application if you had applied for your FAA medical and not received it you cannot fly with your driver's license. The good news is that many people that were disappointed with this were people that had been denied medicals 10, 20 years ago and 10, 20, even 5 years ago it was a different world. We the FAA were acting much like certificating authorities across most of the world today. It was much easier to say no to heart disease or cancer or any number of medical conditions. We have certainly become much kinder and gentler since then and we know by the evidence that you can safely fly with many of these conditions under specified follow up and testing. So there are many airmen that got denied 20 years ago that would have no problem getting a medical certificate if they were to reapply today. And then of course even if they have had something significant we are willing to work with them and offer them a special issuance and of course once you get a special issuance you're good to go. You're good forever more and you can use your driver's license you just have to get that medical ticket you have to get your medical certificate and we're willing to work with you to help you do that. And I will say right now that many people have pointed out that this rule which was not medicals making but this rule that I get asked about frequently is potentially unfair. I admit that. Two brothers that both have the identical seizure disorder. One brother applied for a medical certificate with the FAA and was told no. Seizures and flying airplanes don't go together. Well the other guy never applied for an FAA medical and he wants to buy his light sport aircraft he goes to his private physician his private physician says well Joe you know I know you've got this seizure disorder you're owned to Latin and you seem to drive your car and you know driving a car must be like flying an airplane and this guy is legally entitled to use his driver's license and fly his light sport aircraft. Not fair. But we at the FAA are government employees and if indeed we are aware of honest to goodness medical reasons why you should not get a medical certificate in flying an airplane we are obligated ethically obligated to act and then work with you to get a special issuance or whatever process need be to do it the right way by the rules through the proper channels and with that ladies and gentlemen I consumed 41 minutes so we have 19 minutes for questions. Hi Jim thanks very much I'm not going to pin you down on the dates for the SSRI changes but can you pin down the time frame on the final rule for the increased duration of medical certificates? You know Gary it should be a matter of a couple of weeks which in Washington speak might mean a couple of months but we are in final rule and even though you have to have these meetings with the economist and the lawyers the enforcement lawyers and the statutory lawyers and they can always throw you a curve at the last moment I really, really am optimistic that we'll have that nailed down in a couple of months. So definitely in 2008? Definitely probably maybe in 2008. Thanks. I have a question what do you feel about extending the status of the sport pilot to the level of private pilot certificates? I mean you will not be out of business you still have the commercial part 21 and 135 but I say that because I understand in UK is going in that direction so what's your comments? So you're talking about using a driver's license for a third class medical certificate? Yeah and that's certainly a logical extension that has been brought up before I will tell you that in talking to my counterparts in the UK that they have a medical system that is much different than ours with their national health care system certainly many of their private physicians have have a better idea about the patients that they follow and though are not to get into the pros and the cons of our different medical systems but certainly you can get away with a lot more in terms of medical diseases and eyesight issues and other problems in the United States than you can in the UK so I for one know that there are enough third class pilots that have such significant medical conditions that I think it's in the best interest of our national airspace to keep that a medical certificate you know it would certainly help with FAA resources if we were able to do that but if you look at the medical causals if you look at mishaps that have been because someone has had a heart attack or a seizure or a medical problem in flight that has led to a mishap there are few and far between but those that have happened are all in the part 91 in the third class variety so they're out there and I I think from my parochial perspective we would be on safer sounder ground if we were to keep the system as it was just for a clarification as some of us age a little bit we may elect to go from private pilot to the sport and without any you are allowed to simply allow your medical to expire okay and then that doesn't raise any issues you know I'm assuming you're healthy and everything else expire okay at the end of its term okay and then you go into the sport aircraft category and from there on and that doesn't raise any issues you are correct sir you just let it expire and as long as you weren't denied or suspended or revoked you're good to go it's an instructor pilot who failed to renew his medical after having an MI still able to conduct a biennial flight reviews you know that that would be a question that I would need to get help with from my flight standards brethren I think the answer is yes but I'm really not sure you're going outside of my territory there that's as long as the other guy has a valid medical you see there's a lot of people here that know more than I do which is not uncommon could you give some general information on the diabetic condition with pilots and what the limits are what they consider a diabetic pilot what number and what ramifications and so forth should we be aware of we certificate a lot of diabetic pilots first of all many you know you can clinically have diabetes that is controlled by diet our guide that we provide to aviation medical examiners of what we teach to aviation medical examiners tells them that if you have diet controlled diabetes they can issue the certificate they need to get some testing done but once their testing is done and their blood sugar is under control the AMEs can issue a regular certificate and then there's the category of the diabetic that needs the oral medication used to be called oral hypo glycemic but now there's anti anti hyper glycemic and there's all category of diabetes medicine and basically this is one of those AME assisted special issuances whereby if you show us with a hemoglobin A1C which is the test that looks at your control over time if you get a current status report and the diabetes isn't affecting your vision or your neurological status or your renal status and your A1C is reasonable with you on oral medicines will give you a six year authorization whereby once we give you the medical certificate you get current status reports and testing and your AME can then issue you for the next six years lastly there is the category of diabetics on insulin and here we have very specific protocols whereby third class pilots third class only even though we take grief from some first and second class pilots that are diabetic and would like to see the rules apply to them right now it only applies to third class pilots because of the risk of hypoglycemia but we have some very specific rules about how you test yourself taking snacks along when you'd be required to land and I can't rattle those off the top of my head but they've been used for over a dozen years now and we've had great success with the safety of our diabetic pilots that use insulin that have been able to safely fly you were talking about the blood test what is the FAA sealing for that blood test on sugar content do you know? you know it depends on the laboratory every laboratory has different normals the AC1 test or whatever I thought the FAA had a sealing that if it was .9 or something and above you're considered are you familiar with that? I am familiar with what you're talking about but I'm not going to stick my neck out on a number but it's it's very conservative it's very reasonable we do not expect our diabetics to be as tightly controlled as some diabetologist some medical doctors would like because the real risk of diabetes is not the hyperglycemia the real risk of diabetes is using insulin or one of the oral medications and being hypoglycemic whereby you could actually lose consciousness, have problems concentrating so we like our pilots to fly sweet I had prostate cancer in 2005 had prostate removed in December of 05 and through your special issuance program I received my medical back about 6 months later which is wonderful but I continue to participate in the special issuance program with a PSA of 0 how long do I have to participate and is there a method for early out out of the special issuance? you know that varies that's a real good question that varies on a case by case basis this question comes up all the time in people that have had cancers like melanoma cancers that may have been lung cancers or liver cancers, the kind of cancers that are more likely to metastasize to the brain and then they have to get an annual MRI which is not cheap so lots of them want to know when is this annual testing going to end and by and large we look at 5 years as the time that we would expect someone to get either an MRI or a PSA and of course a PSA is a whole lot cheaper than an MRI but yes there is a way that you can resume special issuance and typically 5 years would be the rule of thumb ladies and gentlemen thank you very much thanks a lot very interesting stay right here we're still on camera