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Incidental Findings and Medical Screenings

“Incidental findings” are those that are discovered by surprise while researching something else. This happens more frequently than expected in both medical and non-medical research. These findings are typically unrelated to what was being researched in the first place.

When working up a diagnostic analysis of a medical problem or during routine screening procedures, incidental findings often present no clinical concern but may be of great significance at times. In fact, they may immediately present themselves as something far more important than what was being researched in the first place. They may very well require more immediate attention than the condition that was being evaluated.

We have all experienced versions of this. A common non-medical example is bringing an automobile for planned routine service. Shortly after the vehicle enters the maintenance bay for its initial inspection, the mechanic emerges with a forlorn look on their face and dollar signs in their eyes. If the unexpected finding is a safety-related issue, we usually acquiesce and get it repaired. That may be an unexpected and expensive decision, but usually, it’s a wise one.

One of the reasons why pilots worry about doing medical tests is due to their understandable concerns about “opening a can of worms” with the FAA. However, opening the proverbial can of worms might save a pilot’s life.

A recent example from my AME practice came from when we were working up a pilot after a seemingly minor change in their FAA-mandated screening electrocardiogram (ECG). Certain ECG changes are considered to be so minor that the FAA does not require a formal evaluation. However, even if the pilot was entirely asymptomatic, there are many ECG changes that do require an extensive cardiology evaluation to comply with FAA protocols.

In this instance, part of the evaluation included an echocardiogram (an ultrasound of the heart) to assess the anatomy of the heart valves and surrounding musculature. What was found was a rare cardiac tumor.

Was this a “gee whiz” finding that did nothing but unnecessarily open a potentially expensive can of worms? Hardly. This tumor markedly increases the risk of stroke in people who have it, because blood can clot around the tumor, break off, and then travel to the brain.

These tumors usually require prompt surgery to remove them. The much less favored alternative is to remain on lifelong anticoagulation, which has potential side effects and risks—and it doesn’t entirely alleviate the risk of stroke.

While the tumor was likely entirely unrelated to the reason the pilot was getting an echocardiogram, finding it may have saved the pilot from eventual incapacity from a stroke and possibly saved their life entirely. FAA medical recertification should not be a problem for this pilot.

Another example from my practice involved a pilot who went to the emergency department for shortness of breath. He was diagnosed with pneumonia and placed on routine antibiotics and an inhaler. Case closed? Nope. I’m paraphrasing here, but the report of the CT scan of the lungs (which, based on the anatomy, will also include the top of the abdomen) went something like this: “Yup, your pilot has pneumonia. However, you might want to take a closer look at their right kidney.”

Further evaluation found that the pilot also had kidney cancer, which was successfully removed surgically. Having pneumonia led to the evaluation that found the cancer while it was still in an early and treatable stage. While not part of my AME practice, a neighbor of mine had a kidney stone nearly 10 years ago. While evaluating it, an early pancreatic cancer was found, which was removed surgically. Usually, by the time pancreatic cancer is found, it’s too late for surgery.

If you read the statistics on pancreatic cancer, it becomes evident that the 10-year survival rate is, at best, dismally low. Yet, I still see this neighbor out walking the local hills daily. His kidney stone may have saved his life. Pilots sometimes do not want to proceed with routine screening tests that are either standard age-related recommendations or suggested by their primary care physician. Again, they don’t want to open cans of worms. Pilots periodically tell me that they will “do those things after I retire.”

But that might be too late. I appreciate that starting a goat rope of an evaluation for the sole purpose of complying with FAA protocols is never a desirable situation for a pilot. However, you have also previously read one of my personal clichés: “It’s easier to keep you flying if you are still alive.”

The sooner a concerning medical condition is found, the more likely it is that it can be successfully treated. This may save the pilot’s career and possibly their life. While a disappointing period of grounding may be required during treatment, usually we get that pilot back in the air afterwards. This is better than the obvious alternative outcomes. If your physician recommends screening blood testing or a procedure such as a colonoscopy or cardiac stress test, think long and hard before declining to do so. Opening that proverbial can of worms sooner rather than later may make all the difference in the world.

In my many years in professional aviation, I did not want to have a significant medical condition rear its ugly head when I was in a remote part of the world. Many of my destinations did not have adequate medical care available. I tell my client pilots that if the proverbial can of worms was to be opened, I wanted it done while I was in my hometown and not in some distant location. Therefore, I tend to comply with screening medical recommendations.

While most incidental findings or routine medical screenings do not lead to life-threatening diagnoses, you certainly do not want to miss those that are of significant concern. Please do not shy away from appropriate medical testing. You and your family—and your flying career or simple love of flying—might be glad that you were proactive with your personal health maintenance.

Source: AIN