A ircraft pilots of all levels of training require varying levels of medical evaluation in order to function as a required crew member. 1, 2 Airmen medical certification must be reviewed at defined intervals and pilots are required to disclose new medical conditions or changes to their health status to their physician. 1, 2 The frequency of regular medical assessment by a Federal Aviation Administration (FAA) designated Aviation Medical Examiner (AME) to maintain a valid medical certificate depends on the age of the pilot and the type of pilot certificate. If pilots are unable to renew their medical certification due to a change in their health status, they may legally lose their flying privileges. 2, 3 For some pilots, this means loss of a valuable hobby but for others this means the end of a career or an extended gap in flight time, which could require additional training. 1 T he FAA deems a variety of medical conditions as disqualifying for medical certificate. 2 An AME must automatically deny or defer a medical certificate to a pilot with symptomatic cardiovascular disease (treated or untreated angina pectoris) or a history of myocardial infarction. 2 Further, if pilots experience symptoms of a medically disqualifying condition (eg, chest pain), they are required to ground themselves from flight operations until evaluation and treatment by a physician can be conducted. 3 While it is possible for the FAA to exercise discretionary authority to issue an airman medical certificate despite a medical history of a disqualifying condition, it can be a long, burdensome, and difficult administrative process. 2

The aviation community and the healthcare providers who care for this population are often aware of pilot healthcare seeking aversion due to their fear of medical certificate disqualification and loss of flying privileges. Though this may be common knowledge to some providers who care for pilots regularly, to the best of our knowledge, there has been no major survey completed on civilian pilots in the United States about their approach to seeking medical care for symptomatic cardiovascular disease and their anxiety over losing their flying privileges. This is significant as cardiovascular disease is common, 4 delayed presentation during a true myocardial infarction has poorer outcomes, 5, 6 and data will likely be a primary driver for any future FAA policy changes. Some smaller studies have previously suggested military pilot healthcare aversion: a 2006 study surveying 325 Israeli military pilots showed 70.9% of pilots who experienced a clinical symptom listed on a health screening questionnaire did not seek medical care. 7 Of those who did seek medical advice, they were more likely to seek advice from a non-physician healthcare provider (ie, dentist, alternative medicine, etc) than a physician. 7 Another study showed 55.5%(n ¼151) of surveyed US Air Force aircrew members did not seek medical attention for upper respiratory infections (URI), which can cause disequilibrium and disorientation in flight. 8 The authors suggested a more rigorous health screening program should be considered for pilots because current programs require pilots to self-identify a symptom or condition. Authors of a 1996 study showed cardiac events in US Air Force pilots increased with age and advocated for more aggressive screening in hopes of decreasing the risk of a cardiac event while a pilot is operating an