Steinkraus LW, Rayman RB, Butler WP, Marsh RW, Ercoline W, Cowl CT. Aeromedical decision making—it may be time for a paradigm change. Aviat Space Environ Med 2012; 83:1006–7.Recent events in the U-2 and F-22 fleets have challenged aeromedical experts, highlighting the need for better in-flight aircrew physiologic and cognitive monitoring capability. Existing aerospace medicine risk assessment tools, while necessary, are no longer sufficient to affect positive safety changes given the evolving nature of the aerospace environment. Cognition and its sub-elements are now primary measures for the “Fit to Fly” decision. We must investigate practical methodologies for determining dynamic aircrew physiologic and cognitive function preflight (selection, retention) and in-flight (selection, retention, performance enhancement). In 2010, a panel of aeromedical experts met to address current paradigms and suggest possible solutions. This commentary briefly summarizes panel findings and recommendations.