SS 22 : What is Aerospace Medicine? Dr. Gray is Interviewed

Session 22

Aerospace Medicine is a subspecialty of Preventive Medicine and very unique usually to the military, though there are civilians equivalents.

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Back to today's episode, I will be interviewed by Ian Drummond, a fourth year medical student and the host of The Undifferentiated Medical Student podcast. Ian interviewed me back in Episode 24 of his podcast about aerospace medicine and I'm playing a part of his interview with me specifically relating to aerospace medicine.

[03:29] What is Aerospace Medicine?

AAMC's Careers in Medicine didn't actually have a description of aerospace medicine although it was listed under Preventive Medicine. Ian, however, will refer to this description provided by the Aerospace Medical Association and we will take it from there.

“Aerospace medicine concerns the determination and maintenance of the health, safety, and performance of persons involved in air and space travel. Aerospace Medicine, as a broad field of endeavor, offers dynamic challenges and opportunities for physicians, nurses, physiologists, bioenvironmental engineers, industrial hygienists, environmental health practitioners, human factors specialists, psychologists, physician assistants, and other professionals. Those in the field are dedicated to enhancing health, promoting safety, and improving performance of individuals who work or travel in unusual environments. The environments of space and aviation provide significant challenges, such as microgravity, radiation exposure, G-forces, emergency ejection injuries, and hypoxic conditions, for those embarking in their exploration. Areas of interest range from space and atmospheric flight to undersea activities. The environments studied cover a wide spectrum extending from the microenvironments of space to the increased pressures of undersea activities. Increased knowledge of these unique environments of “Spaceship Earth” helps aerospace medicine professionals ensure participants are physically prepared, physiologically safe, and perform at the highest levels.”

[05:28] Building Trust and Relationships with Patients

I agree with all of it as a great representation from the organization. One of the biggest things missing which is unique to aerospace medicine is the relationships with patients. In fact, it is a huge factor in aerospace medicine which I think deserves its own call out there.

I will speak specifically to the Air Force although it's pretty similar for the army and navy which also have civilian flight surgeons. There are AME‘s (Aviation Medical Examiner) out in the real world that do physical exams for pilots. There is a civilian equivalent, just a little bit different for the military.

For the military, specifically for pilots, they usually go and see the flight surgeon for a few things. One is the mandatory annual physical examination (crossing their fingers that nothing is found). Second, if something is really wrong and they need help.

Typically, a pilot doesn't want to go and see the flight surgeon outside of those two things because every visit to the flight surgeon is an opportunity to lose their wings, which means they would no longer be able to fly. Because a flight surgeon has that control to make sure pilots and other people interacting with aircraft are safe operating the aircraft, it's their job to make sure that if they have any medical condition, we have to determine if they should continue flying or not.

As a flight surgeon, I was a rated flyer where I got to wear a flight suit and had wings. I was required to fly four hours a month to be part of the air crew to build that rapport and build that trust. I went for an MRI one day because I was having some symptoms and I got diagnosed with MS so eventually I was no longer allowed to go up in an airplane for the Air Force. Because of that fine line between being allowed to fly and have your career or you're not allowed to fly out anymore, it's such an important relationship to have that trust and rapport. It's one of the best parts about being a flight surgeon. There could be cases they're lying and hiding things from us, like a cat and mouse game, because they want to fly. They love their jobs and they love the camaraderie that comes with it and everything else so it's a large part of who they are.

Personally, I thought it was a stupid rule that I got grounded. MS is one of those weird things for aerospace medicine. The Israeli Air Force lets their pilots with MS fly. Ours is less progressive so they worry more about the cognitive decline since 75% of MS patients have some sort of cognitive deficit and that's what worries them. I did argue for a while but I lost.

[11:32] Flying the Plane

There are a couple of caveats here. In the navy, flight surgeons go through some of the pilot training courses. The army may do it like the air force where you go through a little bit of ground pilot school. For instance, they get to ride in a small Cessna plane and fly to see what it's like. The whole point of the flight surgeon is to make sure that pilot and other people can do their job so you have to understand what they're going through. Then you get to see how much there is to do.

I have my private pilot license. I have always been fascinated with airplanes so when I had the opportunity to get my private pilot license, I jumped on that.

As a flight surgeon where I had to fly four hours a month, it meant being part of the aircrew. So the majority of aircraft that I was in were bigger airplanes so I would just hang out in the back or in the cockpit but not actually controlling anything. Sometimes I would talk on the radio and help them with the radio stuff. The one time I got to fly something was in the backseat of an F-16 because the controls are right there.

When you have wings, it means you're in some way affiliated with the airplane. So it's not just the pilots, but also, load masters, navigators, flight surgeons, etc. having wings is just a designation that you're like a “real” Air Force and you're part of the plane considering there are other jobs in the air force that have nothing to do with planes (ex. bus driver, cook, etc.)

[16:08] Civilian Physician vs. Air Force Physician

When you're, say a Primary Care physician, there is almost never this thought about what job a patient does or can they continue to do it. It's usually the patient that asks for some time off because they don't want to work. But as a flight surgeon, that's always the first question at the top of my mind. I have to know what your job is and whether or not you can continue to do it. So if you're a pilot and you come in with a knee pain and I know that if an engine goes out and you need to push full rudder to keep the plane straight and land it, you're probable not going to be able to do that with how bad your knee is. So you can be grounded for a week or two to make sure your knees are better and then come back and see me to reevaluate.

*There is no such term as a “flight surgery” but it's an old name that's been held out for a long time. The actual practice is aerospace medicine and there are aerospace medicine residencies but you are a “flight surgeon” as an aerospace medicine specialist. There is flying but there is no surgery and there's definitely no surgery while flying.

[18:44] A Typical Weekly Routine and Patient Types

A typical week for a flight surgeon is an ambulatory setting where you're seeing patients depending on what based your stationed at as an active duty flight surgeon. In some bases, you see dependents (the family members of the active duty member) while in others, you see retirees. So the types of patients you're seeing vary but you're seeing normal clinical stuff.

You're seeing a lot of occupational health visits. When a pilot comes in for their annual flight physical exam, it's an occupational physical where you check their vision, hearing, and other things making sure their healthy. But a lot of them are occupational-based which means making sure they meet the qualifications for continued flying. If seeing dependents and retirees, flight surgeons are basically a family practice physician so family members are treated for normal aches, pains, and colds, etc.

Depending on where you're at, 50% is seeing patients and another 50% is hanging out with air crew and building rapport, doing “shop visits.” As a flight surgeon, you're an occupational health physician so if your base has airplanes and you're visiting the flying squadron to make sure things look good there and the facilities are clean. You go to the maintenance squadron and make sure people working on the airplanes are keeping a clean environment and not working with lead-based paint and bring it into their offices and where they eat. You're simply making sure the base stays healthy. So you're basically outside of the clinic a lot of times and interacting with the rest of the base population which keeps things varied and you get a lot of diversity.

When you go to site visits, it's like carrying a clipboard with a checklist like making sure they keep separate wipes for their masks or have separate sinks for different things. So a lot of the things are structured that way while some of it is just using your intuition and question-asking skills. Usually, you go out with a team consisting of public health or bio environmental engineering while you're focused on the health side So it's a very collaborative team-based approach.

[23:16] Flight Surgeon as a General Practitioner

50% of the time, a flight surgeon is basically a practitioner except of the military. Also, a large majority of flight surgeons are general practitioners which means they're only internship-trained. This is the way the Air Force gets flight surgeons wherein a lot of them are fresh out of their internship. There are also a lot of flight surgeons with residency training, like OB/GYN, Orthopedics, Family Medicine, or Internal Medicine. You can actually have any specialty and be a flight surgeon if you choose to. And if you have specialty training and become a flight surgeon, you have to go through all the aerospace medicine training before becoming a flight surgeon because it's unique and different.

Aerospace medicine is a subspecialty available to everyone in the military. They usually need flight surgeons so there are several physicians that jump ship from their specialty and subspecialty and come over to the aerospace medicine world.

[24:50] Patient Outcomes

Typical outcomes would be just like a family practice doctor where you're seeing people with their aches and pains, sniffles, and flu so you're treating an acute thing for a week or two and grounding them for a week or two and then they come and see you and things are better.

Although there are also some unique things that could happen like somebody losing their vision or has a random new diagnosis. There are a lot of bad things that can happen to cause somebody to lose their wings. As a flight surgeon, you also take care of firefighters, which is another big occupational health job.

The outcomes are usually normal healthy people but when you get those random diagnosis, it's a life-changer.

[26:23] Most Exciting and Most Mundane about Aerospace Medicine

The most exciting is being able to go out and be part of the aircrew and fly around the world or fly an F-16 or do all sorts of missions, experiencing what the rest of the base is doing. Conversely, the most mundane part is dealing with normal aches and pains like dealing with blood pressure management or diabetes management, basically the boring normal doctor stuff.

[27:10] Wish I've Known About the Specialty

When I got the call to say I was going to be a flight surgeon, I didn't know what it was. When I was in it and now that I'm out of it, I don't think there's really anything that I had wished I had known about other than I wish I would have known about it.

Consider doing aerospace medicine especially those who are on an HPSP scholarship. It's an amazing job and there are so many things you can do. Even if you're interested in a specialty, go be a flight surgeon for a couple of years and then go live the rest of your life. The stories I can tell now, having been a flight surgeon, are going to stay with me forever.

[28:40] What is HPSP Scholarship?

HPSP refers to Health Professions Scholarship Program that offers about 150 scholarships a year where you get into medical school and you apply for the scholarship. Once you get accepted, they pay for medical school and then you owe them a year for a year of scholarship, where you can do a 3-year or 4-year scholarship.

[29:28] Combat, Non-Combat, and AME's

Because it's more of a military-based career, I will divide this into a non-combat and combat.

As a non-combat flight surgeon, depending on where you're stationed, you can be stationed anywhere throughout the world. You can be stationed at a place without planes. But majority of your job is to make sure that the population of that base is healthy. It's always an ambulatory setting. There would be no need for an in-patient hospital-based flight surgeon.

When you're deployed in a combat setting, you can run different parts of the medical evacuation triage tents and stations along the way. When somebody gets injured in combat, they're evaluated and triaged to see if they need to be evacuated out to a bigger hospital or if they can just be treated where they are. As flight surgeon doing that evaluation and determining what kind of aircraft they need to fly on, meaning is this an injury that is going to get worse at altitude or do they need at low altitude, do they need to be in a helicopter and stay low or stay in an unpressurized aircraft at a low altitude. So you're basically doing a lot of cool triage in trying to figure out what's best for the patient based on aircraft, altitude, and other things.

An AME is an Aviation Medical Examiner, a designation where you get certified through the FAA. As an AME, you're usually a family practice doctor or an internal medicine doctor or somebody interested in aviation. It's a cool job because it's usually a cash-based business. You can see Class 1, 2, and 3 pilots which need a certain number of physical exams depending on the class. You have to go through FAA training which is free. The population of AME's has significantly decreased over time so it's now getting more difficult for pilots to find an AME and get their physical exams. An AME is very similar to a flight surgeon where there are strict guidelines that determine whether or not you're able to fly and bases your evaluation on those guidelines and makes recommendations based on that. FAA training is not the same as an aerospace medicine residency. It's a week to two-week long course that the FAA puts on.

You can be a flight surgeon at NASA. I've been down to the space center in Houston and visited the world's largest swimming pool where the astronauts do all their training for weightlessness. And as a flight surgeon in the air force, I did see people that wanted to be astronauts and I would do their initial physical exams before they would go down to Houston to get their full physical.

[36:15] Pilot Physician

Moreover, you could be a Pilot-Physician of which the Air Force gives 20 spots. A student I'm working with is in the Air Force right now and wants to go back to medical school but she's also a pilot, not in the Air Force but she is a private pilot with 600 hours and she flew with the academy on their stunt team.

They typical path for a pilot physician is you're a pilot and if for some reason you get interested in medicine and you go to medical school and you still want to be in the military, you become a pilot physician. So you're a physician first but you have the pilot training and usually, you're doing a lot more higher level things than just seeing patients in a clinic but you're looking at a lot of the regulations being written, research into new technologies, etc. Since there are only 20 slots in the Air Force, it's a highly sought-after position and because there are not enough pilots are going on to be physicians, they're looking for physicians that may be interested in going into pilot training through the air force to be pilot physicians. I did look into this but I didn't pass the age requirement. I was too old to start since 29 is the oldest to start the training and I was already 30 or 31.

The Air Force is taking any physician but you obviously have to go through their aerospace medicine training at some point. The unique thing a pilot physician offers is the research and more of having the deep knowledge base and foundation of having both careers under your belt and being able to make those regulations and see things from both sides.

[39:56] The Biggest Challenge and the Future of Aerospace Medicine

One of the biggest challenges of aerospace medicine is that a lot of people don't understand us so there is much pressure for us to start doing more and seeing different types of patients. Apparently, there is a lot of misunderstanding from the greater Air Force of what our job is.

What the future holds for aerospace medicine in 10-20 years would be that as we go to more and more autonomous aircraft, where we have drones, majority now are remotely piloted. They are not unmanned aircraft, they're manned, just in a different location. Because of that, interest in aerospace medicine will go down. Part of the lure is being able to go fly and so why would you be doing it if there is no plane to fly. There could also be unique psychological challenges that come into play for drone pilots. We're going to fighter planes (F-22 and F-35) that are only single-seat planes, which means the flight surgeon can't go up there and the less experience they get. There will be the heavier aircraft like the C-5 and C-17 and re-fuelers.

[44:35] Final Words

Aerospace medicine is an awesome and great job! Although pretty much specific to the military, there are civilian residencies for aerospace medicine. For this podcast, I'm not going to dive into all medical specialties in the military for two reasons. First, the practice of Pediatrics in the military is not very different than pediatrics in the civilian world and really, there aren't that many military premeds out there to warrant individual episodes. I'm a huge advocate for doing the military to pay for medical school and to serve but I don't think I'm going to dive into it here on the Specialty Stories.

Links:

The Undifferentiated Medical Student

The Undifferentiated Medical Student Episode 24: Aerospace Medicine with Dr. Ryan Gray

Careers in Medicine

Aerospace Medical Association

HPSP

FAA AME training

Pilot-Physician

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