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 is concerned with 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. Flight surgeons have the control to make sure pilots and other people interacting with aircraft are safely operating the aircraft. It's flight surgeons' job to make sure that if military personnel have any medical conditions, 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. 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 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 where patients are lying and hiding things from doctors, like a cat and mouse game, because they want to keep flying. They love their jobs, they love the camaraderie that comes with it, and everything else; so the job 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. 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 I had to fly four hours a month. It meant being part of the aircrew. 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 a designation that you're “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 a 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. 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 base 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 they are 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% of your time 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. You're outside of the clinic a lot of the time 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. 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. 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 in 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, 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, grounding them for a week or two, and then they come and see you and things are better.
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 thing 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. Then you owe them a year for each year of scholarship. 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, 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 you have to do that evaluation and determine 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 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. Flight surgeons base patient evaluations on those guidelines and make 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 for some reason you get interested in medicine, 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. 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. Because there are not enough pilots that 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 takes 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 experience, having a deep knowledge base, the foundation of having both careers under your belt, 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, 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.
Dr. Ryan Gray: Specialty Stories, session number 22.
Whether you’re a premed or a medical student, you've answered the calling to become a physician. Soon you'll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Welcome to the Specialty Stories Podcast. My name is Dr. Ryan Gray, your host here as well as many other podcast. Check out everything that I do, we do at www.MedEdMedia.com. If you're a premed student and you are getting ready to prepare for your medical school interviews, or if you're not going to prepare for them for a year or two, go check out ‘The Premed Playbook: Guide to the Medical School Interview.' It is being released in paperback form on June 6, 2017 and right now I have a pre-order special where you can get about $100 worth of goodies, freebies if you pre-order the Barnes and Noble paperback copy.
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Alright, onto today's show. Today's show is going to be a little bit different, it's a little crossover type show. I am actually being interviewed by Ian Drummond who's a fourth year medical student who is the host of The Undifferentiated Medical Student, and Ian interviewed me back in episode 24 of his podcast all about aerospace medicine. Now if you haven't heard Ian's podcast, you should. Again The Undifferentiated Medical Student is the podcast at www.UndifferentiatedMedicalStudent.com. Again the episode I was in is episode 24. Ian's interview is a little bit different than mine for Specialty Stories, so what I'm going to do, is I'm going to play just a part of his interview with me, the part that relates specifically to aerospace medicine. If you want to go listen to the whole episode, again go check it out, www.UndifferentiatedMedicalStudent.com and it's episode 24. So I hope you enjoy this episode, again with Ian Drummond from The Undifferentiated Medical Student.
Learning about Aerospace Medicine
Ian Drummond: Now is a perfect time to transition to the first part of the interview where I basically ask you to tell us everything about aerospace medicine, and the way I like to start this part of the interview is usually to read you a description from the Careers in Medicine website which is hosted by the AAMC, but in this case the Careers in Medicine website actually didn't have a description of aerospace medicine. It had listed aerospace medicine under preventative medicine, but it didn't have a link to it with the usual description of the specialty. So you helped me find one from the Aerospace Medical Association which is at www.ASMA.org if other people want to go look it up. So I'm going to read that, and then I'm going to ask you what you think of that description and then we'll take it from there.
‘Aerospace medicine: a sub-specialty of preventative medicine. 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 and endeavor offers dynamic challenges and opportunities for physicians, nurses, psychologists, bioenvironmental engineers, industrial hygienists, environmental health practitioners, human factors specialists, psychologists, physicians' 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 on their exploration. Areas of interest range from space and atmospheric flight to undersea activities. The environments studied over a wide spectrum extending from the microenvironments of space to the increased pressures of undersea. 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.'
How much of that do you agree with and what would you add or subtract to ensure that anyone listening was well-informed about aerospace medicine?
Dr. Ryan Gray: I agree with all of it. It's a great representation obviously from the organization that kind of runs-
Ian Drummond: Right from the source. I'm glad to hear that.
Importance of Relationships
Dr. Ryan Gray: Yeah, right from the source. I think one of the biggest things that is missing which is unique to aerospace medicine is the relationships with patients is such a huge factor in aerospace medicine that I think it deserves its own kind of call out there as well.
Ian Drummond: Can you give me an example of that? I mean many specialties have relationships, but why would it be that these relationships are extra important in aerospace medicine?
Dr. Ryan Gray: So as an aerospace medicine physician, as a flight surgeon- and I'll speak specifically to the Air Force because that's my experience, but it's similar for the Army and Navy, and they do have civilian flight surgeons. You can have AMEs out in the real world that do physicals for airline pilots and other pilots as well. So there is a civilian equivalence, it's a little bit different for the military. But for the military, specifically for pilots- let's just talk about pilots to make the conversation easier. A pilot, when they go and see the flight surgeon, they usually are seeing the flight surgeon for one of a few things. One, it's their mandatory kind of annual physical, and they're crossing their fingers that nothing is found. Or two, something is really wrong and they need help. A pilot doesn't typically want to go see the flight surgeon outside of those two things, because every visit to the flight surgeon is an opportunity to lose their wings. And by lose their wings, I mean no longer be able to fly. And so because a flight surgeon has that control, and it's not that they want the control, it's just our job to make sure that pilots and other people that are interacting with the aircraft, make sure that they're safe operating that aircraft. And so it's our job to make sure that if they have a medical condition, we need to determine if they should continue flying or not. And just a brief kind of side story for my story, I experienced this as a flight surgeon, I was a rated flyer, I got to wear a flight suit and had wings, and I was required to fly four hours a month to be part of the air crew to build that rapport, build that trust. I went for an MRI one day because I was having some weird symptoms, and a diagnosis of MS a little bit later, I was no longer allowed to go up in an airplane for the Air Force.
Ian Drummond: Oh wow.
Dr. Ryan Gray: So because there's that fine line between you're allowed to fly and have your career, or you're not allowed to fly anymore, let's figure out something else for you, it's such an important relationship to have that trust, have that rapport, and it's one of the best parts about being a flight surgeon.
Ian Drummond: Oh man, yeah so I can see how trust is extra important. Because I imagine that they probably hide things from you unless they-
Dr. Ryan Gray: They do hide things from us, and it's a cat and mouse game. It's like Dr. House in ‘House' the TV show, it's patients always lie. Yeah well kind of in the aerospace medicine world, they probably are because they want to- flying is weird. Pilots, and navigators, and load masters, and everybody else that's on the plane, and working on the plane, they love their jobs and they love the comradery that comes with it, and everything else, and it's a huge part of who they are.
Ian Drummond: Very interesting dynamics, and I didn't realize that's how you discovered that you had MS, which by the way I hope is a mild case and remits frequently.
Dr. Ryan Gray: Thanks.
Ian Drummond: But I'm sure that sucked to be pulled, to have your wings pulled from you.
Dr. Ryan Gray: Yeah, you're grounding the flight doc? Like how dare you. I was kind of pissed. Like you can't ground me, I'm the flight doc. But yeah, it's a hard thing but it is what it is. I personally thought it was a stupid rule for me. It's interesting, MS is one of those weird things for aerospace medicine. The Israeli Air Force is a little bit more progressive than we are and they let pilots fly with MS. Our Air Force is a little bit less progressive and they worry more about the cognitive decline. It's like 75% of MS patients have some sort of cognitive deficit, and so I think that's what our military worries about, less so than whether you have any sensory motor deficits. Obviously you still need to be able to fly the plane, but for me I'm like, “I'm the flight doc. I'm not flying the plane, I'm just hanging out, and building rapport, and building these people's trust.” So yeah it was- I argued for a while but I lost that argument.
Ian Drummond: Bummer, sorry to hear that.
Dr. Ryan Gray: That's alright.
Flight Surgeons Learning to Pilot Planes
Ian Drummond: So now that we're actually talking about it, one question I have is do flight surgeons- when you say you were up there flying, were you actually piloting the plane or were you just up there in the backseat? And do flight surgeons actually learn to pilot?
Dr. Ryan Gray: There are a couple caveats. In the Navy, flight surgeons typically go through some of the pilot training courses that the pilots go through, so they're trained a little bit more. The Army I don't think does that, and the Air Force does it a little bit- and the Army may do it like the Air Force where you go through a little bit of ground training, ground pilot school, and it's just part of the exposure to say, ‘Hey this is what pilots are going through. Let's go up in a small little Cessna type plane and go fly, and you can fly and see what that's like.' Because again, the whole point of a flight surgeon is to make sure that pilots and other people can do their job if they have a cold, or if they have a knee sprain, or whatever. So you have to understand what they're going through. And so they throw you up in a plane, they give you some ground training, and throw you up in a plane with an instructor pilot, and you fly around in a little plane and you see how much there is to do. It's a lot of overload.
Ian Drummond: Yeah.
Dr. Ryan Gray: I have my private pilot, I got my private pilot, I've always been fascinated with airplanes, and so when I had the opportunity to get my private pilot I jumped on that.
Ian Drummond: Nice, I would love to do that.
Dr. Ryan Gray: Yeah it's awesome. When I say that as a flight surgeon I had to fly four hours a month, that's usually I'm referring to just being part of the air crew. And so the majority of aircrafts that I was in are bigger airplanes, and so I would just kind of hang out in the back, or you're hanging out 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 did get to fly something, I was in the backseat of an F-16, and because the controls are right there, it's a little bit less weird than a pilot in a bigger airplane getting up and out of the way so that you can sit down. Because if anything were to happen, then you'd have to get up, and so it's a lot less to worry about in a fighter jet, that because you have the controls there, and the pilot's still there and he has controls, so I got to pilot an F-16, so that was pretty cool.
Ian Drummond: So you're basically a fighter pilot. At least you get to say that.
Dr. Ryan Gray: I'm basically a fighter pilot. I have a selfie of me in a fighter jet, so that's what I lead with.
Ian Drummond: I am so jealous. That's awesome. So just a quick clarifying tangential question is that so when you say that you have wings, that can mean either you have wings to actually fly the plane yourself, or you have wings to be allowed in the aircraft even as a passenger?
Dr. Ryan Gray: Yeah so wings- when you have wings you're either- it means you're rated- I guess you can be nonrated and have wings. It means that you are in some way affiliated with the airplane. Pilots have wings, load masters have wings, navigators have wings, flight surgeons have wings. Who else has wings?
Ian Drummond: I see so it's not just the pilots.
Dr. Ryan Gray: It's not just the pilots. Yeah having wings is just a designation that you're kind of like the real Air Force. You're like part of the plane. Because in the kind of civilian world, if you tell somebody that you're in the Air Force it's like, “Oh you fly airplanes?” It's like, “Well no I drive a bus, or I'm a cook, or I'm a doctor,” or whatever. Like the Air Force is just a big corporation that has lots of jobs, and a very small percentage of those people actually have wings and fly and do all that stuff. So it's a fun misconception out on the outside world.
Ian Drummond: Yeah and I've definitely from the outside world. Well great, that was phenomenal. I didn't know any of that, so I'm glad we clarified that. And I'll just say I was doing some reading online, and the four hours that you were referring to, I think this was actually on the Navy website that I was reading that you're required to do these four hour not operations, but have four hours with the squadron they were saying- but basically for the reason that you initially were talking about, like the trust. Not only trust but you have to know what they're experiencing, and that's why they have you do at least four hours.
Dr. Ryan Gray: Yeah. So one of the reasons kind of I initially mentioned the difference between a civilian physician who's seeing a patient- let's talk about a primary care doctor. Their patient comes in with lower back pain, or knee pain, and it's like, “Okay great, go to physical therapy,” and there's usually almost never any sort of thought about what job does this person do?
Ian Drummond: Yeah.
Dr. Ryan Gray: Can they continue to do it? Usually the person is asking for some time off because they don't want to work, that's a different story. But in the military as a flight surgeon, that's always the first question at the top of my mind. Yes I care about the knee pain, I care about the back pain, let's think about that and get you better, but I have to know what your job is, and whether or not you can continue to do it.
Ian Drummond: Yeah.
Dr. Ryan Gray: So if you come in with knee pain and you're a pilot, and I know that if an engine goes out, and you need to push full rudder to keep the plane straight and land it, that you're probably not going to be able to do that with how bad your knee is, let's ground you for a week or two, make sure your knee is better, come back and see me, and we'll re-evaluate.
Ian Drummond: Got it. Thank you for that. So if you have nothing else to add off the top of your head, I'll just dive into my first question.
Dr. Ryan Gray: Let's go.
Flight Surgeons in Aerospace Medicine
Ian Drummond: So you are- actually one more clarifying question. If you- I just want to see how the terms flight surgeon and aerospace medicine relate. So is someone who practices aerospace medicine necessarily a flight surgeon? And is a flight surgeon necessarily someone who has training in aerospace medicine?
Dr. Ryan Gray: Yes and yes. As far as I know.
Ian Drummond: Okay.
Dr. Ryan Gray: There may be some random caveats, but yeah it's interesting. There is no such thing as flight surgery.
Ian Drummond: Right.
Dr. Ryan Gray: A flight surgeon is just an old cool name that has held out for a long time, and the actual practice is aerospace medicine, and there are aerospace medicine residencies, but you are a flight surgeon as an aerospace medicine specialist.
Ian Drummond: Got it. So there is flying but there is no surgery, and there's definitely no surgery while flying.
Dr. Ryan Gray: Yes. The only people operating on airplanes are mechanics.
Ian Drummond: Okay, important clarification because I didn't quite realize that was the case when I first started looking at this stuff. Alright so my first question is- and this is going to be for you in the context of an Air Force flight surgeon. What does a typical weekly routine look like, or did a typical weekly routine look like for you? What is a typical series of patients that you would see? And what would be a typical series of outcomes for these patients?
Dr. Ryan Gray: So a typical week would look like any other specialty, an office-based specialty. So ambulatory setting. You're seeing patients, and it depends on what base you're stationed at as an active duty flight surgeon. Some bases you see dependents meaning the family members of the active duty member, some bases you see retirees, so it depends a little bit on the types of patients you're seeing, but you're seeing normal clinical stuff. You're seeing a lot of occupational health visits. So when a pilot comes in for their annual flight physical, it's an occupational physical. We're checking their vision, we're checking their hearing, we're checking other things and making sure they're obviously healthy otherwise. But a lot of it is just more occupational based making sure that they meet the qualifications for continued flying. If we're seeing dependents and retirees, we're basically a family practice person, a family practice physician, and so we're treating family members for normal aches, and pains, and colds, and other stuff that a family practice physician would be seeing patients for. A flight surgeon is a cool job because depending on where you're at, the majority of your time- or I guess it's about 50/50. 50% seeing patients and 50% hanging out with air crew, and building that rapport, and doing what's called shop visits. You're an occupational health physician as a flight surgeon, and so you're visiting- if you're at a base that has airplanes, then you're visiting the flying squadron to make sure things look good there, and things are clean, the facilities are clean, you're going to the maintenance squadron and making sure that people that are working on the airplanes are keeping a clean environment, and not working with lead-based paint, and bringing that into their offices, and where they eat, and other things. And so you're just making sure that the base is staying healthy. And so a lot of times you're outside of the clinic and interacting with the rest of the base population which is pretty fun. It keeps things very varied and so you get a lot of diversity which is pretty cool.
Ian Drummond: Yeah definitely a lot of activities, or at least you get to observe them. When you go to these site visits, do you just have like a clipboard with a checklist and be like, “Okay no oil on the ground. Or no lead paints.”
Dr. Ryan Gray: Yeah so a lot of them are very structured like that, and it's like, “Okay they keep separate wipes for their masks, or they have separate sinks for different things,” and so yeah a lot of it is very structured in that way, and some of it's just using your normal intuition and question asking skills that you learn as a physician, and just trying to inquire about things, and as a physician you have unique skills of looking into things, and asking questions, and kind of digging down deeper, so you use that as well.
Ian Drummond: I can see that. So you're rarely ever doing the work, you're just really in the background observing how others do the work.
Dr. Ryan Gray: Yeah we're not doing the work of what the actual shop is doing, but we're evaluating, and usually I go out with a team. So I would have gone out with public health, or bioenvironmental engineering. They also help keep the base population healthy, and so they have their questions that they're asking, and I'm observing, and I'm following up with different questions more focused on the health side and the medicine side. So it's a very collaborative team-based approach when you go out to do these things.
The Military’s General Practitioner
Ian Drummond: So taking you back to the clinical side of what you do, the ambulatory care, is it fair to say- and you used the term ‘family medicine doc.' Is it fair to say that a flight surgeon then at least 50% of the time is basically a general practitioner except of the military?
Dr. Ryan Gray: Yeah. Yeah exactly, and the large majority of flight surgeons are general practitioners, meaning they're only internship trained. That's the way that the Air Force kind of gets flight surgeons, is what happened in my path, and we'll dig into that. But a lot of flight surgeons are fresh out of their internship. There are a lot of flight surgeons that have a residency training, whether it's OBGYN, or orthopedics, or family practice, or internal medicine. You can have any specialty and go and be a flight surgeon if you choose to.
Ian Drummond: I see. But does that- let's say if you have OBGYN training and you become a flight surgeon, do you have to go through all of the aerospace medicine training before you're the flight surgeon?
Dr. Ryan Gray: Oh yeah, oh yeah because it's so unique and different.
Ian Drummond: Okay so it sounds like aerospace medicine is a sub-specialty that's available to everyone, and I think on the Careers in Medicine website it just said you needed to do a preliminary year, an intern year.
Dr. Ryan Gray: It's available to everyone in the military, yeah.
Ian Drummond: Okay, got it.
Dr. Ryan Gray: Yeah if you want to do that, they always usually need flight surgeons, and so we get a lot of physicians that would jump ship from their specialty- family practice or their sub-specialty, and come over to the flight medicine world.
Ian Drummond: Got it. And so what is a typical outcome for this typical patient, which sounds like it could be any type of patient. Are there any interesting outcomes? I mean I think one that you've already mentioned is well, you had to tell the pilot with a certain condition that the condition would result in him losing his wings, or her losing her wings. Any other sort of typical outcomes for these patients?
Dr. Ryan Gray: Not really. Typical outcome is going to be just like a family practice doc. You're going to see people with their aches, and pains, and sniffles, and flus, and so you're treating that acute thing for a week or two, and maybe grounding them for a week or two, and they come back and see you, and things are better. But there are lots of unique things if somebody is losing their vision, or has a random new diagnosis, then yeah there are a lot of bad things that can happen obviously to cause somebody to lose their wings, or as a flight surgeon you also take care of usually firefighters because that's another big occupational health job, and so you're telling somebody they're not qualified to be a firefighter anymore, which is almost worse than telling a pilot they can't fly anymore. Firefighters are very passionate, and so it's definitely- the outcomes are normal, usually normal healthy people, but then when you get those random diagnoses it's a life changer.
Ian Drummond: Yeah I'm just trying to relate it to I guess other fields, and it really sounds like what you do, it's very similar to family medicine.
Dr. Ryan Gray: Yeah it would be closest to family medicine.
Exciting Aspects of Aerospace Medicine
Ian Drummond: Very cool, thank you. What do you find most exciting about being a flight surgeon or being involved in aerospace medicine? And conversely, what do you find most mundane about aerospace medicine that you tolerated to experience the more exciting aspects of it?
Dr. Ryan Gray: So obviously the most exciting is being able to go out and be part of the air crew and go fly around the world, or fly an F-16, or go do those sorts of missions, going out and experiencing what the rest of the base is doing is pretty exciting. So I think that's the most exciting part. The most mundane part is dealing with again, normal aches and pains. The kind of boring patients if you have those, dealing with somebody coming in with their high blood pressure and trying to manage that, or their diabetes and trying to manage that. It's just the boring normal doctor stuff.
Ian Drummond: Got it. What is one thing you wish you had known about your specialty before entering it?
Dr. Ryan Gray: I wish I would have known about it.
Ian Drummond: Yeah.
Dr. Ryan Gray: Again we'll get into that I guess in the second part, but yeah when I got the call to say I was going to be a flight surgeon I was like, “What the hell is that?” So yeah I don't think there's really anything now that I'm out of it when I was in it that I was like, “Man I wish I would have known about this,” other than I wish I would have known about it.
Advice to Medical Students
Ian Drummond: Yeah. Then is there anything that you would recommend that medical students consider in earnest before pursuing aerospace medicine?
Dr. Ryan Gray: I would consider them to do it, especially those that are on an HPSP scholarship or at the University of Health Sciences, the US medical school. I think as a flight surgeon it's an amazing job, and there's so many things that you can do that I highly recommend it. Even if you're interested in a specialty, go be a flight surgeon for a couple years, and then go live the rest of your life because the stories that I can tell now having been a flight surgeon are going to stay with me forever.
Ian Drummond: Yeah it sounds pretty cool. For everyone listening, but also me, can you tell me what an HPSP scholarship is?
Dr. Ryan Gray: HPSP is Health Profession Scholarship Program. So it's the program- Ian I'm sure when you got your acceptance to medical school it's like, “Okay great and how much are the loans now?”
Ian Drummond: Yup.
Dr. Ryan Gray: So instead of asking that question I went to the Air Force recruiter. I said, “Here you pay for it.”
Ian Drummond: Got it.
Dr. Ryan Gray: So it's a program, it's about 150 scholarships a year that they offer, and basically you get into medical school, and you apply for the HPSP scholarship, and they accept you or not accept you, and they pay for medical school, and then you owe them- it's a year for a year. So you can do a four year or three year scholarship.
Aerospace Medicine Settings
Ian Drummond: Very cool. So here's one of my favorite questions, and I think we've covered parts of it already, but how does the practice of aerospace medicine change depending on setting? For example in-patient versus out-patient, academic versus private versus public, urban versus suburban versus rural, civilian versus governmental versus military, and then even national versus international.
Dr. Ryan Gray: So I think for the purposes of the uniqueness of aerospace medicine because it's more of a military based career, I'll divide the two into more kind of non-combat, and combat.
Ian Drummond: Okay.
Dr. Ryan Gray: So as a flight surgeon you're- depending on where you're stationed, you can be stationed anywhere throughout the world. You can be stationed at a place without planes, I was stationed at a base with no planes which is kind of weird for a flight surgeon. But the majority of your job is making sure that the population of that base is healthy, making sure that the population of the pilots and everybody else that's interacting with airplanes is healthy. It's always an ambulatory setting, there would be no need for an in-patient hospital-based flight surgeon. And so that's the kind of non-combat. And then you can have when you're deployed in more of a combat setting, you can run as a flight surgeon different parts of the evacuation- medical evacuation triage kind of tents, and stations along the way. So when somebody gets injured in combat, they're evaluated and triaged to see if they need to be evac'd out to more of a bigger hospital, or if they can be just treated where they are, or if they need to be sent to like Germany to a big hospital. And it's usually a flight surgeon that is doing that evaluation, and then determining what kind of aircraft do they need to fly on? Is this an injury that is going to get worse at altitude? Or do they need to stay 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 doing a lot of cool kind of triage and trying to figure out what's best for the patient based on aircraft, and altitude, and other things. So I think those are the two biggest distinguishers for aerospace medicine.
Ian Drummond: Great, thank you for that. But at some point I think you mentioned that you can go into aerospace medicine outside of the military. So what does that look like? And then you said that commercial airliners have AMEs?
Dr. Ryan Gray: Yeah so an AME is an Aerospace Medical Examiner I think is the term. It's a designation you get certified through the FAA, at least here in the states. Or Aeromedical Medical Examiner. Something along those lines, I don't know.
Ian Drummond: I'll put it in the show notes.
Dr. Ryan Gray: Yeah, put it in the show notes. Show notes are always the best. But so as an AME, you're usually again a family practice doc, or internal medicine doc, or somebody that's interested in aviation. And it's kind of a cool job because it's usually a cash-based business, and so you say, “Yup-” it's an Aviation Medical Examiner, that's what AME is. An Aviation Medical Examiner, I will see you for there's I think three classes; Class 1, 2, and 3. Airplane pilots are Class 1 pilots, they need physicals it's like every six months or something. And then there's Class 2, and Class 3, depending on the designation. I'm not familiar with that side of it because again, I wasn't an AME. But yeah so you can be an AME, you have to go through FAA training, I believe the FAA training is free which is kind of cool because it's a governmental organization, and so they need AMEs. If you look at the population of AMEs over time it's decreased significantly, and so it's getting harder and harder for pilots to find an AME, and get their physicals, and it's very similar to a military flight surgeon. There are strict medical guidelines that determine whether or not you're able to fly, and an AME knows those guidelines, and bases your evaluation and your physical on those guidelines, and your health, and makes recommendations based on that.
Ian Drummond: Got it. And this FAA training, is that the same thing as an aerospace medicine fellowship or residency?
Dr. Ryan Gray: No, it's like a week long or two week long course that the FAA puts on.
Ian Drummond: I see, so you already have to have some aerospace medicine training and then you take the FAA training?
Dr. Ryan Gray: No you can be an internal medicine doc and have a practice and be like, “I think I want to be an AME.”
Ian Drummond: Oh, okay I see now. So what if you wanted to work at say NASA?
Dr. Ryan Gray: You could be a flight surgeon at NASA. Yeah I looked into that at one point because I was like, “That'd be pretty awesome to be an astronaut.”
Ian Drummond: Yeah can I fly with the squadron then, too?
Dr. Ryan Gray: Yeah you could, you could be- I don't know what you would do flying wise, but you could definitely- I've been down to Houston to the Space Center there and visited I think it's the world's largest or second largest swimming pool where the astronauts do all their training for weightlessness, they do it in a huge pool, so I've been there and seen that, and it's pretty awesome. So yeah, and as a flight surgeon in the Air Force, I did astronaut physicals. I would see people that wanted to be astronauts, and I would do their initial physicals before they would go down to Houston to get their full physical. So it's like, ‘That's cool, this guy wants to be an astronaut. I want to talk to him or her.'
Ian Drummond: No chance you could do your four hours of squadron hang out time in space?
Dr. Ryan Gray: Probably not.
Ian Drummond: Bummer. Very cool. Is there any other context that I haven't asked about that changes the way aerospace medicine is practiced?
Dr. Ryan Gray: The other aspect, and I think I kind of hit on it earlier but I didn't dive into it, is you could be a pilot physician which is cool. And the Air Force I think has about twenty spots to be a pilot physician, and I was actually talking with a student that I'm working with, she's 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 has her private pilot, has like 600 hours, she flew at the academy on like their like stunt team or something.
Ian Drummond: Wow.
Dr. Ryan Gray: And so I was like, “Well why don't you be a pilot physician if flying is such a big part of your life?” She was like, “I definitely will look into that.” So the typical path for a pilot physician is you're a pilot, and 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 and foremost, but you have the pilot training, and it's such a unique position, and usually you're doing a lot more higher level things, you're not just seeing patients in a clinic, but you're looking at a lot of the regulations that are being written, you're doing research into new technologies, and so that's one aspect that I didn't talk about. And because they have about twenty slots, and it's a highly sought after-
Ian Drummond: In the entire military?
Dr. Ryan Gray: In the Air Force. Because they don't have enough people filling those spots, not enough pilots are going on to be physicians surprisingly, they're looking for physicians that may be interested in going to pilot training through the Air Force to be pilot physicians. So that's a cool and unique thing. And I actually looked into it the first year that they were like, ‘Hey we're starting to offer this to physicians to go to pilot training.' I looked into it and I was too old at the time.
Ian Drummond: Oh really? What's the cut-off?
Dr. Ryan Gray: To go to pilot training you have to be- I think it's 29 at the oldest to start and I was already 30 or 31, and so I said, ‘Hey I have my private pilot, I obviously love to fly, this is pretty cool.' And they're like, ‘Yeah we're not doing age waivers.' Usually we say in the military anything is waiverable, but for some reason at that point they weren't waiving it. So the next year they were waiving it, I think if they were waiving it the year that I was interested it may be a different discussion at this point. But I think the MS would have grounded me either way.
Ian Drummond: Oh man, well either way very cool. I did not know that a pilot physician was a thing.
Dr. Ryan Gray: Yeah.
Ian Drummond: The road to get there, can you be any type of physician, or do you also need to have taken an aerospace medicine sort of fellowship?
Dr. Ryan Gray: To be a pilot physician?
Ian Drummond: Yes.
Dr. Ryan Gray: I think they were taking any physicians, but you would obviously need to go through the aerospace medicine training at some point.
Ian Drummond: And then is the unique ability that a pilot physician offers, is it in research or are there various missions that the military needs to fly where they don't have enough space on a plane or something so they want someone who can do two things? You'd be a physician and a pilot?
Dr. Ryan Gray: It's probably more of the research and more of just having the deep, 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.
Ian Drummond: Right, a deeper understanding of both sides.
Dr. Ryan Gray: Yeah.
Challenges in Aerospace Medicine
Ian Drummond: Very cool, totally insightful for me and all new for me as well. What is one of the biggest challenges facing aerospace medicine, and where do you predict your specialty will be in ten to twenty years?
Dr. Ryan Gray: Oh aerospace medicine challenges; I think always one of the biggest challenges is because we're such a unique part of the military, a lot of people don't really understand us, and so when I was talking earlier about this 50/50 kind of thing, you're seeing patients 50% of the time, a lot of times there's a lot of pressure for us to start doing more and seeing different types of patients, and help the family practice docs because they're usually overloaded, and they see the flight surgeon out gallivanting around the base, and hanging out, and flying around, and so there's probably a lot of- I don't want to say jealousy but a lot of misunderstanding of what our job is. And so I think that's the biggest challenge, is that misunderstanding from the greater Air Force behind what we do and what we are.
Ian Drummond: Are there any manifestations of this misunderstanding that are either good, bad, or neutral? Does anyone ever come up and yell at you or something? Like what happens?
Dr. Ryan Gray: Of course there's manifestations. Manifestations are your boss tells you that you're going to start seeing more patients that don't really belong to you.
Ian Drummond: I see.
Dr. Ryan Gray: Yeah so there's always a battle, and it always helps to have a boss who understands the flight medicine world, aerospace medicine world.
Ian Drummond: And so I was calling, or I was likening being a flight surgeon- or at least 50% of what the flight surgeon does to being a family practice physician. But does the military also have family practice physicians that are not flight surgeons?
Dr. Ryan Gray: Yes.
Future of Aerospace Medicine
Ian Drummond: Okay. So where do you predict your specialty will be in ten to twenty years?
Dr. Ryan Gray: Where it is now. It's not going to change much. I think the things that are changing are as we go to more and more autonomous aircrafts, autonomous in a sense where we actually have true autonomous drones, but the majority now at this point are remotely piloted. It's funny, there's always this big argument that they're not unmanned aircrafts. They are manned, they're just manned in a different location. So they're remotely piloted, RPAs, remotely piloted aircrafts. I think the interest in aerospace medicine will go down because of that, because part of the lure is being able to go fly, and when there is no plane to fly in then it's like, ‘Well why am I doing this?' So it'll be different, I think challenges are different as you get drone pilots that are ‘at war' during the day and then they're at home at night in their house. I think there are unique psychological challenges that come into play there. We're going to fighter planes, the F-22 and F-35 that are only single seat planes, they don't have- I think the 22 may have one or two dual seat planes, but the 35 I don't think will ever have any dual seat planes.
Ian Drummond: Meaning the flight surgeon can't go up there?
Dr. Ryan Gray: Meaning the flight surgeon- exactly. So the F-15 and the F-16, the F-18 in the Navy, as those become more antiquated and aren't used, the flight surgeon gets less experience and less enjoyments going and flying in fighter jets because you can't fly in the 22 or 35. So that'll be a big change. So I think those are some of the challenges. I think we'll always have the heavier aircraft like the C-5 and C-17 and the refuelers, the air tankers.
Ian Drummond: When are they bringing the SR-71 back?
Dr. Ryan Gray: I don't know if they are at all.
Ian Drummond: I doubt that they are as well. I'm going to put that one in the show notes for anyone who doesn't know what that one is. I don't know many of the planes that you just mentioned, but I had a roommate that he was a systems engineer, and he wanted to be a pilot- he might be a pilot by now, and he loved I think it's the Black Bird, the SR-71 which was a very sexy looking jet that I think it's one of the fastest ever built, if not the fastest.
Dr. Ryan Gray: Yeah we got the B-2 to kind of replace that one.
Ian Drummond: Oh, okay. Is there anything that I haven't asked you about aerospace medicine that you think people should know?
Dr. Ryan Gray: It's awesome.
Ian Drummond: It sounds very cool.
Dr. Ryan Gray: It's a great job, I'm serious. And we'll get into how I got there, but it's an awesome distraction for a couple years before you start your real life.
Alright there you have it, all about aerospace medicine. Now aerospace medicine obviously pretty much specific to the military, although there are civilian residencies for aerospace medicine. But my goal is not for this podcast, for Specialty Stories, I don't think I'm going to dive into all of the medical specialties, and that's for two reasons. Number one, the practice of pediatrics in the military is not very different than pediatrics in the civilian world. So the medicine practice isn't very different, and honestly really there just aren't that many military premeds out there, I don't think, to warrant doing individual episodes. So to do an episode of military internal medicine may benefit 100 students, but the other 2,000 would be like, “I don't care about military stuff.” So I'm not giving up on the military side of things, I am a huge advocate and evangelist for joining the military to pay for medical school, and to serve, and to be part of the military. It's an awesome thing to wear the uniform, but for the Specialty Stories, I don't think I'm going to dive into it.
So with that said, I hope you have a great week. Come back, check us out next week here at Specialty Stories.
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