Career options in aerospace and aviation medicine.

It is difficult to deny that the term “aerospace medicine” has a certain flair to it, a connotation of a Florida skyline and a wireless headset, the spoken words buoyed by the potential adventure. Although the possibilities may appeal to many of the high-energy individuals who choose emergency medicine, what about the daily life it portends? Would it remain captivating after many years of intense study? This column provides some practical considerations when choosing to specialize in aerospace medicine.

Aerospace medicine is a branch of preventive medicine that promotes the clinical and preventive health of people in flight and space. It is loosely divided into aerospace medicine and aviation medicine. Aviation medicine began in the early 20th century with the arrival of motorized flight, whereas aerospace medicine was launched in the 1960s with the advent of space travel.1, 2 Health issues range from general ambulatory care issues to aerospace-specific topics like exposure to low barometric pressure, reduced oxygen, excess radiation, accelerative forces, and physiologic changes resulting from microgravity. Underlying all these issues is a thorough understanding of human physiology, basic physics, toxicology, infectious disease, and engineering principles.2, 3

In general, physicians trained in aerospace medicine practice health care in populations exposed to flight and space, consult on the physical and engineering aspects of the flight environment, and manage public safety issues at a variety of regulatory agencies. They may choose to specialize in civil aviation, military aviation, or space flight. They might work for the National Aeronautics and Space Administration, the Federal Aviation Administration, a commercial or corporate airline, the Department of Transportation, an aerospace manufacturer, the Occupational Safety and Health Administration, the Centers for Disease Control and Prevention, or in private practice. Practitioners may choose to focus on medical research, they may teach, or they may consult on a variety of preventive, workplace safety, and environmental programs3, 4 or on aerospace health care system development.

Aerospace medicine and emergency medicine are complementary specialties, for several reasons. Each requires the evaluation and stabilization of patients in a less than perfectly controlled environment. Training for mass casualty incidents serves as preparation for airline crashes, and disaster medicine training, along with out-of-hospital care and toxicology, contributes to the preparation for manned space flight. The variety of clinical problems encountered in aerospace medicine overlaps with emergency medicine, ranging from treatment of multiple trauma patients after an airline accident to running a medical clinic for aircrew, which may mirror some of what is seen in the minor area of an emergency department. In addition, the problem-solving and teamwork skills that are inherent to emergency medicine are also basic tenets of astronautics.

The daily practice of a physician in aerospace medicine depends on his or her area of expertise. A medical consultant for a major airline, for example, will oversee the health of the pilots, flight attendants, and ground staff. He or she is likely to run daily clinics to manage the medical problems of the airline crew, such as barotrauma, occupational injuries (back pain is a common complaint), and return to work assignment. The consultant is usually a trained aviation medical examiner (AME) and, as such, gives out the pilot medical certificates from the Federal Aviation Administration, the Canadian Civil Aviation, or the United Kingdom Civil Aviation Authority. In addition, he or she will ensure that protocols are followed, including medical clearance of passengers, medical kit onboard the aircrafts, emergency procedures, and air quality control, to name a few.

Another example is that of a flight physician, who usually works for an aeromedical transport company. This individual is in charge of flight planning, in conjunction with the medical team. In particular, the flight physician will determine whether the patient is fit to fly, assess the patient's oxygen requirements and the aircraft's cabin pressure, and determine if any special equipment is required. The physician escorts patients onboard different aircraft types (ie, small fixed wing, commercial, helicopter) and will work to minimize the risk of barotrauma and problems resulting from the hypoxic inflight environment. Often, this physician is attached to a university center and will be in charge of medical education for residents and medical staff.

A third example is that of a director for a specialized aviation authority, such as the Civil Aerospace Medical Institute or the International Civil Aviation Organization. The director will lead a professional, technical, and clerical team that is engaged in policy development, evaluation, and administration. This individual will develop aeromedical education programs for flight crews and civil aviation pilots. He or she will supervise the creation of the didactic materials used in these programs, as well as general aeromedical publications such as aviation safety brochures and research technical reports.

These jobs have some distinct advantages. If one works for an airline or an aviation authority as a medical consultant, a typical workday extends from 8 am until 5 pm. Despite additional on-call duties, one is likely to be called in only a few times a year (for emergencies such as crash investigations, emergency landings, etc). A flight physician who retrieves injured or ill passengers is afforded the opportunity to discover the world, particularly because some travelers have the desire to visit some fairly unusual places. Some aerospace medicine physicians will maintain a part-time position in an emergency department or another ambulatory setting, providing both variety and the opportunity to maintain clinical skills.

A career in aerospace medicine has disadvantages as well. The daily medical practice of an airline consultant is usually limited to the health care issues of a healthy population. Flight physicians are on call many times a month and may be required to leave within 15 to 30 minutes of a telephone call. Although these physicians often know when they are going to leave, they may not know when they will return: the patient may be more unstable than predicted (potentially requiring an emergency landing) or perhaps the plane will be unable to land because of weather conditions. There is little routine, and by flying full-time, there is a risk of becoming physically exhausted.10, 11 In addition, teamwork is ubiquitous in aerospace medicine: one is likely to take part in several committees, and if one is a flight physician, one works in a confined environment with a medical team (ie, a respiratory therapist, a nurse, paramedics), often for many hours at a time. If you like to work alone, this may be a drawback.

There are many topical issues in aerospace medicine, which you are likely to find yourself debating if you choose this career. Traveler's thrombosis is being addressed by the WRIGHT project (World Health Organization Research Into Global Hazards of Travel), which is a collaboration of an international research project and the World Health Organization. Severe acute respiratory syndrome and aeromedical transport will likely remain a serious issue for anyone in this field, and the effects of cosmic radiation are a continuing concern. Other issues include the use of selective serotonin reuptake inhibitors by pilots, refractive eye surgery in pilots, long-haul flight and aircrew fatigue, and long stay in the International Space Station. If you have a predisposition toward research, there are a plethora of opportunities in this field.

Training options

The routes to becoming a specialist in aerospace medicine are through either civilian training (Table 1) or the military (Table 2). After graduation as a medical doctor at an accredited medical school, one may: (1) enter an internship of choice, and, after completion of the internship, enter a residency in aerospace medicine lasting an additional 2 years; or (2) enter the United States Military to complete a military residency for 3 to 4 years. However, there are many other options available (Table 1, Table 2).

Table 1

Civilian postgraduate training options in aerospace and aviation medicine.

Training Program	Institution	Details	Web Site
Residency	University of Texas Medical Branch (United States)	3 y• 1-y internship at ACGME-accredited program • 1-y graduate course work toward MSc∗ • 1-y practicum	http://www.utmb.edu/pmr/am.htm
		Culminate with ABPM examinations
	Wright State University (United States)	3 y• 1-y internship at ACGME-accredited program • 1-y graduate course work toward MSc∗ • 1-y practicum	http://www.med.wright.edu/asm/res/asmhome.html
		Culminate with ABPM examinations
Fellowship/Masters/Diploma/Certificate Masters	Wright State University (United States)	1 y• International physicians may enroll without an ACGME-accredited internship • Graduate courses in AM, hyperbaric and hypobaric medicine, epidemiology, and environmental medicine, among others	http://www.med.wright.edu/asm/res/asmhome.html
Fellowship, Masters	University of Toronto (Canada)	1-3 y• After residency in EM, FM, or OM • Length of fellowship depends on decision to acquire a Masters∗ of Health Sciences in Occupational and Environmental Medicine	http://www.library.utoronto.ca/medicine/educational_programs/postgrad/med_occ_med.html
Fellowship, Diploma	McGill University (Canada)	1 y• Fellowship in AvM • Aeromedical transport plus training at Air Canada Medical Clinic, Canadian Forces, and Federal Aviation Authority	No Web site currently; contact vincent.poirier@mcgill.ca
Masters	International Space University(France)	1 y (F/T) or 3 y (P/T)• Offers 2 Masters degrees: an established MSS and a new MSM • MSS and MSM share the same program structure, starting with a common curriculum; later diversify into 2 specialized streams	http://www.isunet.edu/academic_programs/mss.htm
Certificate, Diploma, or Masters	University of Otago (New Zealand)	1-3 y (P/T)• Distance education, so students from any country may enroll • Options include a postgraduate certificate in civil AvM or aeromedical evacuation, or a postgraduate diploma in AvM	http://www.otago.ac.nz/aviation_medicine/
		MSc or PhD in Health Sciences, endorsed in either AvM, Occupational Health, or Aero-medical Evacuation, is also available
Certificate, Diploma, or Masters	King's College London (England)	2 wk• Basic course in AvM: permits application for an appointment as an Aviation Medical Examiner for student and private pilots • Advanced course in AvM: successful trainees may apply to examine professional pilots as well 6 mo (F/T) • Diploma in AvM 1 y (F/T) or 2-4 y (P/T) • MSc in AvM or Aeromedical Research	http://www.kcl.ac.uk/pgp04/coursecorres/4/taught
		PhD in Human Aerospace Physiology is also available
Diploma	Université René Descartes (France)	1 y• Includes aerospace physiology, AM, evacu-ations, human factors • Culminates with a written, practical, and oral examination	http://www.univ-paris5.fr/html/5EHLQR3PL5SHEUHC.shtml
Diploma	The Université de Bordeaux (France)	1 y• AM, in collaboration with Université Toulouse-Rangueil	http://www.u-bordeaux2.fr/formation/pdf/medecine/capacites.pdf

ACGME, Accreditation Council for Graduate Medical Education; ABPM, American Board of Preventive Medicine; AM, aerospace medicine; EM, emergency medicine; FM, family medicine; OM, occupational medicine; AvM, aviation medicine; F/T, full-time; P/T, part-time; MSS, Master of Space Studies; MSM, Master of Space Management.

A Masters degree is required for eligibility to sit the examinations for board certification in aerospace medicine by the ABPM.

Table 2

Military postgraduate training options in aerospace and aviation medicine.

Training Program	Institution	Details	Web Site
Residency or fellowship
Residency/Masters	US Air Force	3 y• First year: MPH at accredited school of public health • Second year: practicum in AM • Third year: accredited course of study in either occupational or general preventive medicine	http://www.sam.brooks.af.mil/ram/Default.htm
		In general, candidates apply to US Air Force after completion of internship and 2 years' practice in AM
Residency/Masters	US Navy	3 y• First year: general internship • Second year: MPH at an accredited school of public health • Third year: practicum year done at the Naval Operational Medicine Institute	http://www.nomi.med.navy.mil/text/NAMI/RAM/
Residency/Masters	US Army	3-4 y• As for US Navy, plus optional 4th year: advanced clinical year preparing for the special needs of operational medicine environment	http://www.nomi.med.navy.mil/text/NAMI/RAM/
Fellowship/Masters	Canadian Forces (Air, Land, and Navy)	1-3 y• Options include Fellowship in Aerospace Medicine through University of Toronto, where a Masters of Health Sciences in Occupational and Environmental Medicine is obtained, or through other programs such as the US Air Force, US Navy, or King's College London	http://www.dciem.dnd.ca/publications/factsheets/t21_e.html
			http://www.library.utoronto.ca/medicine/educational_programs/postgrad/med_occ_med.html
Short courses
United States		6 wk to 6 mo• Purpose: to train physicians to be a field flight surgeon in the military • Physicians are treated as aircrew, participate in regular flying duties, and required to meet the same physical standards that the aircrew meet • Offered preferentially to military personnel, but civilians may take these courses	http://www.brooks.af.mil/web/af/main.htm
Canada		6 12 wk• Canadian Forces Flight Surgeon's Course • Purpose: to train military physicians in aviation medicine to support military operations • Worth 100 CME points from College of Family Physicians of Canada • Civilian physicians (including residents) may also take this course	http://www.dciem.dnd.ca/publications/factsheets/t21_e.html

MPH, Master of Public Health; CME, continuing medical education.

The final pertinent issue to consider is that military programs require their trainees to fly, and in civilian programs, although it is not a requirement, flight training is encouraged through several affiliated flight schools. Thus, the strong desire to fly is an important prerequisite.