EMRA Fellowship Guide, 2nd Edition

Aerospace Medicine

Description of the specialty
Aerospace medicine is a specialty that resides within preventive medicine and focuses on the promotion of the health of pilots, astronauts, flight crewmembers, passengers, and patients being transported.  While many specialties deal with abnormal physiology in normal conditions, aerospace medicine is commonly described as normal physiology in abnormal conditions. 

History of the specialty/fellowship pathway
Paul Bert, a French physiologist of the 19^th century, is considered the father of aviation medicine. His observations of the effects of high and low pressure on balloonists are considered the catalyst for further research in the field. In 1918 four physicians became the first American “flight surgeons” after attending aviation school. By 1948, the first center for space research was established in the United States, and the term space medicine was coined the same year. In 1953 the specialty was officially recognized within the medical community. With almost one-quarter of the world’s population traveling by air yearly, and considering the growing interest in and exploration of aerospace environments, this specialty produces experts in maintaining health and safety in such environments. 

Why residents choose to follow this career path
Residents who are interested in discovering, preventing, and managing adverse physiologic responses to an individual in a hostile aerospace environment pursue this career path.

How do I know if this path is right for me?
Are you interested in the effects of low barometric pressures and oxygen tension on the human body? How about the short- and long-term effects of microgravity? Are you interested in learning about topics such as microgravity-induced bone loss, space adaptation syndrome, galactic and cosmic radiation exposure, G force-induced loss of consciousness, vertigo, or desynchronosis? Would you like to participate in the prevention and investigation of aircraft/spacecraft accident investigations? If you answered yes to these questions, this may be the career path for you.

Career options after fellowship/residency
Physicians who have completed this training program have found employment in (but not limited to) the following agencies: National Aeronautics and Space Administration (NASA), Federal Aviation Administration, National Transportation and Safety Board, airline medical departments/clinics, aerospace manufacturing, commercial spaceflight operations, military or other government aviation departments, etc.

Splitting time between departments
Traditionally, the physicians who complete this training primarily take positions solely within the field of aerospace medicine. However, this is not to say that splitting time between a position within emergency medicine and within aerospace medicine is impossible. Some may choose multiple part-time jobs, whereas others may hold multiple appointments within the same hospital system. It will take a bit of negotiation to convince different departments to hire you and agree on a schedule that allows you to split time (including holidays and vacations). Prior to negotiations, consider how much time you wish to spend in each position and seek advice from other physicians who have experience with dual appointments. When you enter such negotiations, remember that your training in both fields makes you a valuable and unique physician.

Academic vs. community positions
This field typically offers more positions for physicians in the community, private, and government sector.

IN-DEPTH FELLOWSHIP INFORMATION

Number of fellowship programs
There are 3 civilian programs, as well as 2 military options:

• Mayo Clinic
• Wright State University
• The University of Texas-Medical Branch in Galveston
• US Air Force Residency in Aerospace Medicine at Wright-Patterson Air Force Base
• US Navy Residency in Aerospace Medicine in Pensacola, Florida 

Differences between programs
The Mayo Clinic is a true fellowship and only accepts applicants who have completed a residency program. Wright State, the University of Texas, and the Navy will accept applicants with a minimum of 1 year of internship completed and thus are considered more of a residency program. (Note: Wright State gives preference to those who have completed residency training, and the Navy requires all applicants to meet the standards of a Naval Flight Surgeon).  While the military programs are open only to military physicians, it is a simple process to transition into the Medical Corps for each branch of service.

The Mayo Clinic offers an opportunity to obtain a pilot's license if inclined and qualified. The program includes obtaining a Master’s of Public Health; the Wright State University program includes a Master’s of Science in Aerospace Medicine; the University of Texas offers either a Master’s of Public Health or a Master’s of Science degree; The Navy program includes a Master’s of Public Health through the University of West Florida. Wright State University offers an Aeromedical Transport Operations pathway specifically designed for those with emergency medicine training who are interested in the administrative aspects of aeromedical transport.

Length of time required to complete fellowship
All of the programs are 2-year training programs.

Skills acquired during fellowship
Fellows will gain the skills to become an aerospace specialist and will be leaders, educators, researchers, administrators, and master clinicians in this field. They will learn how to manage and optimize the health of those in aerospace environments. They will be able to promote aerospace operational safety and apply ergonomic concepts to this environment. They will also be trained in facilitating optimum care of patients transported in aerospace environments.

Board certification afterwards?
This fellowship is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and those who complete this training will be board eligible for certification in aerospace medicine by the American Board of Preventive Medicine (ABPM).

Average salary during fellowship
Resident compensation and ancillary expense coverage varies from program to program. Interested candidates are encouraged to inquire about each program. Applicants to the Navy and Air Force programs will be active duty, and their pay is set by the standard military pay scales, searchable online.

PREPARING TO APPLY

How competitive is the fellowship application process?
The Mayo Clinic only takes 1 applicant per year. Wright University and The University of Texas both take 1-4 applicants per year.  The Navy program publishes a notice every summer, called BUMED 1524, that includes number of spots and the process for application.

Requirements to apply
The Mayo Clinic requires a minimum 3-year accredited residency and board eligibility or board certification. Wright State University, the University of Texas, and the Navy require a minimum 12-month internship at an accredited residency, where 11 of these months must have included direct patient care. Both Wright State and the University of Texas encourage completion of a prior accredited residency program.  The Air Force requires applicants to have served as an Air Force flight surgeon for two years as a prerequisite.

Research requirements
Research is not required to apply for these programs but is strongly encouraged. Research should ideally be within the field of aerospace medicine if possible and also should be near publication and/or submitted for publication.

Suggested elective rotations to take during residency
These include, but are not limited to, the following: hyperbaric medicine, research, NASA aerospace medicine, flight medicine clinic, EMS rotation focusing on flight exposure, global health and travel medicine, aerospace toxicology, health policy, etc.

Suggestions on how to excel during these elective rotations
Be interested and engaged during your rotations and demonstrate your enthusiasm and willingness to be a part of the team. Arrive early and stay late. Be courteous to everyone, all staff and patients alike. Read every night and continue to expand your knowledge base. Your electives are excellent opportunities to find colleagues to write letters of recommendation. With this in mind, it is important to treat every clinical day as if it is an interview day and strive to place your best foot forward.

Should I complete an away rotation?
While you do not need to complete an away rotation, it may be helpful for you to gain exposure in the field and also to help you network. Because this is a small and unique field, chances are your residency program offers limited exposure. There are 2 away electives to consider:

• Wright State University offers a 4-week rotation for both medical students and residents. This rotation is available in October only and includes didactic sessions and various site visits and clinical exposure.

• NASA offers a semi-annual 4-week aerospace medicine clerkship during April and October and accepts both residents and fourth-year medical students.

What can I do to stand out from the crowd?
Your CV should include activities that display your interest in aerospace, demonstrate your leadership skills, and indicate your research experience. Top applicants will have demonstrated interest in aerospace in multiple areas, including having completed an aerospace medicine elective rotation or clerkship, and may even have obtained a private pilot’s license. Seek opportunities such as blog post authorship, literature reviews, lecturing, and attending national aerospace conferences. Becoming chief resident would also be helpful (but is not required). Consider joining a national organization to demonstrate your interest in the field.

Should I join a hospital committee?
Transport medicine and/or safety committee involvement may be useful, and leadership opportunities in general are helpful in building a CV and gaining experience.

Publications other than research
This is highly encouraged. Use FOAMed to your advantage and become active in blog posts and podcasts. Seek out writing opportunities in magazines and journals. EM Resident, published by EMRA, is always looking for authors. Twitter and Facebook, while not traditionally considered publications, may be a great way to network and also to increase the EM community’s knowledge about aerospace topics.

How many recommendations should I get? Who should write these recommendations?
Each program has its own requirements about the number of recommendations required (typically 3 letters). However, all programs at minimum require a letter of recommendation from either your program director or your department chair.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes! Clinical experience is highly valued, especially among those who wish to eventually work as a NASA flight surgeon. The key for applying after residency is to make sure you continue to be involved in leadership and publication activities beyond residency. You do not want 5 years to pass without adding something new to your CV.

What if I’m a DO applicant?
All programs accept USMLE and/or COMLEX scores.

What if I am an international applicant?
The Mayo Clinic will accept J-1 visas and occasionally an H1B visa. Wright State University’s program is NASA-funded and thus can only accept U.S. citizens. University of Texas receives government funding and thus can only accept U.S. citizens as well. The Navy program accepts NATO physicians who have first applied through their respective military service and meet requirements established by their country and the U.S. Embassy.

APPLICATION PROCESS

How do I pick the right program for me?
Applicants should pick a program in a location where they can imagine living for 2 years, where they feel comfortable, and where they can be successful. Your fellowship program should clearly and strongly believe in you and be supportive of your future goals. Do not ignore your inner voice; if you feel uncomfortable at the program during an interview, this may not be the fellowship for you. If you have a spouse or significant other, do not forget their opinion, especially when it comes to program location and their ability to work or thrive in that city.

Common mistakes during the application process
Be truthful on your CV. Be cautious of listing too many projects, especially those that are incomplete or in which you did not have a clear or strong role. It is better, for example, to have 1 complete research project than 3 projects in data collection phase. Your letters of recommendation should be from writers who are strongly supportive of you. If your letter writers seem a bit uncertain when you ask them to write a letter for you, take this as a sign to find someone else. Pay attention to the details, such as making sure there are no grammatical errors and meeting all deadlines. Be courteous to all those with whom you interact, both via email and in person. Being rude to a program coordinator is a guarantee to sink your chances at that program.

Application deadlines
Both the Mayo Clinic and Wright State University have their own application processes, for which additional information can be found on their websites. The University of Texas uses ERAS. Please contact each program and inquire about whether an additional application is required for their master's programs as well. The Navy deadlines are included with the BUMED 1524 notice published each summer, but are generally mid-October. The Air Force deadline is also usually mid-October.

Tips for writing your personal statement
Your personal statement should express your personality and, more important, express your interest in aerospace medicine. Do not fall into the trap of simply repeating what you have already listed in your CV. The best personal statements read as a story and grab your attention from the beginning to the end. Write about that life experience or perhaps patient encounter that initially sparked your interest in the field. Finally, consider explaining how this fellowship would help you attain your long-term career goals.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
Do not become discouraged. Many apply 2 or more times before being accepted because of the limited available positions. We also recommend taking a hard look at your application. Talk to the programs that rejected you and gently ask why so you can address these gaps. It also may be wise to ask someone in a leadership position, such as your program director, to look at your application to help identify weaknesses.

Take steps to increase your activities and also exposure within the aerospace medicine field. Practice your interview skills. Attend national conferences in the field to help you network with physicians and prepare to apply again next year. Worst-case scenario, there are physicians who are involved in this field without completing a fellowship. Seek out these physicians so they can help you build your niche in aerospace medicine.

INTERVIEW PROCESS

How do I stand out from the crowd?
Strive to appear confident in yourself and your abilities without sounding arrogant. Know your application well and be ready to discuss anything listed on it. Be engaging with your interviewer. Be careful not to talk too much or dominate the conversation, but also do not be disengaged or overly quiet. Let your enthusiasm for aerospace medicine and also for their program shine. Make sure to send thank-you letters to all of your interviewers and to the program coordinator afterwards.

What types of questions are typically asked?

• Why are you interested in aerospace medicine?
• Why are you interested in specifically attending our program?
• Tell me more about "blank" that you have listed here on your CV.
• What are your 5- and 10-year career goals?
• Do you have any flight experience?
• Tell me more about your research experience.
• Describe to me your dream job.

How many interviews should I go on?
Applicants should attend all interviews offered (assuming you applied only to the programs you want to attend). 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

• Davis JR, et al. Fundamentals of Aerospace Medicine. 4^th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

• Gradwell D, Rainford DJ. Ernsting's Aviation and Space Medicine. 5^th ed. Boca Raton, FL: CRC Press, 2016.

• Clement G. Fundamentals of Space Medicine. New York, NY: Springer; 2004.

• Reinhardt R. Basic Flight Physiology. 3^rd ed. New York, NY: McGraw-Hill Education; 2007. 

Important skills to practice while in residency to prepare for fellowship
First and foremost, you should strive to become an excellent clinician during residency. Strive to expand your knowledge base of aviation and space medicine if possible. Seek activities that will build your skills in leadership, administration, clinical education, and research.

Tips on how to succeed as a fellow
Fellowship is a unique opportunity for you to gain experience, skills, and expand your knowledge base while under the guidance of mentors and attending physicians. Take advantage of every opportunity and purposefully seek out opportunities beyond the usual course and clinical work. Take time to read every day, and strive to be a master clinician within this field. Remember to always be considerate, dedicated, courteous, and compassionate. Work hard at your master's degree and excel at your coursework. Continue to network and build rapport with those within the field and work toward achieving your dream job after fellowship. 

CONCLUSION

Additional Resources

Journals

• Aerospace Medicine and Human Performance

Blogs

• Aerospace Medicine Safety Blog
• Go Flight Medicine
• Naval Aerospace Medical Institute

National organizations

• Aerospace Medical Association
• Space Medicine Association
• American Society of Aerospace Medicine Specialists
• Society of NASA Flight Surgeons
• Airlines Medical Directors Association
• Society of US Naval Flight Surgeons

Conferences

• Aerospace Medical Association Annual Scientific Assembly
• American College of Preventive Medicine annual meeting
• United States Naval Aeromedical Conference

How to find a mentor
There is no central website that assigns mentors to those interested in the field of aerospace medicine. We encourage you to network with physicians in this field via conferences, away rotations, and email.