teaching training aviation medicine

The UOEH Association of Health Sciences

NII-Electronic Library Service

TheUOEHAssociation ofHealth Sciences

J, UOEH,7(1):9-25 (1985)

Teaching and TrainingUnited Kingdom

Peter HOWARD

Air Commodore, RAF Institute of AviationUnited Kingdem

Abstract :

Kaywords

in Aviation Medicine in the

Medicine. Eimberough, Hampshire,

9

CLecture]

In thc United Kingdom, training in aerospace medicine is provided by a range of post-graduatc courses at the Royal Air Force Institute of Aviation Medicine. 1) An IntroductoryMedical OMcers' (IMO) coursc lasts for two weeks and is attended by all RAF doctors within

the first few months of their entry to the Service, Its objective is to teach thc elcments of

aviation physiology and medicine that they will need in the care of aircrew at a fiying

station, Four courscs are held each year, 2) A Gcneral Aviation Medicine (GAM) course

is available to civilian doctors who wish to gain recognition as Authorised Medical ExamiRcrs

of commcrcial aircrew, or who merely have an interest in the subject. It runs concurrently

with the IMO course, and much of the material is common to beth. Greater emphasis is,however, givcn to clinical tcaching and to civil aviation. The GAM course also occupics two

weeks of teaching, 3) A course leading to the Diploma in Aviation Medicine is held oncc

each year, and lasts for six months. It is open to all whe have at least one year of previousexperience, and has been attended by 244 miiitary and civilian doctors from 25countries.

'rhe D i-Lv rv{cd course covers every aspect of aerospace mcdicine at an advanced

lcvel, and its standard is at least as high as that of a M Sc degree, The Diploma is a

recognised academic qualification awarded by the Royal College of Physicians, 4) Roya] AirForce medical ofilcers receivc an extra three weeks of training immediatcly fo11owing the D Av

Med course, to educate Lhem in procedures and policies specific to the RAF, This AdvanccdCourse is essentially practical, and those who complete it are designated as Flight Medical

Orncers. They receive refresher training given at regular intervals thereafter. 5) Aircreware taught the basic principles of aviation medicine when they attend the RAF Aviation

Mcdicine Training Centre fbr training in the use of thcir personal protective equipment

assemblics. These courscs arc spccific to the type of aircraft to be flown, and a pilot will

undcrgo at least four during his fiying career, 6) Short courses of a specialised nature are

also ofibrcd to clinical consultants, medical students, senior Air Force orncers, nurses and

others, It is now recognised in the Unitecl Kingdom that aviation medicine is a component

of occupational rnedicine, and tlte Royal College of Physicians accepts the D Av Med as

evidence of fbrmal cducation in that branch of mcdicine. The recent great expansion of

occupational medicine in Britain has thus significandy incrcased the requirement fbr the

aeromcdieal training of civilian and military doctors.

aviation medicine training, flight medicine, pilot health care, flight medical oracer,

(Received 15 November i984)



The UOEHAssociation ofHealth Sciences

IO P. HowARD

Formal training programmes in aviation medicine have been evolved in the United

Kingdom over the past twenty years, to meet a variety of needs that have themselves

changed with time. I should like to discuss four of them, all of which have been

initiated and conducted at the Royal Air Force Institute of Aviation Medicine, and to

mention a fifth. In the approximate order of their appearance and history, they serve

the foIlowing purposes:-1. The specialised training of people to undertake aeromedical research and development

(and also to teach others).

2. The general education in aviation medicine of' medical officers from the RAF, the Royal

Nav>, and the British Army.

3. 'l'he

education of civilian general practitioners with an intcrest in the subject or a desire

to gain recognition as licensed medical exarniners of flying personnel,4. The training of RAF doctors as Flight Medical OMcers.

5. The aeromedical training of military aircrew.

The first of these may be quickly discussed and then dismissed. The objective is to

produce an elite group of RAF medical oflicers whose career will be spent almost entirely

at thc lnstitute of Aviation Medicine. They will undertake research into the eflbcts of

the flight environment on man, and contribute to the devclopment and assessment of

methods of protccting aircrew. They will be members of the RAF Speciality of Aviation

Medicine (which might more properly be called Aviation Physiology) and progress through

the grades of specialist, senior specialist and consultant that are common to other disci-

plines such as general medicine and surgery. To do so, they must serve an appren-

ticeship of at least two years in the laboratory and then obtain an appropriate post-

graduate qualificatien, This may be a Master's degree in Ergonomics, or in science, er

even in Occupational Medicine, but they are usually encouraged to work instead for a

PhD. The doctorate takes longer to acquire, but it has three advantages-it carries

greater status, it provides objective evidcnce of the ability to conduct independent personalresearch, and it does not entail the protracted absence from the laboratory required for

attendance on a MSc course. Moreover, the subject of the thesis can be constrained to

the interests of the Royal Air Force, so that both the candidate and the Service reap the

benefit of the programme. For example, a proposal to register for a PhD based upon the

physioiogy ef positive pressure breathing would be perfectly acceptable, but one on the

steroid metabolism of the pregnant pig would not.

The training associated with the acquisition of the higher degree is straightforward,

and it is in no way different from that found in any University department, but a few

words must be said about the earlier education of would-be specialists. There was once

a widespread belief that anyone with enough enthusiasm and a few grains of common-

sense could do research, and that a medical oMcer joining the RAF who had collected a

BSc in Physiology as part of his graduate training was an ideal candidate for a career in

Aviation Medicine, (The view that such research is good fun but not preper employ-

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Training in Aviation Medicine in U. K. 11

ment for an othcer and a gentleman still persists in some quarters)[ As a result of this

thinking, doctors were once recruited straight from hospital posts to the Institute, and

placed in a particular field of environmental medicine (such as altitude or

acceleration), They were expected to amass expertise in that field by osmosis, and to

gain any necessary knowledge of ether aspects of aviation meclicine by occasional visits to

other parts of the laboratory. Those who proved not to have the aptitude or the stamina

for research were detached to appointments as station medical oMcers, in which capacity

they acted as general practitioners in uniform. The successfu1 ones, however, remained

at the Institute-sometimes for more than 30 years without interruption,

This blinkered attitude to the education of specialists in aviatien medicine altered as

the the role of the Institute changed. NNiith a growth in the development function at the

expense of the more fundamental rcsearch, it became essential for the "bench-level"

spe-

cialist to have both a widcr perception of aviation meclicine and a better understanding of

how the Air Force worked. The latter was assured by the introduction of a requirement

for all potential specialists to spend at least one year as the junior medical oMcer on a

flying station before being accepted for specialist training-a policy that was (and still is)greeted with dismay by impatient young oificers eager to win a Nobel prize, but the

wisdom of which is loudly proclaimed by those same men when they have become more

patient and more mature. They then appreciate the considerable value conferred by

their experience of the conditions in which aircrew live and werk-and by actually sitting

in the cockpit of an aircraft. The need for formal teaching; that is, according to a

prescribed syllabus, is also met by treating the future research worker as an ordinary

medical oMcer, and it is to that aspect of training that I now turn.

The initiation of a newlyjoined doctor into the peculiarities of Service life is some-

times a painfu1 process, and the pressure to fit him for duty as quickly as possible puts

training time at a premium, Nevertheless, it is recognised that ItaF medical oMcers

rlable

1. Courses at. RAF InstituLe of Aviation Medicine

Title of course Duration

Fuequcney

{per yoar)

Initial medical officer's' (IMO)

General aviaLion medicine cGA]vl)

Pressure chamber operators' CPCO)

NBC AEA instructers'

DIP aviation medicine

MSc in human and app]led physielogy

Advaneed aviation medicine

Senior medieaE officers'

Flight medical officers'

Station eommanders' Cdesignate)

2 weeks2

wecks2

weeks1

week6

menths

4 weeks3

weeks3

days2

days1

day

33121112z4




I2 P. HowARD

must be made familiar with at ieast the rudiments of aviation medicine. All of them,

whatever their future careers may be, are obliged to spend two weeks at the Institute as

part of a menth-long initial course for medical oMcers, or IMO course (Table l), (Theether two weeks are cernmitted to the Institute of Community Medicine which, despite its

title, endeavours te instruct them in aviation pathology, trepical medicine and occupation-

al health in an Air Force context). The aim of the IAM phase of the course is to ensure

that they emerge with a working knowledge of aeromedical physiology, psychology and

clinical medicine. The range of instruction given to them is in many respects similar to

that received by the general practitioners whose course runs concurrently, the content of

which I shall describe in a few moments. However, the IMO course devotes little time

to civil aviation-merely providing one lecture on medical licensing and selection-and

gives great attention to the practice of aviatien medicine in the Royal Air Force, An

important component of that subject deals with the investigation of in-flight incidents such

as disturbances of consciousness or of awareness, disorientation, malaise and human

error. Occurrences of this kind are not uncommon, and a keen young doctor fresh from

his hospital training is more likely to ascribe pallor and dizziness to coronary heart disease

than to hyperventilation. To be fair, it is not only the juniors who leap to such improb-

able diagnoses, and it has been found valuable to supplement the teaching with a small

pocket guide to the investigation and treatment of in-flight incidents. ･

About 20 per cent of the available time for teaching on the IMO course (Table 2) is

devoted to the problems of altitude and oxygen equipment, a fraction that may seem

surprisingly large, but which experience has shown to be time well spent. In contrast,

little more than 10 per cent of the course is given over to the aviation aspects ef clinical

care in the RAF. The remainder of the 60 hours is divided more or less equally among

the other environmental stresses of flight, but the students are spared much exposure to

the complexities ef aviation psychology. The course ends, inevitably, with an examina-

tion, and those who do not achieve a satisfactory standard are required to attend a second

IMO course at a later stage.

Ten working days is a very brief period in which to impart information on so huge a

sub.ject, and we would be most reluctant to release the immature medical oMcers to be in

sole charge of a RAF Medical Centre. Fortunately, they are never given that respensi-

bility, and we are comforted by the knowledge that, having learned the basic language of

aviation medicine, they will become fluent in its use under the watchful eye of an experi-

enced and senior RAF doctor. The crucial point is that their training has begun, and

that they can then be stimulated to continue it.

The General Aviation Medicine or GAM course was started because of the considerable

interest of general practitioners in the subject. Some of them merely wished to extend

their knowledge (or perhaps to escape from their practices for a relaxing week), but others

had the need to carry out physical examinations on private aviators or professional civil

aircrew. They required no great depth of expertise, and in the five days of teaching

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1'raining in Aviatien Medicine in U, K,

wable 2. Initial medical officers course-ALriation medicine phase

13

Aims

1. Prepare MO fc)r praczice of aviation medicinc fer at least firsL five },ears of service.

2. Provide MO with the know]edge of the physiological and psychological stresses of military

aviation and the princjpEes oi aircraft life support systems and personal and escape equipment

necessary to permit him zo:

Q)InLerpret and treaL aviatien medicine condizions which can arise in medical pvactiee en

a fLying unit.

[2) Check the fit and function of certain items of per'sonaL fLying equipment.

[3]･ Provide aeremedieal adviee in the event ef an inf]ight incident and to conduct the apprupriaLe

investigations,

l,4) Instruct airerew in eEementary aviation medicine.

/[5) Initiare the aeromedieal investigation of an ttircraft accident or eiection.

Contents Duration {hrs)

1. Principaes of flight. airc:raft and flying.

2. Practice of aviatien medicine in the RAF

3. Altitude, pressure cabins and oxygen equipmont

4. Thermal stress.

5. Biodynamies-Long and short duration accelerations,

6. Escape-phs,siology and systems,

7. Surviva]-sea and land survival.

8. Speeial senses-vision, orientatien, motien sickness,

9, Personal equipment,

10. Human performance-aviation psycholegy,

11. Clinieal aviation medieine-general medicine, ENT,

12, Civi] aviation medical licensing,

13. Administration, examination and cvitique.

protection, helmets, harnesses.

noise.

eyes, neur'opsychiatry.

6613.546,53.

.:]3.565391369

Fotlow up training

A . Attend appropriate airerew aviaLion medicine eourse at RAF AMTC (authority:RAFSC1452038f

lfMED dated I8 Aug 83 and STC/31502/10/MED J)ated 2 Sep 83).

B . On-the-jo6 training by FMO/SMO.

oflered by the original courses it was clearly impossible to give them more than a super-

fieial appreciation of aviation medicine, All that could be done was to touch on some of

the principles of the physiology of fiight, to draw' attention to some clinical conditions that

would be incompatible with, or adversely afllected by, flying, and to define fitness criteria

for pilots and passengers.

Although the GAM course was accepted by the Civil Aviation Authority as appropri-

ate training for the Authorised Medical Examiners wh6 carry out the statutory examina-

tions on commercial aircrew, these deficiencies of scope caused some concern. The Insti-

tute was placed under pressure to increase the length of the course and, interestingly, the

urging came not enly from the Authority but also from the students. Plans were tenta-

tively made, without any marked enthusiasm from an already overworked teaching staft to




l4 P. HowARD

extend GAM course to a second week, but the drive to do so eventually came from

outside the United Kingdom. A Committee of the Council of Europe, which had been

created to "harmonise"

the teaching of aviation medicine in the Cemmon Market and

beyond, recommended that there should be two levels of qualification; a Certificate and a

Diploma, I shall return to the Diploma later, but the significant point about the pro-

posed Certificate was that it should be awarded only after attendance on a course involv-

ing not less than sixty hours of formal teaching; that is, fbr at least two weeks. The

syllabus was spelled out in great detail but, not surprisingly, the range of topics did not

difler in any notable respect from that of the traditional GAM course.

The machinery of the Council of Europe moves slowly and, despite the unanimous

acceptance of the idea by the a,viation medical experts of all the nations involved, it will

be several years befbre the prejected European Certificate becomes a fact. However, the

recommendatiQns increased the incentive to modify the General Aviatien Medicine course

in Great Britain, and the firs.t two-week course was held in April of this year,

It is only feasible to operate the extended GAM courses at such an intensity because

they are run concurrently with the IMO course for the introductory training of RAFMedical Othcers, and because the needs of the two groups have so much in

common. Rather more than half of the lectures and demonstrations are given te one

amalgamated class, and I shall mention here only the topics that are specific to the

General Aviation Medicine course. Obviously, much more attention is given to the

peculiar problems of civil aviation, and the question of licensing standards fbr aircrew is

covered exhaustively during the first day. This is probably the most impertant aspect of

aviation medicine for most ef the students-many of them will expect to make a great deal

of money frem the examination of civilian aircrew.

While the RAF dectors are learning about the physiological requirements of oxygen

systems and the oxygen equipment used in military aircraft, their civilian colleagues re-

ceive tuition in the prevention and treatment of hypoxia in light and civil transport

aircraft, and gain practical experience of the effects of hyperventilation, (For some

reason, we do not devote much time on that subject during the IMO course -

hyperven-

tilation is certainly not a hazard to civilian aircrew only). Similarly, the lectures on

survival are difllerently orientated for the two groups; civil aircraft do not have ejectionseats, nor are military aircraft equipped with escape slides.

The ciinical phases of the two courses are almost identical, but the GAM students

receive a protracted lecture and practical sessien en the examination of the eye. Again,

it is not that their counterparts in the RAF can remain ignorant of this subject, but that

they have the opportunity to iearn it elsewhere.

The final two days of the GAM course are totaly separated from the IMO

course. They include such diverse matters as the carriage of patients by air, imported

diseases, the werkload of civil aircrew and the controversial questiens of flight time limita-

tions and rostering, the medical investigation of aircraft accidents and disasters, and first

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Training in Aviation Medicine in U. K. 15

aid and critical care. 1'he course ends with a one-hour examination, in which success is

by no means universal. Those who do achieve a satisfactory mark are awarded an

impressive certificate of competence, while those who do not are presented with a rather

less striking certificate of attendance. It must be said that neither of them is a registra-

ble academic qualification, but the first of them may attain that status if the Councii of

Europe has its way.

The GAM courses have been a huge success. Three or fbur are held each year, and

the fiftieth of the series was celebrated in appropriate fashion in April 1984, A total of

516 students have attended, and the number of applicants shows no sign of

decreasing. Indeecl, the maximum size of each course has had to be raised from 12 to

25 to meet the demand for places. At first sight, this is surprising, because the register

of Authorised Medical Examiners appointed by the Civil Aviation Authority is already fu11

and those who complete the GAM course now have little hope of attaining such recogni-

tion for many years. However, two ether factors act to swell the numbers of students.

The first is that the course provides the basic training needed by airline doctors and

the medical oencers of some foreign Air Forces. In a typical year, about 60 per cent of

the students will be from the United Kingdom, the remainder coming from between five

and nine other countries ranging from Europe to the Far East. The reason for this

overseas interest is mainly financial-the United States is the only other major source of

formal teaching, but Britain is nearer and cheaper and (with due deference to my Amer-

ican colleagues) the standard ef tuition is higher.

The second factor in sustaining the popularity of the GAM course is related to the

regulations for the Diploma in Aviation Medicine, It is not uncommon te find that

would-be students lack the requisite previous experience or training, and their needs are

not infrequently served by the GAM course-especially in its present extended

form, Another obvious requirement is that applicants for the Diploma course shall befluent in English, but an occasional student from overseas who meets that standard may

still benefit from prior exposure to the technical language of aviation medicine. He will

then be advised to attend the GAM course in December and to remain for the Diploma

course beginning in the foIIowing month,

Thus, the General Aviation Medicine course is an exccllent and very popular method

of acquiring basic specialist training and, when the European Certificate is finally estab-

lished, it will be the premier source of such instruction. There is Iittle doubt that the

demand for places will then grow further, and it is very probable that we shall be

requested to increase the frequency of the courses.

The Diploma in Aviation Medicine (Table 3) is unique in several respects; in particu-

lar, it is the enly true postgraduate qualification in aviation medicine anywhere in the

world, By that, I mean that the Diploma is not awarded by the Institute or the Royal

Air Force, but by the Royal College of Physicians, which is an independent, influential

and prestigious body, A doctor who has gained it is entitled to use the pestnominal D




16 P, HowARD

Av Med, and in that respect the qualificatien is equivalent to other College diplomas, such

as those in anaesthetics or pediatrics or industrial health, It is, therefbre, an accepted

mark of specialist status-I shall comment later upon the wider significance of that fact.

When the Diploma was created some l7 years ago, it was intended to give further

education only to rriedical oMcers of the RAF. The first ceurse lasted for 9 months, and

was attended only by RAF doctors. This was just as well, because we were able to learn

from and to cerrect our mistakes, and deficiencies of syllabus and organisation, before the

teaching was made available to a wider public. In subsequent years, the length of the

course was reduced te six months (to bring it into line with other diplomas) and it now

runs from early January to late June of each year. At the same time, attendance on the

course and entry te the final examination was thrown open te the world at

large. Doctors from the Armed Forces and civilian practitioners from other nations

could be accepted provided that they could claim some previous experience of aviation

Table 3, Course for diploma in aviation medieine 1968-1984

Country oE origin Air forceArmy NavyCivilianTotal

Australia

BritainBurmaCanadaChinaDenmark

EgyptGhanaGreeceIndoncsia

IraqJopdanKenva

'KuwaitMalayaNew

Zealand

NigeriaNorwayPakistan

Saudi Arabia

Singapor'e

South Africa

Sri Lanka

SudanUSA

148446

811

1l529312419112

210

1

212

l

41521311

1

122

4

2

22l21

619

1

2

8

1

1

1

1

1

5

2

le

5

3

2

9

1

9

1

1

2

2

Total25 168 13 15 48 244

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Traintng in Aviation Medicine in IJ. K. 17

medicine-although no absolute criteria were laid down, the general requirement is that

an applicant must have been engaged in fu11-time aeromedical practice for one year or

more. This relaxation of the original purpose of the Diploma course has, in fact, assured

its survival, and approximately 60 per cent of the l2-16 students enrolled each year now

come from outside the United Kingdom. Moreover, the RAF component now amounts

to no more than 25 per cent of the total, other British students being supplied by the

Army, the Royal Navy, and the medical staffs of the airlines and the Civil Aviation

Authority. In the past i7 years, 244 doctors from 25 different countries have taken the

Diploma course, and two new nationalities will be represented on the 18th course next

January, The course ends with an examination, conducted at the Royal College, that

consists of two three-hour written papers and two twenty-minute viva voce

exams. Occasionally, a candidate with extensive previous experience in aviation medi-

cine is allowecl to sit for the examination without having attended the course, but such

instances are rare and, under regulations soon to be introduced, no waivers will be

granted,

The divisien of each phase of the final examination into two parts reflects the form of

the course and the pattern of the teaching. The two broad categories are Basic Sciences,

which comprises physiology, psychology and related disciplines, and Clinical Medicine,

which is self explanatory but which additionally includes a good deal of material related to

civil aviation-licensing, international regulations, hygiene and so on, Interaction be-

tween these two is inevitable and necessary, but it has proved to be essential for the

students to have a good grasp of the physiological efllects of environmental stress before

they are addressed by the ciinicians. The majority of the students rather resent the

thought that they need to learn about cardiorespiratory physiology, thermoregulation and

the like. These are subjects that they were taught in their early days as medical stu-

dents, and mature doctors do not take well to the suggestion that they need to re-learn

facts that they initially regard as irrelevant. Stuclents from the Armed Forces (and not

only those of the United Kingdom) have a similar attitude when they find that the

timetable includes lectures on elementary aerodynamics and the principles of

flight. Many of them have been associated with aircrew and aircraft for a number of

years and they consider that they already know quite enough about these matters. The

way to dispel their selfiassurance is simple. On the opening day of the Diploma course,

the students take a short written examination consisting of simple multiple-choice ques-

tions like "What height corresponds to Flight Level 15?", or

"NVhat is the partial pressure

of oxygen in the lungs?", Unlike the final examination, which is intended to find out

how much a candidate knows about aviation medicine, this initial test aims solely to show

him how little he knews. We do not take much account of the results, but he does, and

is usually chastened by the realisation of his ignorance.

It would be weariSefrie to discuss the details of the Diploma course, and I shall only

list the broad headings and the time deveted to each, as an inclication not solely of their




18 P. HowARD

relative importance but also of their complexity. In every case, classroom teaching is

supplemented by tutorials, demonstrations and practical sessiens. It is part of the phi-losophy of the course that, unless there are over-riding safety considerations, each student

shall be personally involved in each practical period, whether it be in the altitude cham-

ber, on the centrifuge, or in the flight simulator.

After seNJen hours of physics and aerodynamics and another seven on the assessment

of scientific evidence, the course proceeds to the study of the environmental stress of flight

and of prevention and protection. The format of each of the subdivisions is the

same. Thus, the large bleck entitled Altitude opens with a review of the mechanics and

physiology of respiration, continues with consideration of hy, poxia and decompression sick-

ness, and includes the basic principles of oxygen systems, cabin pressurisation, pressurebreathing and pressure suits. The total time allotted to these subjects is 45 hours, of

which about 25 per cent is devoted to practical work.

Climatology and survival occupy a similar firaction of the teaching, and especial

emphasis is placed upen lifepreservers, liferafts and survival after ditching in the

sea. The bias towards sea survival has increased in recent years, largely because the

expansion of oMshore oil operations has accentuated the incidence of its occurrence and

brought growing concern for the safety of helicopter passengers and crews. This is but

one example of the requirement continualiy te review the content of the Diploma course to

take account of changes in aviation practice and also to cater for the needs of non-military

aeremedical specialists,

Biodynamics comprises sustained centrifugal acceleration, impact and crash fbrces,

and vibration. Together, these occupy, 23 hours of teaching and practical experience, but

the special category of forces associated with ejection and escape from aircraft is givenanother 10 hours. The practical content of this part is understandably small, but the

students are expected to gain personal experience on the ejection seat rig. If they have

backache bcfbre that session, they are excused, If they have backache afterwards, they

are consoled,

The special senses are covcred in abeut 22 hours, of which by far the greater fraction

is given over to the vestibular system and the associated problems of disorientation and

motion sickness, Vision and ocular hazards in flight receive some attention but, like

hearing and noise, they are dealt with at greater depth in the clinical phase of the course,

Neurophysiology is an inappropriate title for 7 hours ef tuition in what is probablyone of the most controversial areas of aviation medicine; circadian rhythms, sleep and

'shift

working, and their manipulation with the aid ef hypnotic drugs, Research on this topic

began in the United Kingdom many years ago in relation to long-haul commercial airline

operations, and led to the forrnulation by both the civil and the military authorities of

policies on the use of hypnotics by aircrew, It was vindicated and achieved respectabil-

ity during thc campaign in the South Atiantic, when the wise prescription of benzodiaze-

pines by RAF mcdical oMcers allowed aircrew to continue efflectively and safely during




Training in Aviati{m Mcdicine in U, K, 19

operations of unprecedented intensity.

Aviation psychology is the largest single block of the Basic Sciences phase of the

Diploma course. It is also without doubt the least popular, In Great Britain at least,

psychology does not figure as such in the pre-clinical curriculum, and both the concepts

and the jargon of aviation psychologists are unfamiliar to post-graduate stu-

dents, Nevertheless, they are exposed to 46 hours of teaching and tutorials on subjects

like motivation, information processing, selection, social aspects of work, human error, and

workplace ergonomics. Some relicf and common sense is supplied during this phase by a

practical exercise in the human factors assessment of a real aircraft cockpit,

The remaining 20 hours of the non-clinical part of the course encompasses the

aeromedical problems of spccial types of flight-helicopters, VTOL and VSTOL aircraft,

supersonic transports, air ambulances and aeromedical evacuation, agricultural aviation,

and manned spacecraft.

I shall not dwell upon the content of the 63 hours of instruction in clinical aviation

medicine, for it fo11ows entirely conventional lines, and deals with all the disorders that are

of significance in flight or that may impair er disable aviators. Great importance is

naturally attached to latent or overt coronary artery disease and to psychiatric states,

because they are not only the most common conditions that the aeromedical specialist will

encounter but also the ones that will require the most agonising decisions.

Aircraft accidents are also distressingly common, and it is essential that the specialist

shall know how to conduct the medical investigation of any occurrence, whether it be the

crash of a crop spraying aircraft or the catastrophe of an airline disaster. Twenty hours

are allotted to ai,iation pathology, but the instructors are not all medical experts,

Contributions are also made by the Accident Investigation Branch, the fire services, the

police fbrce, and by airfield security personnel. The aviation pathology part of the course

is conducted at the Institute of Pathology and Tropical Medicine at Halton,

Civil aviation could probably be better counted as a third component of the Diploma

course, although for convenience it is included as a part of the clinical phase, In

addition to the complexities of international regulations and air law, the students receive

instruction in the occupatienal health and hygiene of civilian aircrew, cabin crew, passen-

gers, and ground crews, and learn of the procedures for quarantine, disinfestation,

etcetera, For this part of the course, which involves some 4e hours of tuition, they

spend their days at London Airport, Heathrow, where the lectures and demonstrations are

carried out by the staff of British Airways and of the Civil Aviation Authority.

Apart from the weeks at Heathrow and at RAF Halten, the members of the course

pay one-day visits to a large number of other establishments and industrial sites that have

special facilities or equipment related to aviation andlor medicine. Thus, they experi-

ence a wide range of occupational medicine in addition to the strictly aerospace variety,

The time occ.upiqd .by teaching, tutoriais and practical sessions during the six months

of the course is slightly less than 500 hours, a figure that excludes private study, xJisits,



The UOEHAssociation ofHealthSciences

20 P. HowARD

and the written or oral examinations that punctuate all phases, It also excludes the

single most important lecturc, and the one that is most often forgotten at the crucial

moment. It is entitled "How

te pass the examination for the Diploma in Aviation

rvIedicine",

It is generally agreed that the standard of the Diploma is considerably higher than

that of other diplomas awarded by the Royal Colleges of Physicians and of Surgeons, and

that it equates much more closely with a Master's degree in Science. Several attempts

have been made to convert it from the one to the other, but they have not yet met with

success, for two main reasons, The first is that most British Universities require candi-

dates for the MSc to possess a baccalaureate in science, which many of the Diploma

students do not have. The second is that a course leading to the Mastership traditional-

ly lasts tbr 9 months rather than for six. It would be possible to overceme both these

obstacles, but it would be difficult and, because the academic standard and reputation of

the D Av Med are so high, the benefit ef University recognition is not worth the extra

eflbrt and time involved. Nor would the Royal College of Physicians readily re!inquish

its control of so prestigious a qualification as the Diploma.

The whole purpose of the Diploma is to denote that the holder has received specialist

teaching and training in all aspects of aviation medicine, and the outline that I have given

of its content shows how wide that training is. From the fact that a high proportion of

Table 4. Trainirig of Ri'XF medical officer's in aviation medicine

1, AL} medicaL offieers

Intreductorv course c2 weeks}

2. FLight medieai officers

5-10 yr service experienee

Attend course for DIP AIi MED (6 rnonr]]s)

Gain DII' AV MED

Attend advanced ax'iation medieine eourse C3 weeks)

Attend PREL flying course (30 hours)

Attend FMO continuation tr'aining course C2 days) cmce evevy

3 Clinical specialisLs

Attend SrvlO aviation medicine course C3 days) once every 5

4 Specialists in aviation mcdicine

2 yr service experierLce

2 yr trainee specialist (AMTCflAM)

2 yr specialist CIAM)

Gain PHI) or MSa degree

3 yr senior specialist (IAM/USAF exchange)

Consultant (IAMfAMTC/USAF exchange}

5. Medical officer pilot

Basic and adx,anced flying training to fast jet Squadron experience

QFI fast jet Rcsearch/rehabiLitation flying at IA}v{

12-l8 months

years




Training in Av{ation Meclicine in U. K. 21

the students come tfom the civil field or from outside the United Kingdom it foliows that

procedures specific to one Armed Service cannot be covered in detaili nor can there be

any discussion of sensitive or classified material, As a result, RAF medical oracers who

acquire the Diploma are well-grounded in aviation medicine but not yet fu11y educated in

the specialised equipment and techniques used by the Royal Air Force. That deficiency

is remedied by retaining them at the Institute･ for a further 3 weeks immediately after the

Diploma examination, to take the Advanced Aviation Medicine course (Table 4). The

tuitien that they then receive is even more intensive than that of the preceding six months,

and it concentrates upon providing them with "hands-en"

experience of the items and

assemblies of personal equipment worn by RAF aircrew, At the end of the course they

take yet another examination, this time of a very practical nature, They may be re-

quired to diagnose faults deliberately introduced into oxygen equipment, to identify the

components of a complex system, or to demonstrate their ability to fit and adjust a

protective asscmbly, If they are successfu1 (and most of them are) they emerge as

fu11y-fledged Flight )vledical Officers, and are entitled to a special annotation denoting

their status. They are then usua!ly appointed as the Senior Medical OMcer at a flying

station, but one or two may go to the headquarters of one of the major CQmmands, to act

as advisers on flight medicine to thc Principal Medical Orncer and the Air Staffs,

For a selected few, the long period of formal instruction is not yet ended, Instead,

they are attached to a fiying training unit and given 30 hours of air experience in a

single-engined trainer-not enough to turn them into proper piiots, but suMcient to bring

them to the point where they can fly solo. The rationale is that Flight Medical Otficers

arc an elite group who must associate very closely with aircrew, and that empathy with

their "customers"

will be fostered if it is known that the doctor has also flown alone, and

been frightened, Of medical officers who undergo fu11 training to become operational

pilots I shall say nothing, except that it is probably much casier to teach medicine to an

already qualified pilot than to bring a medical oMcer to the required standard of pilotage.

Aviation medicine is no more a static art than any other branch of medicine, and it is

clearly essential that Flight Medical OMcers (and others) shall be brought up to date on

developments in personai equipment and procedures. This cannot adequately, be

achieved by the written word, and it is a firm requirement that every Flight Medical

OMcer must attend at least one of the two or three Continuation Training courses held at

Farnborough each year ([E]able 5), It is worth pointing out that these sessions are not

rigidly structured, nor are they a one-way street. The visitors bring with them problemsthat have arisen in their practice-often including questions raised by the aircrew er

suggestions fbr the modification of items of equipment. They are also given the oppor-

tunity to describe to their colleagues an}r interesting or unusual events on their stations; an

aircraft crash, perhaps, or a case of incapacitation in fiight. By this means, they ad-

vance the education of their fellows and of their former tutors,

Aviation medicine is, and will always be, a specialised discipline, but it ne longer




22

[[h.ble

P, HowARD

5, ConLinuat/ioncour'ses

TiLle of course LengLhlRegularit}, Target populaLion

Senior medical

offic.crs' coursa

Flight rnedical

ofFiecrs' course

3 da.vl

2 per year

2 day/

Lt per year

Senior rvtedica] OE'ficers of

tha RAF clinieal specialties

RAF fLighL rnedical officcrs

and senior medical officevs

of flying uniLs

Servicc doctors from RN

and RAMC with aviation

medieine vespunsibilities

Romarks

To provide infor'rnaLion on new

developments in aviation medlc/ine

To provide flight medical officers

and ser]ior rriedlcai ol'licers ",ith

Lhe neeessary information to brief

Lheir' cxccutiyc and to givc refre-

sher training to airerew of their

LMitSTo

givc flight me(lic;al and senior

thedicaL offleers the opportunity

tu discuss aviation medicinc pro-

b]cm on rheir units

stands in the isolated position that it previously held in the United Kingdom. Until

about 4 years ago, gaining the Dip]oma was, {br a RAF medical officer, a desirable but

sterile objective; sterile, that is, in terms of significance outside the Roya] Air

Force, That situation was changed b}J the formation within the Royal College of Physi-

cians of a Faculty of Occupational Medicine and by the emergence of that discipline as a

speciality in its own right, just as community medicine, anasthesiology, pediatrics and so

on are discrete entities of medicine. 'l''he

new Faculty quickly recognised that many

doctors in the Armed Serviccs had responsibilities far beyond the day-to-day health care ef

military personnel and their dependents, and that their duties often included elernents of

industrial and environmental medicine, as well as the assessment of the efllects of health

upon work and of work upon health, This was especially true of Flight Medical Othcers

who spend (or shou]d spend) the majority of their working day in crew rooms, hangars,

hardened shelters and workshops. Thus, doctors who had acquired experience on fiying '

stations were well placed fbr recegnition as Associatcs of the Faculty; that is, for the first

rung on the ladder of a spccialist career in Occupational Medicine. The ncxt step, and

for many the final one, is elevation to the Membership, The requirements for that are a

period of higher specialist training in an approved post and the possession of a suitable

post-graduate qualification, the most obvious choice being a MSc in Occupational

Medicine. However, the Faculty decided (without any special pleading from the Royal

Air Force) that the Diploma in Aviation Medicine was a fu11y-acceptable alternative to the

Master's degree, and a number of Ri4F medical oMcers were awarded the coveted Mem-

bership on those grounds. What is more, service at the Institute of Aviation Medicine

can be counted as part of the statutory period of higher specialist training, provided that

the work involves applied, rather than fundamental, research,

The significance of these events is great. The Flight Medical Oflicer need no longer

NII-Electronic




Training in Aviation Mcdicine in U. K. 23

feel that hc is neither a clinical specialist nor a generalist-instead, hc can count himself

as of Senior Registrar grade and, what is more impertant, he is recognised as such by the

profession at large. NNiith the very recent creation ol' a full RAF Speciality of Occupa-

tional Medicine, he may even receive the specialist pay alread}, given to physicians aHd

surgeons at a similar stage of their careers. At the end of his commission with the RAF

he can also expect to compete on at least equal'terms for an appointment in industry or in

the Health Service as an occupational physician,

The recognition of the Institute as a training centre apart fi'om the Diploma course

has implications extending outside the Armed Forces. The Facuity of Occupational

Medicine and the Spccialist Advisory Committee associated with it sometimes stipulate

that a candidate for accreditation should spend some of his training period outside his

normal place of employment. For examplc, a medical oflicer working for the Post Office

might be required to widen his experience by a six-months attachment to a chemical

factory or, new, to the RAF Institute of Aviation Medicine. To those of us who preach

the gospel, this is good news.

The aeromedical training of aircrew is now regarded in the United Kingdom as

scarcely less important than the teaching of medical officers, although some of the aviators

would not share that opinion. Until comparatively recently, the only instruction that

they received came from a iecture c)r two during the initial phase of their flying training,

perhaps with occasional later reinforcement from an impromptu talk from the squadron

medical officer when bad weather made flying impossible. The receptivity of the aircrew

was never high, and the lcctures were generally and understandably regarded as irrelevant

intrusions.

With the introduction into RAF servicc of new and more sophisticatcd high-

perfhrmance aircraft, the personal equipment worn by aircrew became more complex and

also more specific to the aircraft type. Flying clothing no longer consisted of an overall,

a leather helmet, a scarf and goggles, but of an assembly of specialised items that reflected

the advances made in the occupational medicine of Hight, The crew oC fbr example, a

Phantom aircraft might require to use any one of four different assemblages according to

whether it was summer or winter, and whether their sortie was to be at high altitude or at

low level.

The fitting and maintenance of the fu11 aircrew equipment assembly, or AEA, became

a skilled trade, but the instruction of customers in its use was an even more skilfull

requirement. In 1964, the Roy, al Air Force created an Aviation Medicine Training Cen-

tre-a single establishment to which aircrew would go for indoctrination in the functions

o{' the AEA. Initially, the cmphasis was on equipment Ibr protection against high alti-

tude, and especially against a loss of cabin pressure at heights where pressure breathing

was necessary. An altitude chamber was used to provide realistic personal experience of

rapid decompression, after prcliminary training in the technique of pressure breathing at

ground level, but it soon became obvious that the chamber had other and more significant

NII-Electronic




24 P. HowARD

uses. Many aircrew had never enceuntered the symptoms of hypoxia and, although that

might be a tribute to the aircraft designer and the oxygen system, it was no credit to the

training programme, A leeture and demonstration of the efi'ects of oxygen lack were

promptly introduced.

As the role of the Aviation Medicine Training Centre expanded, so did the scope of

its teaching. So, too, did the frequency with which an individual returned for

training. At his first visit, early in his flying career, he would be equipped with the

basic AEA appropriate to the training aircraft. On transition to advanced flying training

he would return te be re-equipped and re-eclucated. He would attend ence more upon

posting to a'n operational squadron with yet a different aircraft type and AEA and a later

change from, say, Phantoms to Tornados would involve another visit to the Cen-

tre. This remains the pattern, with the addition of mid-tour refresher training for many

alrcrew,

The declared purpose of the Centre is to train aviators in the donning and use of

their personal equipment, but every opportunity is taken to teach the underlying principlesof aviation medicine in simple tcrms. The first visit conccntrates upon oxygen supplies

and the eflbcts of their lack; at a later stage the fitting of the anti-g suit is preceded by a

lecture on centrifugal force; on each occasion some new aspect of aviation medicine can be

covered and usually demonstrated. The instruction is not solely related to items of

hardware, Disorientation is an exceedingly cemmon in-fiight occurrence, but aircrew are

extrcmely reluctant to admit to it in case they are considered abnormal or hypersensi-

tive, They are all re-assured by suitably elementary Iectures on the function of the

vestibular system, and by experience, in a special Spatial Disoricntation Familiarisation

Device, of the illusions of motion and orientation that can occur, They are totally

comfbrted by the demonstration that all thcir colleagues behave in the same way.

Flying personnel often complain about the number of visits that they are compelled to

make, but they wM grudgingly admit that they have always learned something of value-

this is particularly true of those who have had reason to be thankfu1 for their protective '

equipment and their training in an emergcncy. Fortunately, such situations affect only a

small proportion of the 3000 or so flying personnel who pass through thc Centre each

year.

I have tried to give you some insight into the patterns of aeromedical teaching and

training available fbr five groups of people, chosen because aviation medicine is of over-

whclming importance to their professional lives. In making that selection I have ignored

many who come to the RAF Institute of Aviation Medicine or to the Aviation Medicine

Training Centre for short periods of tuition or to pursue special interests. They include

medical students, nurses, engineers and technicians, consultant clinicians, station com-

manders and a host of others. I have also said nothing about the teachers and trainers

who are responsible for the wealth of education, because the two centres are not schools

run by a group of pedagogues. With very few exceptions, all the lectures, demonstra-

NII-Electronic



The 　 UOEH 　 Assooiation 　 of 　 Health 　 Soienoes

Training　i］1　Aviation　Medicine　in　 U 、　 K ． 25

tions，　tutorials　and 　practical　sessions 　are 　given　by　the　research 　staff 　or 　the　practising

clinicians ；by　people　who 　already 　have　a 　full−time　job．　 That　is　as　it　should 　be，　fbr　in

aviation 　 medicine 皿 orc 　 than 　 in　 most 　 sciences 　 it　 is　 the　 bench　 lcvel　 worker 　 who 　 is　 best

qualified　 to　 instruct　 others ．　 The　 motto 　 of 　the　 Institutc　 can 　 be　 translated 　 as“So　 that

thcy 　may 　fly　safe1 ゾ but　in　thc　context 　of 　aeromedical 　training　we 　might 　adopt 　that　of 　the

Test　Pilots’School，　which 　reads

“ Learn　 to　teach，　 but　 also 　teach 　 to　learn” ．

英国における航空医学の教育と訓練

Peter　 HOWARD

英国王立航空医学研究所　所長

要　　旨：英国においては航空医学の訓練は，Royal　Air　F 。 rce 航空医学研究所で卒後コ

ースの続き

として行われる．1）予備医官コース（An　 Introductory　 Medical　 Officers’Course）は

， 2週間で，空軍人隊後最初の 2 ・3 か月の問ではすべての RAF の医師が参加する、

その目的は将来彼らが空軍基地での乗務員の健康管理に必要な航空生理学や，航空医学を

教えることである．4 コースが毎年開かれる．2）一

般航空医学コース（AGeneral　 AVia−

tion　 Medicine　 Course）は民間パイロットの認定医の認可取得を希望する民間医師また

は，単に航空医学に興昧のある医師も参加できる、3）航空医学のディプロマコース（Di−

ploma 　in　Aviation　Medicine）は 1年に 1回開かれ 6 か月である．このコースは以前に最

低 1 年間の経験のある人に開かれており，今までに 25 か国から 244 名もの軍人や民問の

医師が参加している．このディプロマコースは航空医学のあらゆる面において高度なレベ

ルを包括しており水準は Master　 of 　 Science　 degreeと同じ位，高いものである．ディプ

ロマは RQyal　Col！ege 　of　Physicians によって承認されたものである，4）RAF の医官は

ディプロマコー

スの後直ちに，3 週間の特別訓練を受ける．これは彼らに RAF の政策や

手順を教えるためで，この上級コースは特に実務訓練であり，

このコー

スを終了したもの

は Fhght　 Medical　 Officer〔航空医官〕に任ぜらる．彼らはその後一定期間毎に，再訓練

生涯教台を受ける．5）航空機乗務員は，個人防護装備の組立使用訓練のために RAF 医

学研修コースに参加する際に基本的な航空医学の原理を修得する．これらのコースは飛行

機の種類別に特別な訓練を行うもので，

パイロットはその生涯の間に最低 4 種類位の飛

行機を経験するものである，6）非常に専門的な分野に関する短期間コースが臨床コンサ

ルタント，医学生，

上級空軍士官，看護婦やその他にも用意されている．現在英国では航

空医学は産業医学の一分野として認められている．Royai　College　 of 　Physicians はディ

プロマコー

スを産業医学における正式な教．育過程の証拠として認定している，このように

英国における産業医学の最近の非常な発展は，民間医師および，軍医の航空医学訓練に対

する必要性を益々増加しつつある、

J．uOEH （産業医人誌）， 7 （1）：g− 25 〔1985）

N 工工一Eleotronio 　Library 　

teaching training aviation medicine

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