Toxicology
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Toxicology

Authors

Maricel Dela Cruz, DO, MPH
Medical Toxicology Fellow
Drexel University College of Medicine

Asaad Alsufyani, MD
Medical Toxicology Fellow
University of Virginia Health System

Ryan Surmaitis, DO
Medical Toxicology Fellow
Drexel University College of Medicine

Faculty Editor

Kenneth D. Katz, MD, FACMT, FACEP, FAAEM
Clinical Associate Professor, USF School of Medicine
Clinical Assistant Professor, PCOM
Section, Medical Toxicology
Department of Emergency Medicine
Lehigh Valley Health Network

Special thanks to our 1st edition writing team

Ryan Surmaitis, DO
Natalia Rumas, MD
Clifford Masom, DO
Anthony F. Pizon, MD

INTRODUCTION

Description of the specialty
Medical toxicologists are physicians who specialize in the prevention, evaluation, treatment, and monitoring of injury and illness from exposures to drugs, chemicals, biological, and radiological agents. These specialists care for people in clinical, academic, governmental and public health settings, including poison control centers. Important areas of medical toxicology include acute drug poisoning, adverse drug events, substance use disorders and withdrawal, chemicals and hazardous materials, terrorism preparedness, envenomations, and environmental and workplace exposures.

History of the specialty/fellowship pathway
The American Board of Medical Toxicology (ABMT) was established in 1974 by the American Academy of Clinical Toxicology in recognition of the growing responsibilities of physicians who provided a significant portion of their professional activities to medical toxicology. In September 1992, the American Board of Medical Specialties (ABMS) approved medical toxicology as a subspecialty, recognizing the American Board of Emergency Medicine (ABEM), American Board of Pediatrics (ABP), and American Board of Preventative Medicine (ABPM) as sponsoring boards. ABEM is the administering board. The first examination was offered in 1994 and is currently administered every other year.

Why residents choose to follow this career path
Some current medical toxicology fellows were unaware they wanted to pursue a toxicology fellowship before starting an EM residency. Most applicants describe a specific toxicology case encountered (in the ED or the ICU) which sparked their passion for the field. Others, however, developed their interest more gradually. Residents who have the opportunity to work directly with a toxicologist or consulting toxicology service in a hospital setting are more likely to pursue a toxicology fellowship.

Completing a fellowship allows the physician to develop a niche and become an expert in a specialized field. It can also open doors for new career possibilities such as: academia, occupational or industrial medicine, pharmaceuticals, forensics, research, medico-legal work and medical consulting.

How do I know if this path is right for me?
Participating in a medical toxicology rotation is the most valuable way a resident can decide if a fellowship is right for them. This allows the resident to preview and understand the schedule, lifestyle, and career of a medical toxicologist.  Spending time in a regional poison center is also another opportunity to become familiar with the field of medical toxicology. However, it may be limited in scope and bedside experience is ideal.

Find mentors in the field to help answer questions and provide guidance. The EMRA Toxicology Division can help you get in touch with attending medical toxicologists and current fellows to help guide you.

Career options after fellowship

  • Emergency departments, intensive care units, and other in-patient units in which direct treatment and bedside consultation for acutely poisoned adults and children is provided.
  • Outpatient clinics, offices, and industry job sites where assessments from acute and chronic exposure to toxic substances in the workplace, home and general environment are performed.
  • National and regional poison control centers providing 24-hour phone consultation to health professionals, first responders, public health officials, corporate safety personnel, and the general public regarding hazard identification, decontamination, emergency management, and detailed clinical care of the poisoned patient.
  • Medical schools, universities, residencies, and clinical training sites where medical toxicology is taught and research is performed.
  • Governmental agencies which provide medical toxicology expertise to the U.S. Food and Drug Administration, the U.S. Environmental Protection Agency, and state and local health departments as well as non-governmental advocacy organizations, consumer groups, and industrial associations.
  • Clinical and forensic laboratories which aid in the design, conduction, and interpretation of diagnostic tests and forensic studies.

Academic vs. community positions  
The majority of medical toxicologists divide their clinical time between duties performed in medical toxicology and emergency medicine. In general, academic positions allow a medical toxicologist more protected time (reduction in clinical ED shifts) with increased focus on lecturing, teaching, research, and medical toxicology clinical responsibilities. Community positions tend to have more focus on clinical ED duties. These divisions, however, are completely institution-dependent and will be individualized for the practitioner.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are currently 27 ACGME accredited medical toxicology fellowship programs for the 2018-2019 academic year. EMRA Match offers an interactive map of toxicology fellowship programs on its website.

Differences between programs
While the core curriculum among fellowship programs is identical, they do differ from one another in a variety of ways, including:

  • EM shifts: Some programs require fellows to work a designated number of shifts in the ED as a junior attending in order to receive pay during the fellowship. Some programs are “fully-funded” by the ACGME and do not require these shifts.  However, regardless of this designation, programs generally allow moonlighting as long it does not interfere with fellowship responsibilities.  The choice between these two types of programs is an individual one; however, either type of program provides excellent education and preparation for the board.
  • Number of fellows: This may range from one to three fellows per year. This will factor into your duties and how your call schedule is arranged.
  • Didactics: All programs implement didactics and lectures, but the structure and schedule may differ among them.
  • Bedside Teaching/Rounds: Programs will vary regarding bedside rounds/teaching-at-the-bedside versus phone consultations. Generally, all implement some combination thereof depending on the size and focus on the program.
  • Sub-focus: Programs may emphasize different aspects of medical toxicology such as medical, occupational, environmental, or forensics.

Length of time required to complete fellowship
All ACGME accredited medical toxicology fellowships are two years in length.

Skills acquired during fellowship
Fellows will acquire the necessary clinical and research skills to allow them to function as an independent medical toxicologist upon completion and, ideally, board-certification.

Typical rotations/curriculum
All programs follow the ABEM Core Content of Medical Toxicology, which serves as the foundation of the toxicology board exam. Most toxicology programs do not have blocks or rotations compared to an EM residency. Typically, programs will have the fellow work during day hours performing clinical duties, research, reading, conferences, and didactics. Call-schedules will vary among programs. 

Board certification afterwards?
Fellows completing ACGME accredited programs will be eligible to sit for the ABEM Medical Toxicology Board Certification Examination. The pass rates vary among programs, so be sure to ask during your interview. 

Average salary during fellowship
Fellows are traditionally paid at the PGY-4/5 level depending on their years of residency training. Most programs will allow for moonlighting to supplement your income as well.

PREPARING TO APPLY

How competitive is the fellowship application process?
The 2018 NRMP Match Data reveals a total of 41 applicants for 47 open positions with a total match rate of 87.5%. However, certain programs are extremely competitive. As with other fellowships, limiting applications to a singular geographic area or select number of fellowships can increase difficulty matching. 

Requirements that must be fulfilled to apply
In general, there are no specific requirements needed to apply aside from completing an ACGME approved EM residency, a CV, and letters of recommendation. 

Research requirements
Academic activities which demonstrate an interest in medical toxicology are strongly encouraged. During residency, keep track of interesting medical toxicology cases and actively seek out germane attendings to try and submit them as abstracts to conferences and/or manuscripts for peer-review.  Moreover, take the initiative to ask any attending if he or she has an interesting case for you to publish or has a research project in which you can participate. Remember, the onus is on the resident to seek out these academic projects, not the attending.

Suggested elective rotations to take during residency
Participation in a medical toxicology or poison center rotation is certainly advantageous and recommended, whether at your home institution or another facility. Using an elective for an away-rotation at a program you are particularly interested in would be extremely valuable. Most programs would be thrilled to have a visiting resident on their service.

Suggestions on how to excel during these elective rotations
First and foremost, show initiative and interest in the field. Read, ask questions, see as many patients as possible and offer to help author an academic paper or research project if possible. 

Should I complete an away rotation?
Use your elective time to pursue a medical toxicology rotation at a different institution in which you may have interest or to simply see alternative programs. Most programs enjoy hosting a visiting resident. 

What can I do to stand out from the crowd?
There are several ways as a resident to become involved in the field of medical toxicology. You can join and participate in a national organization such as: EMRA Toxicology Division, ACEP Toxicology Section, American College of Medical Toxicology (ACMT), or American Academy of Clinical Toxicology (AACT). Additionally, as stated previously, actively seeking academic projects are important and demonstrate initiative.

Should I join a hospital committee?
Activities/pursuits/research that show an interest in toxicology are strongly encouraged. 

Publications other than research
Activities/pursuits/research that show an interest in toxicology are strongly encouraged. 

How many recommendations should I get? Who should write these recommendations?
Most programs require a minimum of three, one of which is from your residency program director. The other two can be written by any attending with whom time has been spent or academic projects have been performed.  A letter from a medical toxicologist is certainly helpful.  

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes. Most attending physicians do not want to return as a trainee (and give up their current salary and lifestyle). However, it can and has been done.

What if I’m a DO applicant?
MD and DO applicants are considered equivalent. 

What if I am an international applicant?
The issue with most programs is whether the applicant can eventually sit for the ACGME medical toxicology board examination. As a foreign medical graduate, that may be an obstacle. The specific program of interest should be contacted prior to application to address this potential problem. The current trend in the toxicology match is there are more positions than applicants; therefore, being an international applicant does not place you at a disadvantage. Keep in mind that physicians on Visa cannot moonlight and cannot work as attending during a fellowship. Some programs are not funded by GME office and fellows have to work as an Emergency attending to fund their positions. 

APPLICATION PROCESS

How many applications should I submit? 
In general, applying broadly is encouraged but try to include those of serious interest. 

How do I pick the right program for me?
Geography and funding are two important factors that typically play a role in choosing a fellowship. Moreover, each program has its own strengths and weaknesses.  The best way to evaluate those is to seek out former graduates, contact the program directors and, ideally, participate in a rotation prior to application. 

Common mistakes during the application process

  • Not applying to enough programs. There are usually more positions than applicants during a given match cycle, so every applicant has the potential to match. However, as mentioned previously, some programs are in higher demand than others so this may be a critical issue and, therefore, applying more broadly is a good idea.
  • Not meeting the necessary deadlines. This goes without saying. If you are serious in applying to a medical toxicology fellowship (or any program for that matter), ensure all your material is completed on time. If it isn’t it reflects poorly on the applicant.

Application deadlines
Contact either the program director or program coordinator to find out more about the exact application process. In general, the earlier the better for all involved.  Moreover, this shows enthusiasm and interest. This information is also usually located on the program’s website. Be aware the deadline for rank list submission can be found on the NRMP website. It usually occurs the first week of November. 

Tips for writing your personal statement
Personal statements should be well-written, concise, and include why a fellowship in medical toxicology is being pursued. Highlight all germane activities related to medical toxicology. Have the statement proof-read at least once before submission. Reading poorly-written or rambling personal statements is a detraction for program directors.  

Is this a match process?
Yes, toxicology fellowships participate in the NRMP match. Important dates regarding the match can vary every year so make sure to check the website. Customarily, important dates are:

  • August – Match opens
  • September – Ranking enabled
  • November – Rank list deadline
  • November – Match day

What happens if I don’t obtain a fellowship position?
If you don’t match you should check with your program director and see if there are any programs that didn’t fill their positions and scramble. Ultimately, if you don’t receive a fellowship position you can accept a job as an attending emergency physician and consider re-applying the following cycle.

INTERVIEW PROCESS

How do I stand out from the crowd?
Without a doubt, be prepared. Research the program ahead of time before the interview. Know what has been published from the program or any of its unique features. Dress and act professionally. Relax, and be yourself. Try to enjoy the process and meeting others. The good news is the “crowd” is not as large as some other fellowships. 

What types of questions are typically asked?
Having gone through medical school and residency interviews, most fellowship applicants should be seasoned interviewees. Be prepared to answer basic and simple questions such as:

  • What are your career aspirations?
  • Why toxicology?

The interview process is equally important for the applicant. This is your chance to figure out which program is the right fit for you. Do not be shy about asking any questions to help you make this important decision.

How many interviews should I accept?
There is no magic number. As many as it takes you to feel comfortable about securing a position. 

PREPARING FOR FELLOWSHIP

Textbooks with which to be familiar:

  • Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank's Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill; 2015.
  • Olson KR. Poisoning & Drug Overdose. 7th ed. New York, NY: McGraw-Hill; 2018.
  • Critical Care Toxicology, 2nd Edition.

Important skills to practice while in residency to prepare for fellowship
The number one priority in emergency medicine residency is to become an excellent emergency medicine physician. Most of the same skills are acquired during residency will obviously be applicable to those needed in fellowship. However, learning more about medical toxicology during residency will make you better prepared when starting fellowship. 

Tips on how to succeed as a fellow
One of the most important factors in succeeding as a fellow is to pick the program that is right for you. No two programs are the same, and it is important to decide what you need. Ask yourself, “Is this somewhere where I could work for two years?”, “Do I get along with this group?”, and “Are the program’s goals in line with mine?”. Some nervousness and trepidation is normal. However, if you really have serious reservation or compunction about a program (especially financially or geographically), then it is better to not proceed rather than quit during fellowship. 

Be enthusiastic about your choice and new career. You are on your way to becoming a specialist. Focus on your studies and passion that brought you to this choice in the first place. Try to learn something new every day.

Know your limitations. While many will be looking to you as an expert, do not be afraid to ask your attending probing questions. 

Manage your time efficiently. Make sure you allot time for studies as well as outside interests. Burnout is real; you want to allow yourself time to decompress. 

Maintain a positive attitude. Fellowship is the light at the end of a very long tunnel. Make sure to preserve a good outlook that will help you develop as a clinician and sharpen your medical expertise.

CONCLUSION

Additional resources

Websites

Podcasts

Blogs

Journals

  • Journal of Medical Toxicology
  • Clinical Toxicology

National organizations

  • American College of Medical Toxicology
  • American Academy of Clinical Toxicology
  • Emergency Medicine Residents’ Association
  • EMRA Toxicology Committee
  • ACEP Toxicology Section

Conferences

  • NAACT Annual Scientific Meeting
  • ACMT Annual Scientific Meeting
  • ACEP
  • SAEM
  • ACOEP

How to find a mentor
Choosing a mentor is a beneficial way to help guide your career. Although reputation within the field is important, it is more valuable to choose someone that you respect, is willing to help, and has similar interests. A mentor should be a role model who has certain aspects of their practice or life that you want to emulate. It would be helpful to have a mentor who is a toxicologist in terms of fellowship applications, networking, and career guidance. The best way to find a mentor is networking, whether that is through a toxicology rotation, conference, or research project. A less personal and more challenging approach would be to contact toxicologists nearby, if none exist in your residency. The EMRA Toxicology Committee is also a great resource to use. 

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