Medical Toxicology Careers

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I was thinking it would be good to have a thread to discuss the topic of medical toxicology careers.

Such as, do all EM-trained medical toxicologists in academia continue to do ED shifts? At UMass, the toxicologists span the gamut from basically working full-time as an EP to doing very few shifts, but I think they all at least do a few per month. That seems like a good system to me because then they don't lose their EM skills.

But I guess that begs the question: do all medical toxicologists maintain their EM/peds/occupational health board certification too even if they're not seeing patients? It seems like it would be a lot of extra hassle to do that if you aren't practicing in your residency specialty. On the other hand, it would keep your options open if you wanted to go back.

Originally Posted by Nervous Ned

I was thinking it would be good to have a thread to discuss the topic of medical toxicology careers.

Such as, do all EM-trained medical toxicologists in academia continue to do ED shifts? At UMass, the toxicologists span the gamut from basically working full-time as an EP to doing very few shifts, but I think they all at least do a few per month. That seems like a good system to me because then they don't lose their EM skills.

But I guess that begs the question: do all medical toxicologists maintain their EM/peds/occupational health board certification too even if they're not seeing patients? It seems like it would be a lot of extra hassle to do that if you aren't practicing in your residency specialty. On the other hand, it would keep your options open if you wanted to go back.

You actually pose a question with a somewhat thorny answer. d=)

I am similar to your attendings at UMass; I work in the ED and cover consults & the service in my "nonclinical" time that is alloted to me by virtue of my training/certification & academic status.

Many of us who came in through EM did so because we loved EM as well as MedTox; I for one cannot forsee a time when I'm not working at least somewhat in the ED. However, this is not the case for all and there is a movement being propagated by some of the big names in MedTox to "get away" from EM as they feel our specialty cannot be taken for what it is as long as we're working ED shifts - in other words, "would you expect a cardiologist to practice general internal medicine?"

A similar argument holds for the OccMed & Peds-trained practitioners. They're a relatively small group compared to EM, but it is still valid.

ABEM has said, however, that as long as you initially earn MedTox certification, that you do NOT need to maintain your primary board certification to recertify in MedTox; if you fail in this, however, you need to recertify in your primary board before being allowed to resit for MedTox BC. I know of several individuals who have taken advantage of this and only practice MedTox through their clinic and inpatient consultations.

So yes, it is a bit of a PITA; however, the LLSA for tox now counts for the LLSA requirements for EM, so at least I don't have to double-up that sisyphean task. Right now, I can't see myself gambling recertification for at least 2-3 cycles, but that may change as I advance in my dual career.

I'm curious as to the thoughts of the other Tox people who are on this forum...

Cheers!
-d

This is all pretty abstract for me since I'm so early in my training, but I hope you won't mind if I pose a question.

What would an EM/toxicology career look like in a community setting? If one were perhaps in a small city and the only/one of the few medical toxicologists in an area would it be harder to work more in the ED because of the need for toxicology consults?

I work mostly in the ED with some time spent on-call through our poison control center. I take consult call a few days a months.

Realistically, it is extremely difficult to support a 100% Tox practice through inpatient consultations. The patient volume just isn't there. Unlike hearts, trauma or burns, there is no push to get poisoned patients in front of a toxicologist. While you can try to set up a regional tox referral center, realistically, nobody want to transfer poisoned patients, unless the patient in uninsured. An outpatient practice is hard to start as it takes time to get a referral base.

The problem in a tox practice is how to support yourself. Administration is the easiest means of support however can only be so many poison control center directors and fellowship directors. Inpatient tox units are one way, but you realistically need to be part of a larger hospital/hospital system that will feed the patients to you. Research is another way, but you are reliant on grants. Some have made a career doing this (especially at UMass). There are some industry jobs.

I suspect that most do what I do: A little tox, a little administration and a lot of ER.

For a true community doc it is probably going to be more ED and less Tox. A community tox attending will probably get called for the bad overdoses and the weird exposures. It almost becomes a self fulfilling prophecy: You have to work in the ED and thus are less available, but you can't get your tox patient volume up because you can't have 24/7 availability. Moreover, without partners, you can't maintain constant availability, but it is very difficult to sustain even one physician, let alone 2, 3 or more.

I don't want to paint a bleek picture. I love tox, but there can be serious frustration when it comes to the financial aspects of toxicology. Departments, especially academic ones, will give some protected time, the expectation is that you work in the ED (or primary specialty). 100% tox jobs are out there, but they are fewer and usually require some creativity and lots of hustle.

Originally Posted by Daiphon

Many of us who came in through EM did so because we loved EM as well as MedTox; I for one cannot forsee a time when I'm not working at least somewhat in the ED. However, this is not the case for all and there is a movement being propagated by some of the big names in MedTox to "get away" from EM as they feel our specialty cannot be taken for what it is as long as we're working ED shifts - in other words, "would you expect a cardiologist to practice general internal medicine?"

A similar argument holds for the OccMed & Peds-trained practitioners. They're a relatively small group compared to EM, but it is still valid.

ABEM has said, however, that as long as you initially earn MedTox certification, that you do NOT need to maintain your primary board certification to recertify in MedTox; if you fail in this, however, you need to recertify in your primary board before being allowed to resit for MedTox BC. I know of several individuals who have taken advantage of this and only practice MedTox through their clinic and inpatient consultations.

That seems pretty risky (to not stay boarded in EM/peds/OM as well as med tox). It also seems like it would be a real waste. I mean, your residency training doesn't disappear once you become a subspecialist. Don't cardiologists still board certify in IM as well as cards? Even if they're not practicing as internists, they still ARE internists along with being cardiologists. So analogously, a toxicologist who doesn't do any work in their primary specialty is still an EP/pediatrician/OM doc as well as a toxicologist.

Maybe I'll feel differently in the future, but I can't imagine a situation where I would not want to keep my EM BC up, even if I didn't do any shifts. I am working too hard to become an EP to let that just go like it was unimportant.

Originally Posted by Nervous Ned

That seems pretty risky (to not stay boarded in EM/peds/OM as well as med tox). It also seems like it would be a real waste. I mean, your residency training doesn't disappear once you become a subspecialist. Don't cardiologists still board certify in IM as well as cards? Even if they're not practicing as internists, they still ARE internists along with being cardiologists. So analogously, a toxicologist who doesn't do any work in their primary specialty is still an EP/pediatrician/OM doc as well as a toxicologist.

Maybe I'll feel differently in the future, but I can't imagine a situation where I would not want to keep my EM BC up, even if I didn't do any shifts. I am working too hard to become an EP to let that just go like it was unimportant.

I didn't say it wasn't risky. I said it was an option, and that some take advantage of it. d=)

ABIM has the same rules --> as long as you maintain your certification in your subspecialty, you don't need to maintain your "base" certification in internal medicine provided you don't screw up your subspecialty certification. The attendings with whom I interact tend to keep up with IM certification, but it's not required.

From a practical standpoint (e.g. $$$ & time), it makes sense; but I agree with you, it's a bit on the risky side.

Cheers!
-d