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Dear Toxicologists,

Discussion in 'Medical Toxicology (MD, DO, PharmD)' started by GoBuckeyes913, Nov 2, 2010.

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  1. GoBuckeyes913

    GoBuckeyes913 Intoxicating

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    On the fence about whether to do a Tox fellowship after EM residency. I love the subject of Tox, but unsure of whether or not I love all aspects that come along with it enough to do the fellowship.

    The problem is that we get an elective our 3rd year, however we aren't allowed to do an away rotation at another hospital (you know, malpractice coverage and stuff) and my program doesn't have a tox fellowship.

    Please share your love and hate for toxicology. What is call like? What is rounding like? What are your hours in the ED like weekly? Would you do it again, and was it everything you thought it would be? To be honest, I hate rounding and I hate call, so much that I would rather put a campfire out with my face.

    I would never make a decision without actually at least shadowing a toxicologist, just want some more input before I contact anyone.
  2. BADMD

    BADMD

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    First things first, if you have a day off or two and want to see a "day in the life of," and are willing hang out in Detroit, I'm sure we can arrange something.

    Let's start with the good:

    First and foremost, I like seeing poisoned and ODed patients. As a resident, I was always happy when someone would come in the ED ODed on something. Now, people call me to tell me that someone has come in that way.

    I like being more than "That ER doctor." Basically all of the admitting services in the hospital, even the vaunted surgeons, have consulted me at some point in the last year. We often get called for "undifferentiated hepatitis" and "metabolic acidosis of unknown cause" at the same time or even before GI or Nephro. We work fairly closely with the ICU and they like our input (and even better that we take over short term management, although we are not an admitting service.) These relationships become very helpful when you are in a jam in the ED or if you want someone to do you a favor.

    It is also pretty sweet to have a specialty body of knowledge. I am a jack of all trades and a master of one too.

    There is also something to be said for the change in pace. Instead of seeing 2.5+ patients an hour, I can sit down with something really interesting for 1-2 hours if I want to. I recently saw a patient that had been in the hospital for 3+ weeks. That consult took 2 hours of careful review. Especially as I was studying for boards, that consult really made me sit, think, and research. While consults like that are tedious (and rare), you learn a lot, not just about what you do, but about what other specialists do. You also have a chance to actually break a tough case.

    Tox rounds aren't like medicine rounds. Since, at least in our system, we aren't a primary admitting service, I'm not going to pontificate on the potassium unless it is actually relevant to the toxic condition. Social issues? Usually not too important for us (except with lead poisoning).

    My patients are typically in and out of the hospital. They typically spend a day or two and then are out. Most of them go to the ICU. When they leave the ICU, I'm usually done too. With rare exceptions, I don't think I see most patients more than 2 or 3 times. If the patient becomes a rock, unless I am actively managing, I can sign off.

    My tox days are generally pretty relaxed. I can come in sometime in the morning and leave when I am done. We run a resident rotations, and on those days it is basically 9 - 5, plus or minus.

    Having the tox credentials got me my job. I've recently moved into a leadership position in a residency program after doing some residency support for a year. Additionally, tox got me on to two committees (that comes with a financial reward as well). This comes with protected time where I can do Toxie things that interest me.

    Now the bad:

    Call is a PITA. When I'm on call, I can get called. There is no question that it stinks to get called 4-5 times after going to bed, especially if there is something going on the next day.

    The protected time to additional responsibility time is not equal. Right now I have traded slightly more than 2 ED shifts for 4 on call days and residency responsibility (I am in the process of negotiating for more protected time). The additional in hospital time likely equals the two shifts and that doesn't include stuff that I do at home. I have at least one day a month where things get jacked up and I end up working a long day on short sleep.

    Tox doesn't pay. Very few toxicologist are actually working full time as toxicologists. While I can't speak for others, the patients I see are often uninsured and have very few resources, fewer than those from the ED. The collections on my billing are terrible, much worse comparatively, to my ED billings. There is no question that if I had to live off what I collected, I would be ED only.

    Keeping current is also a PITA. I have to cover EM and Tox stuff. I also will (hopefully) have to do LLSAs for both Tox and EM. The tox boards were unlike anything I have had to do before. The exam and, studying for it, was ridiculous. It was also damn expensive to do the whole thing. Assuming I pass, I am already kind of dreading the recert in 10 years.

    On other notes:

    All tox fellowships are different and have a different focus. UMass is more research based. NY PCC has lots of public health. They all have a different style. You kind of have to pick your program based on where you want to be and what they focus on.

    So all in all, I like what I do. It has had lots of benefits to me but does come with some baggage. You have to decide if that is for you.

    If you are a second year and are interested in Tox, the American College of Medical Toxicology offers a scholarship to attend the North American Congress of Clinical Toxicology, which is every October.
  3. Rendar5

    Rendar5

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    Drat, wish I knew taht earlier =p though my october was completely booked to be fair.
  4. GoBuckeyes913

    GoBuckeyes913 Intoxicating

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    Great perspective, can't thank you enough for sharing. I love tox and seeing the OD pt., and I'm the kind of person who would like to be the "all knowing" specialist in the subject. Currently in the middle of a tox research project as well. Just don't know if that's enough yet.

    I'm PGY2 so I'm giving myself until springtime to decide. I had no idea that different Tox programs are centered around different things. I'll admit that I'm not even sure what to look for in a program. I searched their statistics, but not sure what I should be looking at.

    How many ED shifts do you work/month? Does it take away from pay you could be making? (I've got a TON of med school debt, but who doesnt).

    How many tox calls/month? Do you round everyday?
    I've heard of places that have inpatient tox beds, so I would assume that Tox can primary admit. Sorry for all the questions, you've been a big help :)
  5. BADMD

    BADMD

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    I can only really comment on my deal. The fellow who was one year my junior has a completely different deal from a different hospital system as does one of the other faculty members.

    I work 120 hours per month currently (which is likely to go down with my new residency responsibilities). 140 hours is considered full time. That translates to 13-14 shifts per month and shift are typically 9.5 hours, but can be as high as 12 or as low as 7 depending on which particular shift it is. For that, I round 4 days a month for the entire hospital system and try to cover the routine consults at the hospital where I do most of my ED work. I also have to devote some time to the residency program, although that is more nebulous.

    I get paid less as I am working in the ED less, however I have balanced that with pay from my academic duties. It nets out about the same although I am working more than if I were straight ED.

    Others have different deals. Commonly, a straight shift reduction is given in exchange for academic work.

    Some places do have dedicated inpatient tox beds. I would love to have that, personally. Ward Donovan at Pinnacle has build that for himself. It would be great and allow me to practice more tox. However given the number of bodies that our group has available, I can't ensure that someone will be in the hospital 24/7 and I don't have enough patient in the hospital at anyone time to justify getting people to pull that off. That may change in the future, but getting there is a tough journey. As of now, our group has chosen not to be a primary admitting service. Tox is considered an all ages specialty, so you can justify admitted pediatric patients as well.
  6. BADMD

    BADMD

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    The ACMT Spring Course is March 18-20 in Clearwater, Florida. I have no idea if scholarships are available for interested residents. You can enquire with the ACMT. http://www.acmt.net/contact.html

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