Tox

[clement]

The nature of this Q might be redundant, but can psychiatrists do a tox fellowship?

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[st2205]

The nature of this Q might be redundant, but can psychiatrists do a tox fellowship?

Better to ask on the tox forum, but if you convince a program to take you, you won't be able to sit for the boards since they're only sponsored by peds, EM and occ/preventive med. that being said, there are a number of IM tox people and at least one neuro recently. I'd imagine every program structures it differently but I did a tox rotation out at Albert Einstein in Philly and the tox service there (and to a large part everywhere, I'd assume) is largely didactic based and for educating EM residents. The tox fellows do a lot of teaching and also take call from the poison center, but they also do regular ED shifts, which is probably one of the ways that they can afford to train fellows on an almost purely consult driven field. I think there were four faculty and they'd spend most of their time on ED and then one week would be on for tox.

Anyway, I've considered tox (via psych) as probably the only fellowship I'd be interested in. Had a lot of fun on the rotation. At least 90% of the patients (no joke) are psych patients. The overlap with psych is almost unmatched.

 

[clement]

I'm surprised there isn't a psych sponsored fellowship...That would be neat, certainly given both population and substance overlap.

 

[billypilgrim37]

I'm surprised there isn't a psych sponsored fellowship...That would be neat, certainly given both population and substance overlap.

Neat, but not really that useful. Psychiatry residents really wouldn't be prepared to handle the more complicated aspects of medicine that toxicologists handle on a regular basis.

 

[whopper]

This forum made me look it up and I saw a fellowship that mentioned that they would take someone so long as they were board-certified in the field.

That said, I agree with Billy on this. I've looked at a few tox results on a psychological autopsy and while I knew what it was saying because I have an M.D., it was really an area where I felt this was something that I better get someone with more expertise in the field to check it out.

I think the only time I ever pitted my knowledge on a tox issue against a doctor specializing in the field and still thought I knew more was concerning a self-induced rat poisoning case I had, but in that one, I looked up the data for over a week for about 5 hours a day, scouring every journal article I could find on the issue, and it was only on that specific substance.

 

[st2205]

While I don't think psych could sponsor a fellowship I do think, given certain conditions, it would certainly be possible for a psychiatrist to enter toxicology. They'd probably have to get as much ICU exposure as possible in residency with some possible EM. Keep in mind that a lot of the complicated stuff tox people do is largely a result of fellowship. Peds folks going into a tox fellowship obviously know little about adult acute and critical care. EM folks, while doing some ICU, aren't masters of it. And as far as occupational/preventive med, do they even step foot in a hospital in residency? There would most certainly be some technical difficulties in training someone from psych but there are also some advantages that some of the other guys won't have, especially in the realm of emergency psych.

 

[Bartelby]

Neat, but not really that useful. Psychiatry residents really wouldn't be prepared to handle the more complicated aspects of medicine that toxicologists handle on a regular basis.

Agreed. I did a tox rotation recently and while it was a lot of fun it was all about acute management and stabilization, and then ongoing advice about purely medical issues. The fact that many of the patients were intentional overdoses was irrelevant to how they were managed from a toxicological standpoint, except that they got a sitter and we made sure they did not have hidden fentanyl patches or drug stashes they could harm themselves with once admitted.

 

[Nervous Ned]

The nature of this Q might be redundant, but can psychiatrists do a tox fellowship?

Like others have said, you can if the fellowship director agrees to it, but you won't be able to sit for the tox boards unless you're coming from EM, peds, or PM/OM.

I'm surprised there isn't a psych sponsored fellowship...That would be neat, certainly given both population and substance overlap.

There kind of is; it's addiction psychiatry. That's what I'd suggest doing for anyone in psych who is interested in tox.

While I don't think psych could sponsor a fellowship I do think, given certain conditions, it would certainly be possible for a psychiatrist to enter toxicology. They'd probably have to get as much ICU exposure as possible in residency with some possible EM. Keep in mind that a lot of the complicated stuff tox people do is largely a result of fellowship. Peds folks going into a tox fellowship obviously know little about adult acute and critical care. EM folks, while doing some ICU, aren't masters of it. And as far as occupational/preventive med, do they even step foot in a hospital in residency? There would most certainly be some technical difficulties in training someone from psych but there are also some advantages that some of the other guys won't have, especially in the realm of emergency psych.

No, that's not at all true about peds, EM, or PM. All three specialties get a lot of exposure to critical care and tox, especially EM.

Peds is a sponsoring specialty because young children tend to get into a lot of things they shouldn't, and it all goes straight into their mouths. You also get the adolescent attempted suicides by overdose. The peds residents spend several months working in the pedi ED and in the PICU/NICU. PM/OM residents do a year of medical internship first before going into their specialized training, where they'll do some MICU time and likely an ED rotation along with their regular floor months. They focus more on the environmental tox end of things as opposed to taking care of acutely ill overdose patients.

EM residents spend the most time doing critical care and tox during residency. I'm at a three year program, and I'll have done five months of ICU training plus a dedicated tox month when I graduate. That's pretty standard for EM residencies. We're also the ones seeing ICU players when they first arrive at the hospital and stabilizing them before they go up to the unit, so we get a lot of critical care on our EM months as well. I can't speak to how things are at other programs, but here in Worcester, we see a ton of tox cases in the ED, especially the adult side. I consult tox on the order of once or twice a week on EM months, and that's not including all the minor tox cases or alcohol intoxication/withdrawal cases that we don't consult for. As a tertiary care center, we get tox cases transferred to us from community hospitals too.

All that being said, the tox environment at UMass is probably on the more extreme end. We have a huge med tox division with around a dozen toxicologists, and it's very common to be working with a toxicologist on your regular pod shifts just because there are so many here. We also have a two hour weekly tox conference that draws tox people from all over New England, and a tox podcast. Even if you're not that interested in tox, you can't help but get a ton of tox exposure if you train at UMass.

Agreed. I did a tox rotation recently and while it was a lot of fun it was all about acute management and stabilization, and then ongoing advice about purely medical issues. The fact that many of the patients were intentional overdoses was irrelevant to how they were managed from a toxicological standpoint, except that they got a sitter and we made sure they did not have hidden fentanyl patches or drug stashes they could harm themselves with once admitted.

I agree that our focus is much more on the medical stabilization side of things versus the psych side of things. Like many academic centers, we have a separate psych ED. So what ends up happening is that the really sick tox patients, including those who are withdrawing from alcohol, get admitted to medicine/peds or the ICU, and the admitting team consults inpatient psych. The stable patients go to EMH (Emergency Mental Health) to be evaluated.

 

[Daiphon]

Well said, all... sorry about the late reply; long, bad shift last night = less SDNing in the morning.

Speaking of shifts, one other thing to consider is that many programs help pay for you with you working ED or clinic shifts, or as a peds hospitalist. Many, not all, and this is a somewhat contentious issue within the realm of tox fellowships right now, to boot.

If you're not BC/BE in EM/peds/occ med, you can't really supervise residents in these realms, either... as you'd be at an academic center for the fellowship, this also could pose problems.

My advice: if interested, ask... worst case is a bunch of 'no thank you' replies; but if you find a willing FD and can work out the kinks, go for it.

Cheers!
-d

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