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Is it hard to get into after an EM residency? It doesn't seem like there are that many programs, so I would imagine a lot of people don't match. Harder than IM -> Cards/GI?
How competitive is tox?
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Depends on the program. Competitive programs are competitive. There are plenty of programs that don’t fill every year and very few applicants who don’t match. Those that don’t match often don’t match because they were geographically limited and didn’t get into the 1-2 programs they applied to. I only know one person who didn’t match and that was because he applied to one program where his wife was doing an IM fellowship and then the Tox program lost funding for the fellowship spot for that year.
Also depends on the interest. In general, those that do fellowship in EM are probably looking for academic positions, particularly in tox, which is not a large proportion of people who go into EM overall. Cards/GI is generally going to be more competitive because more people are interested in pursuing the fellowship, partially due to the fact that you can make bank in private practice after the fellowship. So it’s not just limited to those who want to do academics. Tox is not the most lucrative in private practice, it turns out.
Also depends on the interest. In general, those that do fellowship in EM are probably looking for academic positions, particularly in tox, which is not a large proportion of people who go into EM overall. Cards/GI is generally going to be more competitive because more people are interested in pursuing the fellowship, partially due to the fact that you can make bank in private practice after the fellowship. So it’s not just limited to those who want to do academics. Tox is not the most lucrative in private practice, it turns out.
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Does it make any sense to pursue a Tox fellowship without interest necessarily in Academics? What if you just like the idea of dividing your time between ED/ tox work and simply enjoy the deeper physiology of tox? Plus having a possible "out" from shift work when you get older. Is that reason enough to do the fellowship?
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It’s hard to find Tox jobs outside of academics. Almost all poison centers are connected with an academic center. There are some private toxicologists but they are not very common, because, like I said previously, it’s not very lucrative. Reimbursement for a Tox consult is low because it’s mostly advice and no procedures (infectious disease is also low reimbursement) and there are very few Tox patients in general. Most academic centers, which will have the most Tox patients, have less than 200 consults a year. It’s totally possible, it would just be difficult, and require a significant lifestyle change if you chose to leave EM and do Tox full time as there would be a very significant decrease in you income. Not everyone is motivated by money, but it’s something you should be aware of and plan appropriately. I went into Tox because I want to divide my time and I enjoy it. If my body ever feels like it can’t do EM anymore I’ll probably also do full time Tox. But I also want to do research and teach at an academic center, so it really works out for me.
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These are still great reasons to do a medical toxicology fellowship. The way I see it, the tox training will make you a better EM physician if you decide to just do that after you're done. There are plenty of those that do the fellowship and dont go into significant tox work, but the depth of knowledge they gain is still useful.
There are also many people that do tox outside of academics. Some people I know that have gone into nonacademic tox include: working at the health department, working at the FDA or CDC, working at a national lab, doing legal work (like tox forensics), or running their own tox consult services (with or without EM time sprinkled in). The money may not be as much as working shifts in the ED, but the lifestyle and personal gratification makes up for that in my opinion. Though you can always supplement with a few EM shifts a month and make the same, if not more.
Academics may be the easiest route with tox, and most people that go into toxicology wanted to be in academics in the first place. But its not the only track. It is definitely harder to do full time toxicology outside of academics as stated above, but its not impossible. You would just have to find your niche and sometimes it may take time to build up.
