I am so sorry you haven't received any replies yet! I am a newly minted tox fellow, so I will try to answer your questions.
I will have to agree with you, EM is amazing but emotionally difficult over a long career. This was one of the big factors that brought me to tox. I also feel that it can only make me a better doctor in the long run if I decide to do EM full time afterwards. In tox, patients can be so much more grateful of your work helping them. It’s a whole different environment from solely seeing patients in the ED. I always joke that in the tox departments I have travelled to all over the country, their chairs are always comfortable and new, and their computers are ergonomically set up for your comfort. Think of any ED you have ever been to. Almost all of the physician chairs are uncomfortable, taped together, or falling apart (and that is if you are lucky enough to get a chair in the department. Sometimes you have to stand!). Point is, I feel appreciated as a toxicologist, something that is not always the case with the current ED climate and politics. But I digress…
1. The typical attending schedule can vary a lot! From what I have seen on rotations/heard from toxicologists over the years, it all depends on what you decided to do with it. You can be a tox consultant, and basically work a similar schedule as an infectious disease physician... If you don't know what that is like: it’s like being on call (may get called overnight) but not having to go in immediately to see the patient. It can be a "show up at 9am to see the patient and be done by 12pm" kind of schedule. One doc I work with does tox half the month, then works at a private hospital in the ED half the month. She does two weeks on tox where she is on call (with the fellows) for about 4-5 days a week. On these days, she shows up to discuss patients and teach during table rounds in the morning (8am-12pm). Then the next two weeks, she works 6-8 shifts in the ED. She likely makes a bit less than she would if she just worked in the ED 12-16 shifts a month at a private hospital, but she has more flexibility with her schedule (gets out of tox around noon on these days!). I would think this would lead to a better work life balance.
2. I have not done medicolegal work in tox, but we just had a good ACMT lecture by several nationally known toxicologists that do this almost full time. It seems that the toxicologist can bill an hourly rate similar to what you would make in the ED per hour (if you don't know what this is, its usually $150-250 depending on what part of the country you are in, but it seems like they make on the higher side for legal consulting). Theres a lot of back work that goes into it, definitely a lot of digging into the literature and knowing your stuff. It can be difficult since the other lawyer may try to discredit you on the stand at every turn. Nonetheless, people that do this seem to like it. It can be flexible since a lot of time is spent preparing at home (they charge hourly for "researching the case" as above)... However, it can also be less flexible since court dates are sometimes last minute and non-negotiable.
3. It was hard for me to find specifics when I was applying too! The websites are not always accurate or updated, and usually there is vague information. I interviewed at 5 places, three of which I rotated at. Here are some general things I know (some is hearsay, take it with a grain of salt), if you want more specifics just ask...
There are 28 programs in the country. Arizonas program (can't remember which one though) is heavy on inpatient critical care. They have their own Crit tox service, and the schedule can be more intense because they are literally in the hospital managing their own patients directly (as opposed to being only a consultant as discussed above in #1), but it is solid training on crashing patients in real time (which you may not get elsewhere).
San Francisco (UCSF/California Poison Control) is literally one of the top programs in the country (yes, this is solely my opinion). Obviously, there are some logistics that come with living and working in SF, as it is really expensive. However, they have a poison center that is run by pharmacists, and the education is top notch because of it. Many other poison centers are run by nurses that are specially trained, which isn't bad either, but the daily learning potential from a pharmacist that knows the mechanisms of drugs is undoubtedly more beneficial to training. They also have a solid lab and can run more specialized tests on tox patients (so good that other places send them samples to run sometimes). Fellows work at the poison center mainly the first year (learning from daily rounds, and teaching rotators), and during the second year they do cool rotations that they want to set up (like forensics, working with the medical examiner on autopsies, etc). When I was there, the second year fellow was at the botanical garden everyday learning about cool toxic plants. There is only 1 fellow a year, but it didn't seem that bad being the only one.
Atlanta (Emory/Georgia Poison Control) has the CDC aspect that is pretty cool. There are some great public health opportunities with the CDC. Their program is set up with the first year being in the poison center, and the second year spent working in the CDC. Their CDC topics seem kind of interesting, but may include an international aspect of tox or public health topics (like working on protocols for maternal health). The coolest part of this program is that if there is a toxicological emergency anywhere in the world, you have the option of going to the location with the CDC! There are 2-3 fellows each year (the third fellow is typically a military person that gets funding though the military, so they don't always have one each year) and they also have a few international fellows each year. These international fellows are not accredited spots. They are doctors in their own country and do not have a US medical license, therefore they don't see patients or take call, but they participate in daily toxicology table rounds.
Denver (Rocky Mountain Poison Center) is a tox powerhouse. They do a lot of FOAM for tox. They get a lot of calls from questions directed from the poison center when they are on call though... but these calls are a great learning experience. They have 2-3 fellows each year (one is military just like I explained above). There is a lot of opportunity for research, and they have the finances to allow for it. This one is very competitive, if not for the location alone.
Oregon (Oregon health and science university) has a really chill vibe. I liked the city, and the fellows there have a great environment to learn. The hospital is very nice (it has a sky lift between the city and the hospital which is on a hill!). They seem to have an emphasis on environmental toxins (mushrooms, etc), but obviously there are a lot of street drugs in Portland. They have 2 fellows a year.
Chicago (Toxicon) is not a program that I have visited, but I have heard they have a heavy emphasis on environmental tox.
UT Southwestern (Parkland hospital) is the program I am currently a fellow at. It has 2 fellows a year, and there seems to be a good mix of environmental (lots of snake bites in Texas) and drugs of abuse/overdoses. There is the benefit that many national toxicologists come to visit and teach the fellows from time to time. There are a large number of toxicologists on staff. The call schedule is not too brutal since there are so many fellows. There are a lot of consults (typically ranges 1-3 per day, but can be more) from both the childrens hospital and multiple adult hospitals on campus. So far, I absolutely love it.
ACMT has a nice laid out contact sheet with each program listed (see link below). There is a column on it that says “shift/service” requirement. The programs that say “yes” are the ones that require some shifts as part of your fellowship salary. From the ones I interviewed at, this list seems to be correct. Typically, the amount of ED shifts you have to do is around 4-8 a month. There is a caveat to this rule however… For instance, my program at UT Southwestern “does not have a shift requirement”, but I have to do 4 shifts a month (and I’m only allowed to do 4 shifts a month, no more or less) in order to keep up my EM skills during fellowship. I get paid as an attending during those 4 shifts though, so it’s a pretty good deal (it almost doubles my fellowship salary).
https://www.acmt.net/_Library/Fellowship_Programs/MT_Fellowship_Programs_Grid_2018.pdf
4. Being “smart enough” for tox was always a concern for me. All of the toxicologists I have met are geniuses… If you have ever read my posts over the years on SDN, you know that I did not do so hot in undergrad, or med school for that matter. On the plus side, I am a research-o-holic.
There is good news for you though, tox is not necessarily that research heavy. Tox research is hard to do because poisoning people is frowned upon… Thus, writing up case reports or data mining from the poison center database are acceptable. Even though you may not like research, it may just be that you haven’t found a topic that you are passionate about yet. When you are excited about something, you will want to share it with everyone around you. Just think of the coolest patients you’ve seen with the wildest stories in the ED that make you smile just thinking back on them… This is literally EVERY DAY in tox. After fellowship, you can still be a tox attending and not do research. There is no real demand to “produce” like there is for PhDs. Again, this field is what you make of it.
There was a time in residency when I flip flopped on really wanting to pursue tox… But I knew if I didn’t, I would regret it my whole life. In fact, I have met about a dozen people at national EM conferences who have told me that they once wanted to do tox but didn’t pursue it because of the constraints in their life (financial, family, etc), and they have regretted it ever since. It’s a decision that is definitely hard to make.
Toxicologists are always the NICEST people on the planet, do not hesitate to email any of them on the ACMT list (or feel free to message me!) if you are still interested in tox or have any more questions!
