Every year, EM residents ponder whether to do a fellowship. In the ALiEM Chief Resident Incubator, a handful are very interested in a medical toxicology fellowship, but I woefully am unqualified to provide any advice. So in a “phone a friend” moment, I boldly sent out an email requesting advice and insights. I received two amazing replies from Dr. Lewis Nelson (NYU) from a fellowship director’s perspective and Dr. Annie Arens (UCSF) from a fellow’s perspective.
NAC Masters: Lifestyle of the Medical Toxicology Fellow
Medical toxicology is a 2-year ACGME fellowship available to EM residency graduates. There are more than 20 programs across the nation to choose from, each providing a unique experience. While it may seem the specialty is centered around recommending N-acetylcysteine, IV fluids, benzodiazepines, and supportive care (not entirely incorrect), Medical Toxicology covers a wide range of topics. A toxicologist specializes in a wide variety of exposures including: envenomations (spiders and scorpions and snakes, oh my!), occupational exposures (don’t drop Mercury thermometers), drugs of abuse (just say no), toxic plants (don’t forage mushrooms), public health (who knew there was lead in THAT?), and many other topics.
Fellowship Curricula and Schedule
The lifestyle of a toxicology fellow varies from program to program but is generally balanced between ED shifts and medical toxicology responsibilities. In general, a fellowship schedule means a transition from an almost exclusively shift-work schedule to a more regimented academic schedule peppered with ED shifts. Not every program requires fellows to work ED shifts, and the number of ED shifts per month varies depending on the program. Most programs also allow fellows to moonlight.
First Year of Fellowship
Typically the first year is clinically focused on learning medical toxicology with a combination of didactic sessions and bedside/telephone consultations. Call schedules vary based on the number of fellows, call volume, etc. Call is usually home call, and most consultations can be completed over the phone; however, most fellows are also responsible for bedside consults at their home institution(s). Poison Control Centers often cover an entire state, or even multiple states, so evaluating each consult at the bedside is unrealistic. Inpatients may be seen individually with fellows and faculty, or fellows may have more formal bedside ‘rounds’.
Second Year of Fellowship
The second year also varies greatly between programs; however, this year is most commonly centered on allowing fellows to explore their particular interests with electives as well as focus on completing research projects. Second-year fellows are often still required to take call throughout the year and may have some responsibility in teaching and mentoring their junior fellows.
In addition to being available for telephone and bedside consults, fellows will have additional academic and/or poison center responsibilities. Medical toxicology programs often have a didactic curriculum, or a reading schedule for fellows to learn core content. Many fellowship programs are affiliated with the local poison control center and fellows are expected to review cases each day and discuss cases with a faculty member, or review interesting cases with staff members and rotating students and residents. This provides a teaching opportunity for fellows, and an excellent learning opportunity for rotators. Fellows are also involved in research projects allowing the opportunity for fellows to publish their work in academic journals. Annual medical toxicology meetings provide another forum for fellows to present research topics and practice speaking to large audiences.
Love to teach?
One of the advantages of a medical toxicology fellowship is the opportunities for teaching. In addition to educating providers during telephone and bedside consults, fellows are expected to teach residents and medical students during their clinical rotations. This may include creating lectures or simply discussing individual topics during rounds. Fellows will have the occasion to give Grand Rounds presentations to the Poison Control Center, medical staff, and even the general public.
The reason why people pursue a medical toxicology fellowship is as varied as why people choose EM. Medical toxicology fellowships allow clinicians to excel as academic emergency physicians but also allows for careers outside of EM. Practically, it provides an additional skill set as a clinician and unique research opportunities. The majority of fellows go on to use their training as academic emergency physicians, focusing on toxicology research projects and medical education. A number of other fellows decide to practice in Addiction Medicine or consult for a pharmaceutical company. Most importantly, a medical toxicology fellowship allows exploration of one of the most fascinating topics in medicine and combines teaching, community outreach, and public health initiatives. It provides a valuable skill set that complements any EM career.
Perspectives from a Medical Toxicology Fellowship Director
If you love the idea of having niche knowledge that has practical implications and can make a difference in patient care, doing a fellowship is worth considering. Medical toxicology is a bona fide subspecialty of emergency medicine (EM), complete with a unique body of knowledge 1 , professional organizations, program accreditation standards, and a board certification exam. Like virtually all of the subspecialties in EM, and unlike many of the subspecialties outside of it, doing a fellowship will not necessarily take you away from your chosen primary specialty… which can be good or not depending on your interests.
Many Academic Career Options
A distinct advantage to pursuing a fellowship in medical toxicology accrues for those who are interested in a career in academic medicine. A study done in 2000, identified that most respondents felt that their toxicology fellowship influenced their decision to pursue an academic career. 2 Many developed a toxicology practice, which likely amounted to inpatient consulting for most. However, an outpatient practice can be attractive to some, and nowadays a career in addiction medicine fills a very necessary void. They felt that their training also changed their clinical responsibilities, and shifted their focus away from a primary practice of EM towards education, often in fellowship training programs. Most have some contact with poison centers after graduation. 3 Some fellowship graduates leave EM altogether and pursue careers in venues such as governmental agencies (e.g., CDC, FDA) or industry (e.g., pharma or consulting firms). 4
A brief review of my graduates from over 20 years (about 50 fellows), shows that the career choices span the spectrum. Some are or have been residency program directors, department chairs, medical toxicology division chiefs; some work for the government; some run poison centers; several have taken a grant-pursuing research pathway; and several have found careers working outside of the USA. Many sit on or chair known institutional committees, such as Pharmacy and Therapeutics (also knows as Drug and Formulary) or Quality and Safety.
The majority of graduates still consider the ED their home, but enjoy the kudos that they derive from being the go-to person in their department for all things pharmacological. Drugs of abuse, self-harm attempts, medication errors, envenomations, childhood exposures, public policy issues, the list goes on and on. However (as noted above), if you are interested in leaving or minimizing work in the ED, medical toxicology can provide a pathway out.
Variability in Fellowship Curricula and Experiences
Fellowship programs themselves tend to be heavily focused on, not surprisingly, clinical care and scholarly activities. Each has its own balance of conferences, journal clubs, clinics, and research efforts to support training. There is often a direct link to a poison center, which allows fellows to mine an entire region or state for good case material. But the need for a poison center is not universal, and often the uniqueness among the programs are a major attraction… links to departments of health, governmental agencies, admitting services, critical care units, snakebite victims, hyperbaric centers, among others.
Some programs have ED shift requirements, but they are limited by the ACGME to 12 hours weekly, and many have eliminated this requirement altogether. Some programs require clinical work to pay the fellowship salaries, but often fellowship positions are tied to housestaff pay lines, which serves as the basis for abolishing the shift requirement. However, for most it is essential to maintain your primary skills in EM, and for those programs that do not have required ED time, moonlighting is usually allowed.
Fellowship training is a great way to expand your clinical and academic horizons. With many academic EM training programs hiring only faculty with advanced degrees, research grants, years of experience, or fellowship training, medical toxicology training may allow you to begin or accelerate your career trajectory. You will be joining a small cadre of primarily emergency physicians, who love intellectual pursuit, nuanced debate, and concerns for both individual patients and public health.