ACMT News

Clinical Toxicology: Built Better Than They Knew
Reflections on Yesterday, Today, and Tomorrow

Frederick H. Lovejoy, Jr., M.D.
From the Boston Children’s Hospital and the Harvard Medical School,
Boston, Massachusetts, 02115

Int J Med Toxicol 2000; 3(5): 32
See also Ellenhorn Introduction


I am tremendously grateful to receive the Ellenhorn Award. I am thrilled to join a marvelous group of distinguished colleagues who are prior recipients Redetzki, Goldfrank, and Robertson. I remember Matt Ellenhorn fondly, mainly from these meetings. He was always part of the action, always questioning, always striving to get all of us to think more deeply and clearly. When Matt came to the podium speakers would turn pale and a hush would come over the room. When we had practice sessions in Boston, all would vie to be Matt Ellenhorn for a day; any question was fair game. He was a superb influence on this gathering and his contributions live on his book and in our memory.

I take for the subject of this talk, the title of a wonderful book reflecting on the history and the leaders of the Children’s Hospital in Boston, "Built Better Than They Knew", and adapted for this talk: "Clinical Toxicology Built Better Than They Knew -Reflections on Yesterday, Today and Tomorrow". In that spirit, I hope you will allow me to reflect briefly on five elements of our history: 1.) The Eras of Modern Toxicology 2.) Professional Development, 3.) Service to the Public, 4.) Scholarship and New Knowledge, 5.) Leadership and Leaders

Eras of Modern Toxicology

Modern toxicology as we know it had its beginnings 47 years ago with the establishment of the first poison center in Chicago. Other critical dates followed the formation of the American Association of Poison Control Centers and the establishment of the National Clearinghouse for Poison Control Centers in 1958; the formation of the American Academy of Clinical Toxicology in 1968; the formation of the American Board of Medical Toxicology in 1974; the first joint meeting of the American Association of Poison Control Centers and the American Academy of Clinical Toxicology in 1975; the articulation of criteria for certification of regional poison centers in1978; the establishment of fellowship training requirements and the first certification of specialists in 1983; the formation of the American Board of Applied Toxicology in 1987; the achievement of American Board of Medical Specialties sub-board status and formation of the American College of Medical Toxicology in 1992; and, soon to be celebrated, the 60th anniversary of modern clinical toxicology and poison control in the year 2003.

Within this 47-year history, two distinct eras are suggested, pre-1975 and post-1975. It was in fact at the annual meeting held in Kansas City that the AAPCC and the AACT came together to form a union which has existed for 25 years. The first era, 22 years in duration from 1953-1975, pre-dated the meeting in Kansas City. It was an era of conceptualization, an era which saw the rapid proliferation of poison centers, and an era that saw the creation of the AAPCC, AACT, and ABMT. It involved separate meetings of the Association and the Academy and it saw coordination of poison centers located mainly in hospitals by federal agencies. The post-Kansas City era saw the implementation of joint meetings, maturation of our professional organizations, great progress in professional development, accountability and certification, and alignment of poison centers with state agencies. It would be my belief that the tremendous progress made over the past 47 years has in large measure occurred as a result of our ability to come together and to work together for a common cause and a common good.

Professional Development

Our four major organizations have developed because of sustained commitment and focus over a 47-year history; the AAPCC for 42 years; the AACT for 32 years; the ABMT and now its extension the ACMT for 26 years; and the ABAT for 13 years. These organizations, working and meeting together have given all of us a home, a professional community, supportive colleagues to relate to and ultimately credibility for all of our activities. Our national meetings (see table 1) have been powerful instruments for professional growth and change.

Table 1. Professional Meetings

Year

AAPCC

AACT

AAPCC/AACT

1961

Chicago

   

1962

Chicago

   

1963

Chicago

   

1964

New York

   

1965

Chicago

   

1966

Chicago

   

1967

Washington D.C.

   

1968

Chicago

Chicago

(Organizational)

1969

Chicago

Chicago

 

1970

Houston

San Francisco

 

1971

Chicago

Philadelphia

 

1972

   

Aspen

1973

Chicago

San Diego

 

1974

San Francisco

Montreal

 

1975

   

Kansas City

1976

   

Seattle

1977

   

Canada

1978

   

Chicago

1979

   

New Orleans

1980

   

Minneapolis

1981

   

Salt Lake City

1982

   

Aspen

1983

   

Boston

1984

   

San Diego

1985

   

Kansas City

1986

   

Santa Fe

1987

   

Vancouver

1988

   

Baltimore

1989

   

Atlanta

1990

   

Tucson

1991

   

Toronto

1992

   

Tampa Bay

1993

   

New York

1994

   

Salt Lake City

1995

   

Rochester

1996

   

Portland

1997

   

St. Louis

1998

   

Orlando

1999

 

 

La Jolla

2000

   

Tucson

They have allowed us to share our new knowledge, to benefit from the critical analysis of colleagues, to profit from shared experiences and to solve mutual problems together. By any standard, the effort in its aggregate has been immensely successful (see table 2).

Table 2. Annual Meetngs of the AAPCC, AACT, CACAT, ACMT, and ABAT

 

1968

1968

1975

1978

1983

1990

1999

Location Chicago Chicago Kansas
City
Chicago Boston Tucson La Jolla

Sponsors

AAPCC
AAP

AACT

AAPCC
AACT
CACAT
ABMT

AAPCC
AACT
CACAT
ABMT

AAPCC
AACT
CACAT
ABMT

AAPCC
AACT
CACAT
ABMT

AAPCC
AACT
CACAT
ACMT
ABAT

Meeting
Duration (in
days)

.5

.5

3.5

3.5

4.5

4.5

7

Presentations
& Abstracts

10

6

37

81

107

153

223

Individual

24

 

60

147

210

306

488


 

A linear positive line of accomplishment is clearly evident. Initially aligned to Pediatrics and less than one day in duration, the activities now include all four organizations as well as our Canadian colleagues and last nearly a week. At last year’s meeting there were over 200 presentations and abstracts, close to 500 individual authors and an attendance of over 700 people. This is evidence of individual contribution of which we should all be justly proud (see table 3).

Table 3. Location Professional Meetings 1961-2000

Years East Midwest West Total
1961-1974 4 12 4 20
         
1975-2000 9 6 11 26
         
Total 13 18 15 46

One can see that the initial era prior to Kansas City had a middle of the country flavor. Gradually in the post-Kansas City era, the West seems to have gained ascendancy, but in the aggregate 46 professional meetings have been distributed over the country with remarkable equity over our 40 years of meeting.

Professional development has also brought with it a critical focus on quality, accountability for performance, and effort to both evaluate and to certify. Poison Center certification under the auspices of the AAPCC began in 1978. High standards and high expectations have been responsible for the constant improvement in the quality of services of poison centers. Untold hours of preparation and examination have led to the certification of physician’s initially through ABMT and subsequently, through the Herculean efforts of the ABMT leadership, in achieving the American Board of Medical Specialties sub-board status. Through the initiative of the AACT, the American Board of Applied Toxicology was created in 1987 and now serves as an important certifying body for non-physicians. Specialists are now certified and re-certified since 1983 through the AAPCC, helping to assure a high level of knowledge and a quality of response. Finally commencing in 1983, criteria were established for fellowship training in clinical toxicology. Today, 16 fellowship training programs exist in the United States helping to assure a clinical and research base for training and an avenue for subsequent academic and practice careers in toxicology. All of these efforts have, taken time, toil and effort. The end result has been a level of accountability and quality that I believe we can all be proud of. Finally, in an effort to develop ourselves as an effective community we have focused on communicating often and well through our journals, Human and Veterinary Toxicology and Clinical Toxicology and through our newsletters. The efforts of Thoman in AACTION, of Aronow through the Poison Pen Letter, McGuigan, Olsen and Kulig through AACT Update and Robertson in Robby ‘s Roost have all served to keep us informed and involved.

Our opportunities for the future are several. First, because of our diverse background and thus often diverse purpose, it will be essential to maintain a focus on the common goal of enhancing the field of toxicology. It will be important to avoid unnecessary conflict and to "avoid the thick of the thin". The whole will multiply strengthened by strong parts and each must be assiduously encouraged and supported. Secondly, our meetings should become a focus not only for our own education, so superbly carried out currently in workshops and presentations, but also an opportunity for training others especially at our own institutions. Use of the "training the teachers" model can be enhanced by transportable lectures and syllabi and creative use of website technology. Finally, increasing use of computer technology and communication through the web will allow for a nationwide toxicology website. This will allow, for example, a "year-round annual meeting" for the purpose of enhanced communication, research collaboration and education in toxicology.

Service to the Public

Edward Press was Chair of the American Academy of Pediatrics committee on accident prevention and chair of the Chicago poison control committee. Mullins was an epidemiologist on loan from the CDC to the Chicago Board of Health. First published in the American Journal of Public Health in December 1954, A Poison Control Program outlined the major elements of a poison control program that apply even today; information and treatment of the poison emergency with follow-up, data collection, professional and public education, and research. Other centers followed rapidly -Cincinnati, Boston, Washington, Durham, Dallas, Louisville, New York City and Phoenix. The progress was all the more remarkable because the prevailing model at that time was the European treatment center, accessed by professionals only, and championed by prestigious centers in Edinborough and Paris, led respectively by Professors Henry Matthew and Louis Roche. By 1978, over 661 centers existed in the U.S. and Canada, both speaking to the power of a good idea, but also highlighting shortcomings including lack of funding, attention to professional development, regionalization and certification.

The new era began in the 70’s with the combining of multiple centers into a single center for larger statewide geographic areas, as exemplified by the Massachusetts Poison Control System or by the covering of a larger number states as illustrated by the Rocky Mountain Poison Control Center. This trend has progressed in concert with the movement in the 80’s of the AAPCC to enforce standards thereby assuring quality and excellence. The salutary affects of this effort can be seen (see Table 4) with a proliferation of poison centers up to 1978 and then a rather remarkable reduction to the current number of 73 in 1998 [52 (71%) being certified and 21(29%) being non-certified].

Table 4.  Poison Centers by Year in the United States of America

1953 1  
1955 17  
1958 250  
1963 530  
1970 590  
1978 661  
1980 466  
1991 104  
1998 73
  • 52 (71%)

    Certified

   
  • 21(29%) Not Certified

 


By any standard the record is remarkable: as of 1997, 3.65 million calls annually, 72% for human and animal exposure and 28% for information; 99.8% of the entire U.S. population served by a poison center; 79% of the U.S. population by a certified center; 86% of the centers providing toll-free access; 75% providing services for the deaf; 69% providing language translation; and, with an annualized poison center budget in the aggregate of $81 million dollars, an average cost per exposure of approximately $33 dollars. This is truly a remarkable record that we all should be proud of.

Prevention has been an equally important focus. The pre-Kansas City era focused on the host, the agent, and the environment and an effort to impact all three. Gradually prevention moved to controlling the agent itself. The efforts are well known to all in this room: wide publication of poison center telephone numbers; coordinated efforts through emergency medical services to enhance care from the site of injury to hospital care; the distribution of ipecac syrup into homes and activated charcoal into hospitals. Public education has occurred through well-coordinated National Poison Prevention Week efforts, warning labels have increased awareness and major studies have clearly demonstrated effectiveness of safety closures to prevent poisonings.

Our opportunities for the future are several. First, major opportunities are embodied in the Poison Center Enhancement and Awareness Act of 1999. Poison Centers must be made financially stable. As an essential public service, public funding must be secured and made secure. Further, in financially strained time, priorities determine funding and each of us can help each other locally through coordinated and effective advocacy for the necessity of allocation of resource dollars to our efforts. Secondly, a single access point nationally, to all certified centers regionally, and paid for federally, is essential to achieve universal access to poison services. Inability to pay must not be a deterrent to receiving toxicology services and care. Centers must also strive to be able to provide services in multiple languages in a country that will become increasingly multicultural. Thirdly, recalcitrant clinical areas must be pursued with new ideas and models of care, including adult poisonings and suicide, environmental toxicology, abuse of drugs by adolescents and finally new approaches to the prevention of medical drug error.

Scholarship and New Knowledge

A reasonable purview of scholarship and research in clinical toxicology, in the judgement of most, includes outcomes research, clinical research and interpretive scholarship.

Commencing with the card file of Jay Arena in the 40’s and 50’s, the Clearinghouse 5x8 card in the 60’s and 70’s, the pilot computerized version of the Clearinghouse system and the Poisindex microfiche system of the 70’s, and currently the Poisindex IBM mainframe and CD-ROM personalized computer systems of the 80’s and 90’s, centers have increasingly had at their hands accurate information to disseminate to the public. Enough credit cannot be given to Barry Rumack for his efforts to create this essential base of knowledge for toxicologists and ultimately the public at large. This database, in turn, has allowed for national data collection, first accomplished as a pilot project by Veltri and Litovitz in 1983, and now compiled, edited and recorded each year through the remarkable efforts of Litovitz and others in the American Journal of Emergency Medicine. This is outcomes research at its best, and a major achievement in support of our efforts.

Identification of major advances in our knowledge of drugs and poisons rapidly identifies major contributors to the advancement of our field. To mention only a few - Snakebites’- Russell, Activated Charcoal - Corby and Decker, Aspirin and anti-pyretics - Done and Temple, Bedside Toxicology - Goldfrank, Occupational Medicine - Becker and Kimbrough, GI Decontamination - Robertson, Krenzelok, Manoguerra, Oderda, and Tong, Organophosphates - Doull, Acetaminophen Rumack and Peterson, Plants - Lampe, Safety Closures - Scherz, Theophylline - Shannon and Olsen, Cardiovascular Catastrophes - Benowitz, Methemoglobin - Curry and Hall, Accident Prevention Strategies - Woolf.

Much has been accomplished but there is still much room for improvement. Consider the possibilities for the future through private and public funding in the area of outcomes research. The Agency of Health Care Policy and Research has now been transformed into the Agency for Health Care, Research and Quality (AHRQ) with NIH RU- 1 comparable status. The Robert Wood Johnson Foundation, the Pew Charitable Trust, the Packard Foundation and the Commonwealth Fund all are major available sources of funding for outcomes research. In the area of patient oriented research, the NIH has now established the K-23 for new mentored patient oriented research career development (replacing the prior CAP Award) with funding for up to five years. The K-24 has also been established as a mid-career investigator award for patient oriented translational research, again with five-year funding. Finally the K-30 has been established as an institutional award intended to enhance clinical research training. It would be my hope that the future would include greater access to these sources of funding.

In the area of interpretive scholarship, the record is also tremendously strong. In the area of journals, Clinical Toxicology had its beginnings in 1968 through the leadership of Rappolt and Angle and for 32 years has thrived through the remarkable leadership of Redetzki and Angle. This Journal has shared information with us, informed us and maintained a high level of quality. In addition, at this meeting, you have honored Fred Oehme who since 1975 has served this community through his Journal of Veterinary and Human Toxicology. This journal for over 25 years has served as a fine repository for Association and Academy information as well as clinical toxicology articles. Finally, the newest journals, Drug Safety, the Internet Journal of Medical Toxicology, Annals of Emergency Medicine and Emergency Medicine have joined the previous two journals in serving as important repositories of toxicology contributions.

In the area of textbooks, I believe ours is an enviable record. The next table (see table 5) notes the major contributors prior to 1975 Gleason, Gosslein and Hodge, Thienes, Dreisbach and Arena and since 1975, we have been well served by the Herculean efforts of Klaassen and Doull, Goldfrank, Ellenhorn, and Haddad and Shannon.

Table 5. Toxicology Texts

Prior to Kansas City
  • Gleason, Gosselin, and Hodge —Clinical Toxicology of Commercial Products
  • C. Thienes — Clinical Toxicology
  • R. Dreisbach Handbook of Poisoning
  • J. Arena - Poisoning
Post Kansas City
  • Klaasen, Amdur, and Doull — Toxicology, 5th Edition, 1111 pages
  • Goldfrank, Flomenbaum, Lewin, Weisman, Howland, Hoffman — Toxicologic Emergencies, 5th Edition, 1589 pages
  • Ellenhorn, Schonwald, Ordog, Wassenberger — Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd Edition, 2046 pages
  • Haddad, Shannon, and Winchester — Poisoning and Drug Overdose, 3rd Edition, 1257 pages

With contributions now in their second to fifth editions and with the total pages ranging from over a thousand to 2000 pages, these sustained contributions of our colleagues have been truly remarkable.

Our opportunities for the future are several. First, we must vigorously pursue new funding sources for outcomes and translational research. The NIH and the private sector are investing in this area, an area critical to the advancement of our field, and so must we. Second, we may wish to develop poison centers increasingly along the lines of Centers of Excellence. An increased focus on groupings of experts, galvanized through common purpose, offering diverse expertise and with opportunities for productive linkages through schools of medicine, public health, pharmacy, nursing and governmental agencies, all will help to attract new sources of funding and professional expertise for productive futures. Finally, superior clinical research in toxicology is enhanced through access to large population bases. Centers might wish to simulate the Oncology clinical trial groups by joining together in formal working groups for the purpose of coordinated natural history studies, outcome studies, and therapeutic trials.

Leadership and Leaders

In the end, individuals achieve major contributions. To name them all would be difficult indeed, but to not give credit and to not express my personal admiration for what they have done would not serve this talk well. So, to mention only some, the roots of the AAPCC finds its leadership in Press, Shirkey, Arena, Alpert, Lampe, Haggerty, Scherz, Angle, Sunshine, Picchioni, Robertson, Mofenson, Aronow, Mclntire, Done, and Lawrence. The AACT owes its genesis to Comstock, Graeme, Quimby, Rappolt, Thienes, Teitelbaum, Thoman, Oehme, Decker, Ott, Aldrich and Redetzki. Europe achieved a major influence through Mathew in Edinborough, Roche in Paris and Goeverts, in Belgium. The ABMT had its early roots in the efforts of Teitelbaum, Redetzki and Robertson and found its current home in ABMS as a result of the tremendous efforts of Becker, Rumack, Goldfrank and Banner. The ABAT is rapidly developing major stature as a result of the efforts of Veltri, Krenzelok, Tong, and others. One would not want to forget the early major contributions of Verhultz and Crotty from the National Clearinghouse for Poison Control Centers in the 50’s, 60’s and early 70’s and Boyd and Micik who led the EMS efforts in the 70’s ‘and 80’s. In addition, three individuals must be mentioned for their sustained critical support: Tony Temple with McNeil Consumer Products Division, John Pepper with Hoffman LaRoche and Barry Rumack with Micromedics.

And finally, the list of the leadership of each of our organizations who deserve our special gratitude. I have taken the liberty of making these lists available as I believe they will be useful to you in the future as they have been for me in this talk (see table 6).

Table 6. AAPCC Presidents

1958

Edward Press

1958

George Wheatley

1958-1960

Robert Grayson

1960-1962

William Curtis Adams

1962-1964

Robert Haggerty

1964-1966

Harry Shirkey

1966-1968

Irving Sunshine

1968-1969

Jay Arena

1969-1970

Charles Walton

1970-1972

Howard Mofenson

1972-1974

Mitchell Zavon

1974-1976

Carol Angle

1976-1978

Robert Scherz

1978-1980

Matilda Mclntire

1980-1982

Anthony Temple

1982-1984

Barry Rumack

1984-1986

Regine Aronow

1986-1988

Anthony Manoguerra

1988-1990

William Robertson

1990-1992

Toby Litovitz

1992-1994

Gary Oderda

1994-1996

Richard Weisman

1996-1998

George Rodgers, Jr.

1998-2000

Blaine (Jess) Benson

2000-2002

Alan Woolf

So, the list of the 25 Presidents of the American Association of Poison Control Centers (see table 7); the list of the 17 Presidents of the American Academy of Clinical Toxicology (see table 8); the list of the seven ABMT Chairs and the five ACMT Presidents.

Table 7. AACT Presidents

1968-1970 Eric Comstock
1970-1972 Griffith Quimby
1972-1974 Clinton Thienes
1974-1976 Ronald Okun
1976-1978 Jack Ott
1978-1980 Fred Oehme
1980-1982 Frank Aldrich
1982-1984 Mark Thoman
1984-1986 Helmut Redetzki
1986-1988 Frederick Lovejoy
1988-1990 Donald Kunkel
1990-1992 Michael McGuigan
1992-1994 Wayne Snodgrass
1994-1996 William Banner
1996-1998 Ed Krenzelock
1998-2000 Jeff Brent
2000-2002 Milton Tennenbien

Table 8. ABMT/ACMT Presidents

1974-1976 Daniel Teitelbaum
1976-1978 Helmut Redetzki
1978-1980 Frederick Lovejoy
1980-1986 William Robertson
1986-1988 Charles Becker
1988-1990 Barry Rumack
1990-1992 Lewis Goldfrank
1992-1994 William Banner
1994-1996 Paul Pentel
1996-1998 Ward Dononvan
1998-2000 Michael Shannon
2000-2002 Robert Hoffman

In the end, it has been the commitment and dedication of these 54 individual leaders that I believe has been critical to our successes over the past 47 years.

The opportunities for the future are several. The future of toxicology depends on outstanding leaders. To achieve future success we must first attract the best and brightest into toxicology out of Emergency Medicine, Pediatrics, Medicine, Pharmacy, and Nursing. We must assure that toxicology is seen as an attractive field and career so as to successfully attract the best. Second, we must be good mentors. We must foster the best training for these young individuals so they can contribute to and advance the field in their own light and in new and important ways. We must use our institutions and often training sites external to toxicology to optimally achieve their professional development. Finally, we must maintain our diversity and develop the best in each of our professional areas of expertise. Significant synergies emanating from individual professional expertise has been a hallmark of our field and should remain an essential goal for the future.

In summary, a compass for the future might include: for professional development: a.) a focus on common goals, b.) increased use of training the teachers model, c.) creation of a web based toxicology community; for public service: a.) stabilized financial support, b.) single point public access available to multi-lingual callers, c.) new approaches to old challenges; for new knowledge and research: a.) pursuit of new funding sources, b.) creation of Centers of Excellence, c.) use of clinical research working groupings; for future leadership: a.) attracting the best and brightest, b.) wise mentoring, c.) synergizing our professional diversity.

I close with two quotes. The first from Charles William Eliot, Harvard President in the late 1800’s who took that institution from a local college of learning to the position it currently enjoys: "A good past is positively dangerous if it makes us content with the present and so unprepared for the future". And a story that President Kennedy often used to tell: The great French General Marshall Lautey had retired to Morocco following World War I and was discussing when to plant a new orchard with his gardener. His gardener lamented that it would take at least 50 years for the trees to reach maturity. Marshall replied, "Then we haven’t a moment to lose; we must plant tonight."

Thanks so much for the opportunity to talk to you and this honor. Good luck.



Int J Med Toxicol 2000; 3(5): 32
See also Ellenhorn Introduction

This article is located at http://www.ijmt.net/ijmt/3_5/3_5_32.html

Quick Survey
Please rate this article:
1 2 3 4 5
(5 is best)
Comments?

Ellenhorn Introduction" name="hdnSource" />


IJMT Home | Current Issue | Past Issues | Search | Technical Support | Send Comments to ACMTNet

Copyright 1999-2003, American College of Medical Toxicology.