Original Contribution

The Current Practice of Bedside Medical Toxicology in the United States

Charles A. McKay MD
Division of Medical Toxicology
Department of Traumatology and Emergency Medicine
University of Connecticut School of Medicine and Connecticut Poison Control Center

Int J Med Toxicol 2002; 5(1): 2


ABSTRACT

Although medical toxicology was founded by a clinically-driven need for appropriate assessment and treatment of poisoned patients, it is the general impression of many in the field that bedside evaluation and treatment of poisoned patients is not the general practice pattern of most medical toxicologists. The extent to which toxicologists who directly treat patients incorporate this function into their practice is also unclear. A survey of the members of the American College of Medical Toxicology revealed that although a bare majority provide direct clinical care, most of these are solo practices, with little formal structure, and poor remuneration. Fewer than 100 hospitals nationwide have a medical toxicologist available to them for direct patient care. If the concepts of specialized centers for patient care, postgraduate education, and research within medical toxicology are to succeed, leaders within the specialty will need to demonstrate the value, vitality, and viability of such an entity.

BACKGROUND

Medical toxicology was sanctioned by the American Board of Medical Specialties (ABMS) in 1992. General discussion and results from recent surveys suggest that while the work of medical toxicology is limitless, the economic stability is uncertain.(1,2) The origin of the specialty centered on the acute evaluation of the poisoned patient. This clinical basis has been the hallmark of the physician toxicologist. The evaluation of the severely poisoned patient makes use of all of the physician’s knowledge and ability in the areas of biochemistry, pharmaco/toxico-kinetics and dynamics, and critical care. Evaluation of the occupationally exposed individual similarly requires a blend of scientific knowledge, history taking skills, judicious laboratory utilization, and an appreciation for the distinction between association and causation. The American College of Medical Toxicology (ACMT) Position statement on the care of the poisoned patient states, "The American College of Medical Toxicology believes that victims of severe or unusual poisonings should be treated at a center for poison treatment, when regionally available. Proper care of patients with significant or ill-defined poisoning includes a consultation with a medical toxicologist."(3) The Facility Assessment Guidelines for poison treatment centers published by the ACMT also stress the importance of supervision by a physician with "demonstrate(d) expertise and special interest in the field of medical toxicology."(4)

Yet the general impression is that few medical toxicologists maintain an active clinical practice or provide on-site patient care. There has been discussion within the ACMT regarding an evaluation of the role of the hospital-based medical toxicologist and formal steps for accreditation of Centers for Poison Treatment (CPT). CPTs provide a broad-based, in-depth clinical, educational, analytic and research base for the clinical practice of medical toxicology. As one component of this evaluation, we conducted a survey of the membership to determine the current and planned practice in this aspect of medical toxicology.

METHODS

A 20-question survey was formulated using input from the ACMT Practice Management Committee and review by the membership at an annual meeting to determine the demographics and characteristics of toxicologists who maintain a CPT. A CPT was defined as "a hospital or geographically proximate hospitals with practicing medical toxicologists who perform bedside consultations or admit patients primarily to their service. The availability of other specialty and ancillary services must support the care of the critically ill, poisoned patient and there must be a demonstrable commitment to teaching and research." The questions in the survey are listed in Table 1. The survey was e-mailed to all active members of the ACMT for whom e-mail addresses were available. Nonresponders were sent the survey a second time. Although committees and the Board had discussed preliminary results in various forums, there was no formal dissemination of the results prior to the second request.

RESULTS

Of the 315 members listed in the ACMT directory, 294 had e-mail addresses. A total of 67 surveys were returned. Only 2 were from the second mailing. These responses represent the practices of 143 individual toxicologists (48% of the membership), and include 1 response each from Australia, Canada, and Iceland. Those foreign responses are included with the U.S. centers.

Although 55 services (82%) offer bedside patient care, only 36 of these (65%) consider their services to be part of a "center for poison treatment." The 55 services that provide bedside care cover 125 hospitals with an average of 2 hospitals per service (consultation service: median of 2 hospitals with a range of 1 to 7; admitting service: median of 1 hospital with a range of 1 to 5). The average number of toxicologists within each service is 2, with a range of 1 to 7. A range of administrative structures was described, with 8 departments, 15 divisions, 12 sections, 5 multidepartmental, and 9 "informal" structures represented. Twenty-seven programs indicate they offer toxicology fellowship programs with 14 of these being ACGME-accredited.

Each service formally sees an average of 228 patients annually in a variety of settings (Figure 1 and 2) although the range of patient encounters is from 10 to 970, excluding one outlier listed as 2,250 evaluations. It is of note that only 30 centers report seeing children, while only 19 see outpatients in a clinic setting. A variety of diagnoses were listed by responding centers (question #20 of the survey). However, acute medication overdose of over the counter analgesics, drugs of abuse, or psychiatric medication comprise 4 or 5 of the "five most common diagnoses in the last quarter" for 16 of the 20 centers providing diagnoses or ICD9 codes.

The majority of responders, 50 of 66, are associated with regional poison control centers (PCCs), providing physician back-up coverage with some member(s) of the groups holding medical director positions (37 of 64 responses). A lesser proportion receives financial support from these PCCs. Thirty-four responders indicated that they received funding for 0.025 to 2 medical toxicologists via the poison centers (median 0.5 FTE). One response coded as "9" was considered a typographic error as the responder also indicated that they did not hold medical director positions.

Only 38 of the services indicate they bill for patient care. The reimbursement generally goes to the department or institution, with only 26% of the services being paid directly. The estimated collection percentage for the 24 responders to this question ranged from 0-100%, with a median of 55%. Although only 18 of the responders provided information on approximate annual billing, the range is striking. The median income for patient care-related activities is $30,000, with a range of $ 0 – 2.5 million. Only 5 centers indicate billings in excess of $100,000/year.

DISCUSSION

This survey indicates that the active bedside patient care by medical toxicologists is provided in a largely unorganized, non-reimbursed fashion, or is rarely provided by the majority of medical toxicologists in this country. The range of number of patient evaluations seems extremely high, but this is consistent with the retrospective recollections of previous toxicology fellows as reported by Wax and Donovan (1). Of note, the majority of previous toxicology fellows in that report considered the number of actual patient contacts to have been insufficient, while the number of telephone contacts were considered excessive. It would appear that the majority of the country, although now well served by poison information centers, does not have active medical toxicologists at their call. Although there are a number of anecdotal cases where the lack of bedside presence is stated to result in poor patient outcome, this has not been formally studied or validated. A report from Australia suggests that an interdisciplinary toxicology service with good interactions with Psychiatry can decrease length of stay.(5) Although when Clark et al reviewed the outcomes of patients with tricyclic antidepressant overdoses seen by their service in consultation they were unable to find differences in length of stay or mortality, they did document savings in laboratory charges and decontamination decisions.(6)

Although survey response was not complete, the respondents represent both a geographically and clinically diverse (admitting vs. consulting; pediatric and/or adult) practice sample that includes nearly half of all ACMT members. As with any non-validated survey, there is difficulty being certain that the respondents read the questions in the same sense as the question makers intended. For example, although a listing of most common ICD9 or medical diagnoses were requested, several respondents listed levels of service. Additionally, we did not specifically indicate whether consults or outpatient evaluations were numbers of contacts or individual patients. We did not ask about relative or absolute time commitments to this or other areas of practice nor how practitioners view the bedside clinical practice of toxicology relative to other areas of practice. Such information is important for those considering a clinical practice of toxicology.

Those who consider acute patient care or evaluation of the occupationally or environmentally exposed patient an important part of the practice of medical toxicology should provide information and direction to the ACMT Board and members. Whether as a symposium or consultative forum, successful groups could present their business plans to the college for adaptation elsewhere or for discussion of particular or unique arrangements. It is likely that outcome studies will also be necessary to convince hospital administrations and prehospital care systems to embrace the concept of regional poison treatment centers. Documentation of improved outcome of patients under specialized care with high volumes compared to those treated for similar diagnoses in other settings has been provided for a number of surgical conditions and complicated medical problems, such as vascular surgery, myocardial infarction, diabetes mellitus, and multiple trauma. (7-9) Given the time-sensitive nature of overdose management, the trauma center model and experience would seem the best fit for this aspect of clinical toxicology. An evaluation of time commitment and staffing requirements would also provide useful information for fellowship-trained medical toxicologists considering their practice options.

CONCLUSION

A clinical practice of medical toxicology is possible and is successfully practiced by some toxicologists in the U.S. However, the vast majority of hospitals and the poisoned patients they serve in this country do not receive care by bedside medical toxicologists.

ACKNOWLEDEMENT

I gratefully acknowledge the efforts of Tom Martin MD, other members of the Practice Committee and members of the American College of Medical Toxicology for their inputs into the survey design; and to all who returned the survey. Thanks are due to Martha Souders, Heather Miller, Donna Rhoades, and Anne Schambaugh at the Pennyslvania Medical Society for compiling raw survey data.

REFERENCES

  1. Wax PM, Donovan JW. Fellowship training in medical toxicology: characteristics, perceptions, and career impact. J Toxicol Clin Toxicol 2000;38:637-642.
  2. Goldfrank LR. The medical toxicology fellowship. J Toxicol Clin Toxicol 2000;38:643-644.
  3. Role of the medical toxicologist in the care of the severely poisoned patient. ACMT Position Statement. http://www.acmt.net
  4. Facility assessment guidelines for poison treatment centers. http://www.acmt.net/CPT FAG.html last accessed 01/10/02.
  5. Whyte IM, Dawson AH, Buckley NA, Carter GL, Levey CM. Health care. A model for the management of self-poisoning. Med J Australia 1997;167:142-6.
  6. Clark RF, Williams SR, Nordt SP, Pearigen PD, Deutsch R. Resource-use analysis of a medical toxicology consultation service. Ann Emerg Med 1998;31:705-9.
  7. Nash IS, Corrato RR, Dlutowski MJ, O'Connor JP, Nash DB. Generalist versus specialist care for acute myocardial infarction. Amer J Cardiol 1999;83(5):650-654.
  8. Rosenblatt RA, Baldwin LM, Chan L, Fordyce MA, Hirsch IB, Palmer JP, Wright GE, Hart LG. Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities. J Fam Pract 2001; 50(8):676-680.
  9. Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, Rivara FP. Relationship between trauma center volume and outcomes. JAMA 2001;285(9):1164-1171.

TABLE 1: Survey questions utilized

  1. Name of group/CPT: _____________________________(Optional) Location: ____________________(Optional)
  2. Number of medical toxicologists providing patient services to your CPT:
  3. Do you have a poison information center in your area? Y/N Which one? _________________________________
  4. Do you or your partners provide physician back-up coverage to a poison information center? Y/N
  5. Do you or your partners hold medical/associate medical director position(s) at a certified poison information center? Y/N If so, how many FTEs are paid for this service? ______ Paid by what source: ___________
  6. Does your program offer a fellowship in medical toxicology? Y/N accredited? Y/N
  7. Do you or your group offer bedside consultation? Y/N
  8. If not, do you plan on providing this service in the next two years? Y/N
  9. Do you admit patients to your medical toxicology service? Y/N
  10. If not, do you plan on providing this service in the next two years? Y/N
  11. If NO to both questions 7 and 8 - please return the survey now
  12. Do you consider or refer to your service as a "center for poison treatment" or similar entity in (check all that apply):

    __ Casual conversation within your department

    __ General knowledge among the medical staff at your institution

    __ Knowledge and/or acceptance by local/regional poison center

    __ Any form of advertisement (website, print,…)

    __ Formal designation within institution (letters of agreement, transfer arrangements, etc.)

  13. Number of hospitals to which you have admitting ____ or consulting only privileges ____
  14. What is your institutional structure of Medical Toxicology? Department, Division, Section, other (informal, multidepartmental, etc.) ___________
  15. Type of services provided and annual census or number:
    InpatientAdmissions to tox serviceOn-site consults
    Adult
    Pediatric
    OutpatientOn-site consults
    ED
    Clinic
    Other (Please Describe)
  16. Do you bill for your services?
  17. If so, what is your collection percentage?
  18. Do you get paid for your services? Directly Department Institution
  19. What is the approximate annual billing for your service?
  20. Please indicate the most frequent 5 diagnoses or ICD9 codes in the last quarter?

FIGURE 1

*includes one of the non-U.S. centers

FIGURE 2

*includes one of the non-U.S. centers



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