|Internet Journal of Medical Toxicology
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Is Medical Toxicology Becoming a Pastime?
Graduates of Medical Toxicology Fellowship Programs Will Not Primarily Practice The Specialty
Robert J. Hoffman, MD
Assistant Clinical Professor of Emergency Medicine
State University New York, Downstate Campus
Director, Division of Toxicology
Maimonides Medical Center
Int J Med Toxicol 2002; 5(1): 4
Background: Anecdotal evidence led us to hypothesize that physicians completing fellowship training in medical toxicology were unlikely to primarily practice toxicology.
Methods: Using a telephone survey, in April 2000 we contacted all physician fellows in toxicology fellowships in the U.S. to determine if they would practice toxicology after graduation. Fellows in their final year of training were asked what their medical practice would include after completion of their fellowship and were asked if they would primarily practice toxicology.
Results: Seventeen graduating toxicology fellows from eighteen programs were surveyed. No graduating toxicology fellow remaining in the U.S. after graduation (n=12) intended to primarily practice toxicology. Most indicated that they would practice their primary specialty, usually emergency medicine (n=9), and would practice toxicology to a limited extent or part-time (n=9). A few had no plans to practice toxicology to any extent (n=3). These latter fellows reported preferring to practice toxicology, but stated that they had no employment opportunity to do so. All foreign nationals returning to their home country (n=5) indicated that they would practice toxicology. Of these, 4 intended to practice primarily as toxicologists and 1 intended to practice pediatrics primarily and toxicology part-time.
Conclusion: No graduating toxicology fellows remaining in the U. S. intended to practice toxicology primarily. Several had no intention to practice toxicology to any extent. Foreign nationals returning to their home country will all practice medical toxicology, most as a primary practice. Efforts may be needed to develop employment opportunities for medical toxicologists in the U.S.
Currently, well-defined jobs for medical toxicologists include opportunities in practice, poison centers, industry, government, and academics. Despite many such opportunities, anecdotal information as well as published data suggested that many physicians graduating from medical toxicology fellowship training programs do not practice medical toxicology as their primary specialty. The purpose of this study was to assess the career path of one class of graduates from medical toxicology fellowship programs.
In this IRB-approved survey conducted in April 2000, we contacted all physician fellows in medical toxicology fellowship programs in the U.S. to determine their intended practice after graduation. The list of medical toxicology fellowship programs was compiled from those published by The Society for Academic Emergency Medicine (www.saem.org), and the American College of Medical Toxicology (www.acmt.net) cross-referenced with those from the American Council of Graduate Medical Education (www.acgme.org). Using a semi-structured telephone survey, we asked the following of fellows in their final year of training:
- Where will you be working after you graduate?
- What medical specialty will you practice after completion of your fellowship?
- Will you primarily practice toxicology?
- To what extent will you practice toxicology?
Primary practice was defined as 50% or more of clinical or academic duties, part-time was defined as any percentage less than 50%. During this telephone interview, an open ended format allowed for the surveyed fellows to make comments or ask questions regarding the practice of medical toxicology.
Every graduating fellow (n=17) from all 18 active toxicology fellowship programs in the U.S. was surveyed. All agreed to participate and completed the process. Twelve of them intended to remain in the U.S. after graduation. The remaining 5, all foreign nationals, intended to return to their home country after graduation. Of those remaining in the U.S. after graduation, none intended to practice toxicology as a primary specialty. Most (n=11) intended to practice their primary specialty, including emergency medicine (n=9), occupational medicine (n=1) and internal medicine (n=1). Additionally, most (n=9) indicated that they would practice toxicology to a limited extent or part-time. Three had no plans to practice toxicology to any extent. One among this group had no plan for employment after graduation and had no expectation of practicing toxicology after graduation. All of the graduates who had no plans to practice toxicology expressed an interest and preference to do so, but reported that they had no toxicology employment opportunity.
All foreign nationals returning to their home countries (n=5) including Australia (n=1) and Thailand (n=4) indicated that they would practice toxicology. Most of these (n=4) intended to practice toxicology primarily, and one reported that her primary specialty, pediatrics, would comprise approximately 75% of her duties and toxicology the remaining 25%. All these foreign nationals indicated that there was a particular need for trained toxicologists in their home countries.
This study clearly indicates that among the medical toxicology fellowship graduates surveyed: 1) None remaining in the U.S. after graduation planned to practice toxicology as a primary specialty; and 2) Most planned to practice toxicology part-time or to a limited extent. Both the percentage of graduates intending to practice toxicology primarily as well as the percentage of time that graduates intended to spend practicing toxicology has diminished significantly relative to the survey data published by Wax.1 This decrease in toxicology practice by fellowship graduates is particularly noteworthy given that only two years elapsed between the survey by Wax and that presented herein.
Within the scope of this study, it is impossible to determine why these practice trends exist. We believe that this may be due to U.S. graduates of medical toxicology fellowship programs preferring not to practice toxicology primarily as well as a lack of clearly defined toxicology practice opportunities.
This surveyed group expressed a universal interest or plan to practice toxicology to some extent. Pursuit of postgraduate subspecialty education in medical toxicology, plans to practice medical toxicology, and verbal communication of interest in practicing this specialty provides evidence that these fellowship graduates want to practice toxicology. This study, however, was not capable to determining if they want to practice toxicology as a primary specialty.
Regarding the issue of limited practice opportunities in medical toxicology, there is evidence that practice opportunities are available. At the time of authorship of this manuscript, the internet web site of the American Association of Poison Control Centers (www.aapcc.org) advertised 5 vacant employment positions for medical toxicologists. In the 2 years prior to manuscript publication, 25 vacant employment clinical toxicology positions for physician medical toxicologists are advertised in one journal alone, including some that have remained unfilled for months or years. These employment vacancies range from directorship or assistant directorship of 9 poison control centers 2,3,4,5,6,7 and 7 clinical toxicology positions 8,9,10,11,12,13,14,15 as well as positions that require technical scientific expertise beyond medical or clinical toxicology for combined work in clinical toxicology with occupational health, research or other academic responsibilities. 16,17,18,19,20,21,22,23,24,25
This evidence indicates that unemployed and underemployed medical toxicology fellowship graduates exist in an environment with chronically unfilled employment positions for medical toxicologists. This situation mirrors the trend for other medical specialties such as emergency medicine, the most common primary specialty of surveyed graduates. A multitude of factors, particularly geographic location and salary, may influence physicians' decisions regarding acceptance of employment.
Another issue is the possibility that too many toxicologists are being trained. At the time of this survey, 17 fellows were graduating from 18 fellowship programs. This study occurred during the period of ACGME review and accreditation of medical toxicology fellowship programs. Since this study was completed, the number of medical toxicology fellowship programs actively accepting fellows for training has dramatically decreased due to lack of accreditation by the American Council for Graduate Medical Education (ACGME). This culling of fellowship training programs will likely result in a decrease in the number of physicians trained in medical toxicology. It is the opinion of the authors that overabundance of medical toxicologists is not significant or relevant cause for the trend of medical toxicology fellowship graduates not primarily practicing medical toxicology.
We do believe that there are significant potential employment opportunities for medical toxicologists that are underdeveloped and untapped in most of the U.S and that there is a tremendous role for expansion of toxicologists' services within the established health care system. These include health care markets underserved or not yet served by toxicology services, health care consumers unaware of or with inadequate access to toxicologists, non-health care consumers that may utilize the services of toxicologists, as well as a private sector need for toxicologists.26
A significant factor influencing employment and reimbursement of medical toxicologists is very fundamental and crucial: Historically, medical toxicologists have little experience or training in reimbursement for services. Toxicologists are unique in that they frequently provide subspecialty services in poison control centers and emergency departments without subspecialty reimbursement. Reimbursement for services by health care providers is standard in virtually all other medical subspecialties. The familiar practice of toxicologists' services being available at no charge to the health care providers and patients should be evaluated. Billing practices of U.S. toxicologists varies significantly, and toxicologists practicing part-time are likely to bill and collect less for their services than full-time toxicologists.27 A limited number of U.S. markets have successful fee for service toxicology practices.28 These consultative or admitting services provide distinct medical care from regional poison control centers, and competition between such services and poison control centers is not necessary. Established toxicology services may serve as models for toxicologists elsewhere to develop similar practices. Fellowship training in medical toxicology should include instruction regarding the organization and management of fee for service practice models, as well as preparation for post graduation employment.
Limitations of this study include survey before graduation, when the actual employment of graduates may have been significantly different than anticipated. Additionally, only one graduating class was surveyed. It is possible that the employment pattern of this group may deviate from other graduating classes.
In summary, graduates of medical toxicology fellowship training programs remaining in the U.S. are unlikely to practice medical toxicology as a primary specialty, and some will not practice toxicology to any extent. This circumstance exists in an environment of numerous available employment opportunities for medical toxicologists, and appears to be much more complex than simply lack of available job opportunities for fellowship graduates. It is in the best interest of medical toxicologists to address all paradigms of toxicology employment.
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