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Medical Toxicology Over 25 Years

Past President Lewis Nelson, MD, FACMT, shares his perspective on the evolution of medical toxicology over the past 25 years as part of ACMT’s 25th Anniversary in 2018.

During my 25 years in medical toxicology (short by comparison to many!), I have witnessed the growth of our fledgling subspecialty to see it become one of the premier areas of scholarly and clinical efforts in the house of medicine. Although we grew out of the specialty of Pediatrics, we have settled solidly in the house of Emergency Medicine, and there is good reason for that.

Emergency medicine was (and remains) a young specialty interested in expanding its footprint (read: credibility) by supporting its emerging subspecialties. The work pattern of an emergency physician was a good fit for medical toxicology, since it provided relatively ample free time to pursue one’s scholarly interests. Similarly, the clinical practice of medical toxicology is better aligned with emergency medicine than with typically inpatient-focused specialties. Nearly all acutely poisoned patients arrive through the ED, most are discharged, and most patients are stable (and less interesting) by the time they leave for their inpatient bed. Indeed, many of the pediatricians who have joined the medical toxicology community over the past 25 years have had additional subspecialty training in pediatric emergency medicine. However, more physicians from alternative training backgrounds have entered our specialty and bring with them remarkable value and have, to the individual, made an important impact that helps define our specialty.

So where have we come in this very brief quarter century?

By almost any measure we have come very far. Given our meager 500 or so board certified diplomates, some of whom no longer are involved with the practice of medical toxicology, we have done remarkably well on both the micro and the macro level. Much of this has been due to our deep engagement with the specialty, the affection we have for learning or teaching, or, maybe most importantly, the passion we have for helping our patients and populations. Shepherding us through this growth has been ACMT. It is almost surreal to think about what ACMT was like when I first became involved compared to what it looks like today. We, ACMT and its constituency, have maintained a healthy saprophytic relationship these last two decades, and together we have brought the study and practice of the management of human poisoning to what we know it as today.

Medical toxicologists are now solidly integrated into the fabric of medical practice. Wherever we hang our shingle, we are quick to develop networks rooted in our academic and consultative practices. Most such efforts expand well beyond the ED walls and into the inpatient and outpatient units, and often within the community. A few pioneering individuals have made clinical consultation and primary patient management their full-time job. Our uniqueness is clearly in our knowledge, skills, abilities, and experiences in helping physicians, and therefore patients, navigate the tricky waters of poisoning management. It does not take long after arriving at the bedside to show the value that we can provide to the care of human beings suffering from one of a million potential exposures. Many of us affiliate (for little to no compensation) with regional poison centers to provide diagnostic and treatment advice to others and to advance our own learning through association with other knowledgeable people.

In many academic medical centers (the most comfortable home for many of us) we have become departmental and institutional leaders. We are well represented as department chairs, program leaders, and research directors. We flourish as committee leaders, especially of those focused on quality improvement, medication use (P&T and Medication Safety), and research (IRBs). Of course, we are quick to become educational trailblazers of medical students, pharmacy students, and those in other training programs, nearby institutions, and far-away national professional organizations. And many medical toxicologists integrate into the community and work with public health advocates, high schools, community groups, and others to try to improve the community’s knowledge about the health risks where they live and work.

Medical toxicologists have been quick to adopt the skills needed to manage patients with substance use disorders. Examples include receiving a DEA waiver to prescribe buprenorphine to treat substance use disorder, implementing naloxone distribution harm-reduction programs, and developing opioid stewardship programs to reduce the risks inherent in pain management. To gain further credibility in this area and bolster the services deeply needed by our patients, dozens of medical toxicologists have attained board certification in addiction medicine. 

On a grander scale, medical toxicologists are sought as consultants, and even employed by, governmental agencies, such as the Food and Drug Administration, Department of Homeland Security, and the Centers for Disease Control and Prevention. These and other agencies have requested our guidance and assistance on key projects, such as the response to fentanyl exposure in law enforcement, disaster preparedness, or management of children with environmental exposure risks. ACMT has been proactive and tireless in its effort to expand the recognition of the important roles that we can assume in public health decision-making.

ACMT has allied with other professional organizations to help advance the care of poisoned patients. ACMT codirects the venerable PEHSU, a daunting prospect even five years ago, and has worked on guidelines in association with, among others, the American Academy of Clinical Toxicology, American Society of Addiction Medicine, and the National Association of Medical Examiners. ACMT of course has its own journal (it’s been a while), its own annual meeting (it’s been a while too), and its own, well-attended monthly webinars (conflict of interest declaration needed here!).

Anyway, we have arrived as a medical specialty, still young and vulnerable. That said, we cannot rest on our laurels and have to keep actively cultivating our future. ACMT and its members have been, and will continue to be, a great team. We must continue to work together in that saprophytic relationship, providing mutual support and continuous engagement, to assure that our next 25 years will be as bright as the last 25.