Solving Mysteries as an Academic Medical Toxicologist

Session 135

What do Sherlock Holmes and medical toxicologists have in common? More than you might think! Join me to find out what makes this specialty so exhilarating for Dr. Ziad Kazzi from Emory University.

Read along to check if this is something you’re interested in and find a ton of resources you can tap into towards the end of this episode! Meanwhile, please check all our other podcasts on Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:40] Interest in Medical Toxicology

In 2002, it was the end of Ziad’s second year of a three-year residency in Emergency Medicine at Emory University. He was looking for a fellowship and wanted to do a fully accredited fellowship with board certification.

Born and raised in Lebanon, Ziad was an international medical graduate. He had a J-1 visa when he moved to the U.S. And it was required to be enrolled in an ACGME-accredited program. ACGME stands for Accreditation Council for Graduate Medical Education.

At that time, he was initially left with two choices – medical toxicology and sports medicine. Since 2002, they’ve had nursing medical services becoming board-certified for emergency medicine, which is another one added to his options.

His first driver for his decision was that he wanted to do pediatric emergency medicine. Sports medicine wasn’t just something he wanted to do as a subspecialty. The second driver for his decision was the environment at his university that drew him in.

[05:45] What is Medical Toxicology?

Medical toxicology is a board-certified subspecialty by the American Board of Medical Specialties. It’s similar to the likes of cardiology and gastroenterology. It’s also currently sponsored by three other boards, namely: preventive medicine residency, pediatrics, and emergency medicine.

At present, 90% are university medicine graduates feeding into the specialty. The specialty is really dominated by emergency medicine.

The specialty is quite broad in its areas of expertise. Most people think of medical toxicology as someone who assesses and manages acute overdoses of medications. This is a common practice pathway but that’s not the only thing they do.

'Medical toxicologists are involved in the assessment and management of chronic environmental and occupational exposures and poisonings.'Click To Tweet

Lead Poisoning and Environmental Exposure

For instance, they deal with lead poisoning and environmental exposure to lead in children. As well, they treat occupational exposures to mercury and other chemicals. Some of them are known, others are less known chemicals. They know about some of the toxicities and others are still being researched.

Medical toxicologists look at the occupational and environmental pieces and they’re experts on these. They have clinics where they see people on an outpatient basis like a neurologist.

Chemical Emergencies

They also work in overlap with disaster medicine and emergency preparedness. They’re experts in chemical emergencies such as the HAZMAT (hazardous materials) accidents and chemical disasters, as well as radiation injuries. Think about people contaminated with radioactive material after a bomb explosion or a nuclear weapon detonation.

They assess health effects and how they potentially treat some of these. The principles overlap with toxicology because it involves personal protective equipment, decontamination, and sometimes, chelation.

Forensics

Medical toxicologists also get involved in forensic cases occasionally and provide their opinion about a forensic question as well as laboratory questions. They’re not as experts as their laboratory medicine colleagues but they overlap them and have some expertise sought after occasionally.

Education

They’re also educators at emergency medicine programs at medical schools where they play roles in various components of the curricula such as pharmacology.

Poisoning Prevention

They’re involved in the prevention of poisoning. They do a lot of public health prevention through their work at one of the nation’s poison control centers serving as medical directors or assistant medical directors.

They may also serve as consultants where they cover the poison center for any medical backup questions that the poison center staff are unable to solve on their own.

Research

Medical toxicologists do research both nationally and internationally. They address questions about antidotes and toxicities. They look at ways to prevent or tools to present poisoning.

Envenomations

They treat envenomations from snakes, scorpions, spiders, marine envenomations like stingrays, marine poisonings, pufferfish poisoning, botulinum toxin, etc.

Addictions

Some of their colleagues are also working on addiction medicine with the rise of the opioid epidemic.

'With the opioid epidemic we're experiencing in the U.S., there's a big need for additional specialists to take care of our patients with opioid use disorders.'Click To Tweet

Because of their expertise in opioid overdose and drug overdose in general, they also play a role in cleaning patients with addiction problems specifically with opioid use disorders. They provide them with medication-assisted therapies and treatments.

[11:40] A Role in Industries

Medical toxicologists can play a role in the industry, working for the chemical industry or pharmaceutical industry. The employers are looking at expertise in assessing toxicity from different chemicals or from the pharmaceutical products they’re developing.

Some of them develop more interest in sub-areas because it’s difficult to be covering all of these broad topics.

It’s a two-year fellowship so you spend a lot of time learning this. Beyond the fellowship, you get to spend the rest of your life learning that.

[12:32] Traits that Lead to Becoming a Good Medical Toxicologist

Medical toxicologists are interested in life-long learning. They’re all curious individuals who are passionate about what they do.

'It's a really fun specialty that teaches you a lot of fun facts.'Click To Tweet

Being a really fun specialty, Ziad says they’re wonderful people to have dinner with because they can tell stories all night long. The can practically talk about different things – mushroom poisoning, snake bites, kerosene incidents, and exposure to chemicals and rheological agents.

People tend to be passionate about life-long learning but they do tend to specialize in specific areas.

For Ziad, he focuses more on ionizing radiation, nonionizing radiation, global toxicology development, developing toxicology capacity around the world. But he does dabble with other areas as well.

He takes calls for the poison center, sees patients at the bedside through the clinic, and does research and education as well.

[14:17] Typical Setting

Ziad works at the medical disclosure service at about one week per month. In his practice with partners, he gets to be the attending on the tox service one week per month. They’re an outpatient service so they don’t admit their own patients. They consult and see the patients in the emergency department when they’re consulted by the emergency physician or by an internal medicine specialist, neurologist, or trauma surgeon, or ICU physician.

During the week, they have a clinic week and see outpatients in the clinic. When he works as an emergency physician, he sees overdose patients at the same time.

Ziad uses his expertise in the area but he doesn’t necessarily wear the hat of the medical toxicologist when he’s seeing those patients. He would consult his partner on call for the day to provide their expertise.

[15:25] The Biggest Misconceptions Around Medical Toxicology

'The misconceptions around medical toxicology are more pronounced outside the U.S.'Click To Tweet

Although not as pronounced as in other parts of the world, the U.S. is still struggling with some areas of misconceptions.

In general, Ziad clarifies that they are not forensic toxicologists. There’s a big group of toxicologists around the world that are actually forensic toxicologists. They’re deceived as clinical toxicologists when they’re not. Same with the laboratories where they’re not analytic toxicologists.

They have colleagues who are analytical toxicologists around the world that are often thought of as clinical toxicologists when they’re not.

They are not pharmacists either. They work very closely with clinical pharmacists especially at the poison center level and in academic settings.

'We're not pharmacists.'Click To Tweet

Some people think of them only in the setting of a poison center and that they don’t see patients. But they do. In fact, there are many more medical toxicologists than poison centers. So most of them are not hired by poison centers.

You have more toxicologists than poison centers and those individuals are taking care of patients.

Research has shown that hospitals that have medical toxicologists participating in the care of patients can save resources in terms of lab testing, stewardship of antidote use, and shortened length of stay.

[17:55] The Sherlock Holmes of Hospitals

Ziad describes their specialty as being like Sherlock Holmes at the hospital where they get mysterious cases. The majority are known overdoses but a good number are mysteries too. Some of them are more misused than others.

'We're not pharmacists.'Click To Tweet

They can link up physical exam findings or a symptom with a lab finding with a vague history or occupation. He cites how they’ve done this to the sultanate of Oman who was poisoned by a pufferfish.

Sometimes, too, they’re not toxicologic. They get better than others in going through infectious disease possibilities or autoimmune possibilities and psychiatric and mental health illnesses because they have to. So they have to wade through all of this.

[20:22] Taking Calls

Ziad differentiates the call at the hospital and the call at the poison center, for which he actually takes calls for both. He also does a consultation call for a university in Lebanon. So he has three areas where he gets calls.

At the poison center, his fellows are his first call. They screen the calls for him and they manage data collection and the initial assessment plan. They staff these calls with him over the phone or at the bedside if he’s around.

Typically, a medical toxicologist in training is supposed to have at least about 250 bedside consults per year for two years to graduate. And every case is staffed by an attending like himself. In their section, they have about six attendings so they divide the number by six to get the average.

'Our poison center receives about 100,000 calls a year.' Click To Tweet

A medical toxicology fellow or attending is involved in about 10% to 20% of the cases. This is about 10,000 cases per year where a medical toxicologist is requested for backup. This pretty much gives you an idea about their consult.

The telephone consultation service at the American University of Beirut receives about 15 consults per month. This is usually handled by one of the medical toxicology attending physicians.

[22:50] The Training Path and Mitigating the Barriers

Ziad explains that everyone is welcome to apply. The boards that sponsor the American Board of Medical Toxicology are those of Emergency Medicine, Pediatrics, and Preventive Medicine.

The trend has been that emergency physicians are the ones that end up in the fellowships. They’ve also seen trends where they see new sources of fellows. Their colleagues are trained in internal medicine, neurology, nephrology, critical care medicine, and medical psychiatry.

'There is no barrier for any specialist to do a subspecialty in toxicology.' Click To Tweet

Being a member of the board, Ziad and other members look at these issues because they want to teach the diversity of their fellows and professionals. And they realized they need to reach out to all the specialties to do that.

Some barriers in the field include the comfort level of the specialist in seeing potentially critical patients. A good number of their patients are in the ICU. And if you’re not coming from a specialty where you deal with critical patients, you may be less comfortable in the specialty.

The other issue is compensation. The practice models and the training fellowship models work best for emergency medicine. And Ziad sees this as a barrier that they try to mitigate at the American College of Medical Toxicology.

Other practice pathways include addiction medicine, emergency preparedness, and radiation injuries. This may not be appealing to colleagues from other specialties and this is another barrier.

[26:20] Message to Primary Care Physicians

Looking at primary care physicians from an outpatient perspective, medical toxicologists wish to build more bridges between medical toxicology and primary care physicians.

He wishes to tell primary care physicians that they can be helpful to their patients in preventing the adverse effects of drugs. They can prevent poisonings from environmental toxins and occupational toxins. They help them assess environmental toxin exposure.

They also want to make sure they understand what they do not do. This includes assessing some of the environmental exposure such as toxic molds. And sometimes, in the environmental hypersensitivity, people are sensitive to unknown environmental exposures. They see these patients but they can’t do much more than just communicate to the patients and reassure them. And sometimes, this can be frustrating to the patients.

'There are some things we do not do that they think we do.' Click To Tweet

[28:15] The Most and Least Liked Things

Ziad likes the fact that it gives him more depth of knowledge in a variety of topics. It allows him to be helpful to colleagues in other specialties. He interacts on a regular basis with critical care professionals, trauma surgeons, general surgeons, neurologists, and psychiatrists.

'It gives me professional satisfaction that I'm actually helping other specialists in the care of their patients.'Click To Tweet

The reason he’s taken interest in ionizing radiation and global development of toxicology is that radiation injuries and radiation emergencies do not have a subspecialty dedicated to its care.

This is when he recognized that medical toxicologists have a unique set of skills already in their assessment and management of chemical exposures. They can apply this to radiation such as personal protection, decontamination, chelation, and risk communication.

Medical toxicologists are very good at communicating long-term risk from a specific exposure especially when it’s something they don’t have a lot of data on. So you have to communicate that properly to the patient in order to manage their anxiety and concerns.

They have a lot of success in the U.S. in preventing poisonings although they still have a long way to go. The rest of the world has many issues like policy, insecurity, lack of training, lack of surveillance, lack of research, lack of resources.

They’ve found a lot of satisfaction bringing this skillset to different parts of the world like Lebanon, the Middle East, and the North African region where Ziad works. He has also worked with the Republic of Georgia, the Republic of Kazakhstan, and India. He finds this very regarding on a personal level.

On the flip side, what he finds the most challenging is being on call. Even if you’re working at a place where you don’t get all the calls, you still have to be available. He’s lucky to be in a state where there are attendings he shares calls with.

That being said, he thinks he had made the right choice in discovering toxicology. His specialty has really kept his brain cells challenged and on his feet. And he encourages students to learn more about it.

[33:20] Help Spread News About the Specialty!

The American College of Medical Toxicology has created the clerkship council for medical toxicology just to try to coordinate efforts among all of the medical student educators and learners in their area.

They seek to spread the news about the specialty to medical students. They also do an annual forum for residents at their annual meeting. Residents come in and attend some lectures. They get to meet with other program directors.

[34:20] Final Words of Wisdom

If he had to do it all over again, Zian would still have chosen the same specialty. He even alludes to this specialty in saving him from burnout.

Professional burnout is a real threat to a variety of specialists and having the fortune of having this diversity in his practice is his antidote to burnout.

One week he’d be rounding with fellows. The next week he can be working in the ER and seeing patients. Another week, he’s also traveling to a remote area where he teaches toxicology or meeting with people in governments. Then the fourth week, he’s probably doing some more admin work and doing research.

'Diversifying what you do limits your risk of burnout.'Click To Tweet

Finally, he wishes to tell students and residents who want to learn more about medical toxicology to seek resources. There are about 500 medical toxicologists in the U.S. so it’s not a large specialty.

Focus your efforts on specific resources such as the American College of Medical Toxicology, the Society for Academic Emergency Medicine – Toxicology, the American Association of Poison Control Centers. The CDC (Centers for Disease Control and Prevention) does a lot of work in environmental health, occupational and environmental toxicology.

Finally, reach out to a toxicologist at your institution and in your city. Schedule a call or meet in person. Schedule a clinical clerkship or rotation at a toxicology site. Consider attending one of these meetings. Listen to podcasts about medical toxicology such as Tox in Ten and The Tox and the Hound.