Academic Psychiatry 27:50-53, March 2003
© 2003 Academic Psychiatry
A Survey of Medical Toxicology Training in Psychiatry Residency Programs
Marianne Ingels, M.D.,
David Marks, M.D. and
Richard F. Clark, M.D.
At University of California–San Diego Medical Center, San Diego, CA, Dr. Ingels and Dr. Clark are affiliated with the Division of Medical Toxicology of the Department of Emergency Medicine, and Dr. Marks with the Department of Psychiatry. Dr. Ingels is also affiliated with the San Diego Division of the California Poison Control System and with Integris Baptist Medical Center, Oklahoma City, OK. Address correspondence to Dr. Clark, 200 W. Arbor Drive, San Diego, CA 92103-8676. E-mail: rfclark{at}ucsd.edu
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ABSTRACT
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Objective: To determine the extent of medical toxicology training provided in U.S. psychiatry residency programs. Medical toxicology is a newly recognized field of medicine. Many patient consultations are common to psychiatrists and medical toxicologists, including intentional drug overdoses and adverse reactions to psychotropic medications. Methods: The authors surveyed the directors of all accredited U.S. psychiatry residency programs by mail to determine how much formal training in medical toxicology, if any, is provided in these programs. Results: Eighty program directors (48.6%) responded. Replies indicated that only 4% of psychiatry residency programs were affiliated with institutions offering defined medical toxicology electives. Although residents in 65% of programs could choose to design a medical toxicology elective, this had been done in only 2 programs. Only 41% of programs responding offered specific didactic lectures on medical toxicology topics to psychiatry residents. Conclusions: The results suggest that few psychiatry residency programs have formal medical toxicology training curricula and that, in programs responding to the survey, little interaction occurs between medical toxicologists and psychiatry residents.
Key Words: Toxicology • Surveys of Psychiatric Residency Programs
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INTRODUCTION
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Psychiatrists are called upon to evaluate and treat patients with a wide variety of conditions. A newer field with which psychiatry shares a great number of patients is medical toxicology. The American Board of Medical Specialties recognized medical toxicology as a subspecialty in 1994. The Sub-board of Medical Toxicology is cosponsored by the primary boards of Emergency Medicine, Pediatrics, and Preventive Medicine, with training programs housed under each of these specialties.
Medical toxicologists are physicians who specialize in the care of poisoned and envenomated patients. This includes patients with drug overdoses; patients intoxicated by or withdrawing from drugs of abuse; patients with adverse drug reactions (including monoamine oxidase inhibitor reactions, serotonin syndrome, dystonic reactions, and neuroleptic malignant syndrome); patients who believe they are being poisoned (either by another person or by something in their environment); and patients with known occupational or environmental exposures to toxins. There are many poisonings, with agents such as mercury, for which psychiatric symptoms may be a clue to the diagnosis. Other compounds, such as the plant jimson weed (Datura americana and others), cause a delirium that is sometimes misinterpreted as a primary psychiatric disorder. Medical toxicologists can function independently from poison centers, but they are often intricately involved in poison center operations. For certification, poison centers are required to have a board-certified medical toxicologist serve as Medical Director to provide oversight of poison information provided to callers.
There is no specific mention of toxicology training in the American College of Graduate Medical Education (ACGME) requirements for psychiatry residency programs, but some of the requirements are related. Residents are to be "especially conversant with medical disorders displaying symptoms likely to be regarded as psychiatric and with psychiatric disorders displaying symptoms likely to be regarded as medical." They are to be familiar with the "use, reliability, and validity of ... laboratory testing" in general. Residents are to have training and experience in drug and alcohol detoxification, and in the evaluation and management of suicidal patients. The curriculum is also to include "adequate and systematic instruction in ... psychopharmacology" (1). The purpose of this study was to determine the extent of formal medical toxicology training in psychiatry residency programs.
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METHODS
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We produced a survey to assess the degree of toxicology training available to psychiatry residents in training programs (Appendix A). This survey was mailed to the program directors of all accredited psychiatry residency programs in the United States as listed in the most recent Graduate Medical Education Directory (2). The survey was re-sent to all program directors a month later to try to encourage participation by those who did not return the initial form. Responses were returned by mail or fax.
Results of the survey were evaluated by descriptive statistics. The Human Subjects Committee of our institution reviewed and approved this study.
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RESULTS
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Surveys were sent to 173 psychiatry residency program directors. Two institutions responded that their residency programs were no longer in existence. Of the remaining 171 programs, 80 program directors (46.8%) responded.
No responding program requires a medical toxicology rotation, and only 3 programs (3.8%) were affiliated with institutions that have medical toxicology electives already defined and available to their residents. Fifty-two program directors (65%) reported that their residents could design and complete their own toxicology elective, though this had actually been done in only 2 programs (2.5%). Only 16 programs (20%) have formal interactions with medical toxicologists. Forty-three programs (53.8%) reported the presence of a medical toxicology service at their institution. Written comments indicated that some program directors did not differentiate between a poison control center and a physician-run, hospital-based medical toxicology admitting or consulting service.
Respondents indicated that most toxicology training for psychiatry residents occurs in didactic lecture format. Thirty-three programs (41.3%) reported that specific medical toxicology lectures are given to the residents, with an average of 5.4 lectures per year. Nineteen program directors (23.8%) included comments that medical toxicology topics are covered within the context of psychopharmacology or other lecture series. Specific lecture topics covered by various programs relating to toxicology included drugs of abuse (60%), withdrawal syndromes (58.8%), neuroleptic malignant syndrome (58.8%), adverse effects of psychotropic medications (57.5%), drug-induced psychosis (55%), drug-induced altered mental status (53.8%), serotonin syndrome (53.8%), tricyclic antidepressant poisoning (45%), use and interpretation of drug screens/drug testing (42.5%), analgesic (aspirin and acetaminophen) poisoning (12.5%), general management of the poisoned patient (12.5%), toxic syndromes (8.8%), and drugs used in suicide and overdose (2.5%).
Psychiatry program directors were asked to rate the utility of medical toxicology training for their residents on a scale from 1 (not at all useful) to 10 (very useful). The mean rating was 6.3, with a median of 6, suggesting that program directors view medical toxicology training as slightly more than moderately useful.
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DISCUSSION
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Psychiatrists care for suicidal patients, patients on psychotropic medications, and patients with acute neuropsychiatric symptoms of unclear etiology. Patients on psychotropic agents are at risk not only for developing adverse drug reactions, but also for attempting suicide with these medications. According to 1998 data from the American Association of Poison Control Centers, the categories of "sedatives/hypnotics/antipsychotics" and "antidepressants" were the fourth and fifth most common categories of drugs involved in adult toxic exposures, and they ranked fifth and second in numbers of deaths from poisoning in this country (3). We have consulted on cases where patients have been "medically cleared" following a drug overdose by primary physicians both in an office setting and in the emergency department, only to develop toxicity after transfer to a psychiatric ward or service. Psychiatrists may also be called upon to evaluate patients who have been initially misdiagnosed with psychiatric disease, such as those with toxicity from sympathomimetic agents, anticholinergic compounds ("anticholinergic toxidrome"), or withdrawal syndromes. Medical toxicologists in many institutions work closely with Psychiatry to help provide medical clearance of patients prior to psychiatric dispositions.
Our survey lists some of the more common toxicology-related topics that are covered in didactic sessions by psychiatry residency programs. Other such topics could also be useful. Psychiatry residents could benefit from diagnostic and treatment information on subjects such as hallucinogenic plants and mushrooms, drug-induced movement disorders, and receptor physiology. Autonomic pharmacology is an area that many physicians review only infrequently after the first or second year in medical school, yet the vast majority of toxic syndromes seen in poisoned patients are directly explained and easily understood by these pathways. Specific lectures covering the most common toxins leading to morbidity and mortality in overdose should be addressed, especially when these effects can be delayed (such as acetaminophen). Finally, reviewing how the institution's toxicology laboratory can assist in diagnosis and management of poisonings should be considered.
Whether these topics can be covered in total by psychiatry faculty is a question that must be individually answered by psychiatry residency directors. Residency programs in fields such as emergency medicine with diverse training backgrounds often seek "off-service" rotations for trainees, encouraging individual didactic sessions relating to the specific subspecialty during the period of rotation. Our institution's medical toxicology program offers elective rotations to medical students and residents of all specialties interested in more focused didactics on this subject. Measuring the impact of our rotation on resident and student fund of knowledge is difficult, but feedback from rotators has been positive and interest in our program is increasing.
Our results show that 16 responding programs have some type of formal interaction with medical toxicologists. However, 43 programs reported the presence of a medical toxicology service at their institution. Considering that many toxicology services do offer clinical training rotations, it is possible that this discrepancy demonstrates a lack of communication between disciplines. One way to enhance the pharmacology and toxicology training of psychiatry residents would be for residency directors to contact the medical toxicologist at their health care facility to inquire about didactic or rotation possibilities. Since curricula exist for toxicology training for both emergency medicine residents and medical toxicology fellows, psychiatry residency directors could consult these documents through the ACGME office to assist in evaluating the applicability of certain topics.
Some limitations to this study should be noted. Fifty-three percent of program directors did not respond to the survey. In addition, data regarding forms of toxicology training not specifically addressed by the survey questions may not have been captured by this study.
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CONCLUSION
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Our data suggest that although psychiatry program directors who answered our survey feel that knowledge of toxicology would be useful to their residents, there is currently little formal training in this area in their respective residency curriculums. It is possible that more didactic interaction could allow both medical toxicologists and psychiatrists to improve care for patients with drug-related pathology.
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REFERENCES
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- Program requirements for residency education in psychiatry. Accreditation Council for Graduate Medical Education. http://www.acgme.org
- Accredited programs in psychiatry. Graduate Medical Education Directory 1999-2000. Chicago, American Medical Association, 1999, pp 868-883
- Litovitz TL, Klein-Schwartz W, Caravati EM, et al: 1998 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999; 17:435-487[CrossRef][Medline]
This article has been cited by other articles:
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J. L. Roffman, A. B. Simon, K. M. Prasad, C. J. Truman, J. Morrison, and C. L. Ernst
Neuroscience in Psychiatry Training: How Much Do Residents Need To Know?
Am J Psychiatry,
May 1, 2006;
163(5):
919 - 926.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
