Clinical Toxicology (2013), 51, 913–917 Copyright © 2013 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2013.857779
COMMENTARY: 2012 NACCT CAREER ACHEIVEMENT AWARD LECTURE
Future directions for clinical toxicology and toxicologists FREDERICK H. LOVEJOY Jr
Clinical Toxicology Downloaded from informahealthcare.com by Northeastern University on 01/13/14 For personal use only.
Department of Pediatrics, Harvard Medical School, Boston, MA, USA
Alan Woolf, thank you for that wonderful introduction of this Career Achievement Award. Over the years our paths have crossed often in the pursuit of our callings in the vineyards of healing of the Boston Children’s Hospital, thus your words are very meaningful. I also want to thank my friend of longest duration in toxicology, Barry Rumack, who introduced me at these meetings last year as well as today. He did his usual great job then and today and my gratitude is profound. Finally I want to thank all of you for this honor. I began with you at my first toxicology meeting in Montreal 39-years ago; I departed from you for academic and pediatric labors at Harvard and Children’s Hospital; I now return and it is good to return. I have decided to offer you today thoughts that are grounded in my current work and that I hope may be useful to you as physicians, nurses, and pharmacists in your work. A word about my career to better understand the title of the talk. My career is perhaps a “Tale of Four Careers”. The first, following pediatric residency and 2 years in the Navy in Morocco as a medical officer, involved becoming deeply embedded in the care of the sickest, hospitalized patients at the Children’s Hospital coupled with administrative leadership of a residency group of 65 for 4 years as chief resident. This was followed by 18 joyous years of emersion in a second career of research and writing, administration and clinical care in toxicology, and direction of the statewide Massachusetts Poison Control System. Then came a third, a passion for medical education, through leadership for 10 years of the pediatric clerkship for Harvard medical students rotating at the Children’s Hospital and for 27 years as program director of the Children’s Hospital’s pediatric residency program and later the Boston Combined Residency Program. The fourth career has been an administrative mélange of interim department chair twice and for 20 years shepherding pediatric academic promotions at Harvard Medical School. Why do I tell you all of this? Simply because it is from these
exposures to remarkable colleagues and mentors, unending challenges, and many opportunities to witness the ingredients of excellence and success, that some lessons have been learned, far afield from the world of toxicology but perhaps with some cornels of wisdom. Hopefully a few will be useful. It has been said that anything of true value is built on the shoulders of those who go before. In that context it is useful to perhaps consider the abiding strengths of toxicology, followed by the persistent challenges, and then what might be the response to each. First, three strengths of clinical toxicology: 1) Public and professional service, 2) Information retrieval and dissemination, and 3) Collaboration across disciplines. From its earliest days in the 1950s service to the public at large as well as to a diverse and large group of professionals has allowed toxicology to stand unbounded by limitations imposed by institutions; a discipline with a wide purview able to speak at a state and federal level and on the broadest issues in toxicology. It has spoken eloquently to poisonings affecting the public, to care, education and research issues important to a broad array of professionals, and through advocacy to important public policy issues at a state and national level. Toxicology has had a bully pulpit that it has taken superb advantage of in the past and should in the future. Secondly, toxicology has had a long and rich tradition of information acquisition based upon access to large populations and subsequent useful dissemination of that information. Through highly effective cooperation, it has generated national, population-based data through poison centers. It is a long way from the 4 by 6 cards and Poisindex microfiche and CD ROM to today’s real time, automated drug and disease reporting and surveillance. This is a record to be rightly proud of. As a result of this accomplishment clinical toxicology has been an important and generous servant for the public good. Thirdly, toxicology has a rich tradition of being able to collaborate effectively within and across disciplines. This collaboration has been exemplified in 60 years of national meetings from the first in Chicago to this meeting today in Atlanta involving physicians, nurses, pharmacists, veterinarians, and public health professionals. In fact the American Academy of Clinical Toxicology, the American
Received 14 October 2013; accepted 16 October 2013. Address correspondence to Frederick H. Lovejoy, Jr, MD, Department of Pediatrics, Harvard Medical School, 300 Longwood avenue, Boston, MA 02115, USA. E-mail: [email protected]
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Association of Poison Control Centers, and the American College of Medical Toxicology and our colleagues from Canada, Europe, and Asia stand as glorious examples of effective collaboration across disciplines. These synergies in clinical research, education, and care serve as powerful models for growth in the future. Toxicology, I believe, also has three challenges that must be considered and hopefully overcome in the future . They include: first, financial challenges; second, a capacity to attract the best and the brightest; and third, the fact that the discipline still is small in number and thus its impact and influence, especially in academia, are limited. Insufficient funding has always been a challenge. Its limited supply has hampered the important work of poison centers, has hampered the education of a sufficiently large number of young trainees in our discipline, and has curtailed toxicology’s ability to carry out its important research. Outstanding basic, translational, clinical, and outcomes research must go hand in hand with robust competitive funding. Research dollars, not clinical dollars alone, should be the cornerstone of quality research programs. Investigators, support staff, and trainees all need the assurance of the opportunity for this support. Going forward this deficiency should be addressed. Secondly, attracting a constant flow of the best and the brightest into our discipline has been a challenge. Toxicology fellowships programs are limited in number and in the number of fellows they train. While many fellowships are creatively supported, training grants are few and most fellowships are funded by multiple local, clinical sources external to toxicology. Because dollars equate to time, this limits commitment of time to important research, education, and clinical work in toxicology. This is a negative for attracting the best and the brightest. Like Willie Sutton, bright, talented, young trainees go to where dollars and support reside and are found in abundance. Thirdly, the discipline has significantly grown since the 1970s and 1980s, as evidenced by the wonderful attendance at our national meetings. Still, when toxicologists return home, they stand relatively alone in their area of expertise. A significant corpus of broadly based, professional expertise is only infrequently aggregated, thereby limiting a robust research, teaching and clinical presence. Toxicology thus has not yet achieved the size sufficient to receive the institutional and departmental recognition it deserves. As a result toxicologists and toxicology are under-appreciated. And so I have been reflecting on some humble suggestions that you might wish to consider. These come in three areas: a) suggestions for young clinicians, b) suggestions for the current leaders in toxicology, and c) suggestions as to potential future directions for the discipline. My thoughts have been formed through observing successful careers and disciplines and, as applied to toxicology, I hope, may be useful. Cognizant that today is built on the shoulders of those who have gone before, I will mention toxicologists from my day, some no longer with us, who I admired greatly and who contributed importantly to our field of toxicology.
First some suggestions for young physicians; I will mention six. 1.
2.
3.
“Listen to Your Passion and Your Expertise.” Young people succeed if they have a passion for their work. They also succeed and are happy if they place themselves in a position to be successful. Young people know what they are good at and what they do not do well. Knowing one’s areas of strength and pursuing it and avoiding one’s areas of weakness is critical. Being stuck in an area which you are told to pursue, or think you should pursue and lacking the skills to be successful, is a formula for failure. We as young physicians looked upon Jay Arena and Harry Shirkey, founders of modern day toxicology, with great admiration. They so beautifully and persistently exemplified this passion. Young people need to be helped to know their strengths and their passion. I often told house officers, laboring to make a difficult career decision, to get away from the hospital and work. Go to the mountains or the seashore for the weekend. Listen to your gut and above all listen to your spouse. More than anyone they have your best interest at heart and they can be totally honest. If one wakes happily each morning with the same decision, it is probably the right decision. “Get Well Trained in Emerging, Synergistic Disciplines”. Train yourself so that you can set yourself apart. Become an expert in a smaller, circumscribed area of your discipline so that you have unique knowledge and skills. Strive to be widely sought after whether it be for your clinical acumen, your research accomplishments, or your teaching skills, but in an area that is valued and relevant. The “road less travelled” can be lonely, even ulcerogenic, but it is also less crowded with less competitors, as my prior chief, the revered Dr. Charles Janeway, suggested when I was considering toxicology versus infectious diseases as a career. By so doing you can be recognized locally and regionally earlier and as your sphere of influence enlarges, nationally. “Don’t Take Side-Trips”. Prime Minister Nehru near the end of his life was once asked what he viewed as the reason for his great success. He responded, “I didn’t take side trips”. What he was saying was, stay focused; determine your goals clearly; undertake the next lecture, research project, or invitation consistent with your goals. Dean Synder of the Harvard School of Public Health also said it well, “Remember it is not a matter of how smart you are. It is a matter of how much glue there is between the seat of your pants and the seat of your chair”. Make the excellence of your research, your lecture, your clinical care count. Focus and hard work will yield results. These attributes exhibited so wonderfully by our esteemed colleagues, Barry Rumack and John Doull, beautifully illustrate these principles. Clinical Toxicology vol. 51 no. 10 2013
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“When in Rome, do as the Romans do”. Most of us are in academics (pharmacy, nursing, medical schools, major health centers, etc.), with some in industry and a few in practice. Research, clinical care, and education are the criteria for promotion. It is important to know these criteria, the rules of engagement. They serve as your compass. Order your professional life so you have time to write, to analyze your data, and to present your work. One morning while working on a paper, my boss, Dr. Mary Ellen Avery, the discoverer of surfactant deficiency as the cause of hyaline membrane disease, entered. I rose to say “good morning”. She responded firmly, “don’t talk, write.” I wrote. Go to the library, leave your office, stay-athome, anything that facilitates the writing process. Increase your sphere of influence from local, to regional, to national as you move up the academic ladder. Obtain funding for your work. The remarkable careers of Michael McGuigan, Milt Tenenbien, Matt Ellenhorn, Carol Angle, Fred Oehme, and our late colleague Michael Shannon magnificently illustrate these principles. “Seek out Good Mentors, Good Collaborators, Good Friends”. As exciting new fields are important so also are the mentors and faculty who work in those fields. In our hospital the successful divisions who produce successful fellows and future junior faculty are clear to all. They help their fellows and junior faculty to develop their own areas of expertise and excellence; they counsel no side trips; they encourage and reward written scholarship; they know good collaborators. These are the places to train and entrust one’s career. Successful careers are built on committed mentors and collaborators whether they be in clinical care or research. Search out those who are generous, wise, and supportive. Finally maintain local and national friends. As the time passes, you can be helpful to them and they to you, especially when supportive letters are requested at the time of promotion. Our revered colleagues, Helmut Redetzki, Lewis Goldfrank, and Bill Robertson, demonstrated these halcyon attributes to the benefit of us all. “Develop a National Visibility”. In our training program for residents at the Children’s Hospital we have a rule, “You present at a national meeting; we pay”. Developing the habit of going to national meetings, both in toxicology and in one’s specialty, is essential: to see the research, to observe the leaders, to promote your work, and to become known. Ideas for future research projects are generated, collaborations are formed. Toxicology has done this well over the years, our junior colleagues have been the beneficial recipients of this effort. The many presidents of our august associations, and I would like to particularly recognize Mark Thoman, over the years have enabled, with great dedication and perseverance, this to occur and we are all grateful to them.
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Now suggestions for toxicology leaders; I will respectfully describe five. 1.
“Attract the Best and the Brightest”. The number of newly trained toxicologists remains far too small. Those elements of toxicology, the diagnosis of the unknown overdose, the untold number of opportunities for clinical research, and the lecture in an area that most are less familiar with, are attractive and powerful draws for young residents. Charismatic teachers and mentors and respected faculty and ambitious trainees are essential to create an attractive, exciting, and robust learning and research environment. Finally a willingness to send trainees away to learn the new science is essential. David Nathan, physician-inchief at the Children’s Hospital and later President of the Dana Farber Cancer Institute, as a young division chief went to the Whitehead Institute at MIT in the early 1980s to learn molecular biology himself and then sent his brightest fellows there each year. The results were palpable. Residents flocked to his fellowship. Success breeds success. Young trainees, who become successful and revered for their work, become powerful role models and powerful magnets for attracting others into their field. Chuck Becker and Alan Done did this brilliantly in days past.
2.
“Enhance Through Collaboration”. Remarkably fertile and productive relationships have been established between toxicology and emergency medicine, and schools of pharmacy and nursing over the years. More, however, can be done in other areas and the opportunities are many. They include involvement with schools of public health, public policy, education, and business as well as new disciplines that interface closely with toxicology: informatics and bio-surveillance, molecular pharmacology and genetics, outcomes and quality improvement research, and collaborative translational investigation. These collaborations will yield new ideas, new sources of funding, and new and enhanced visibility. Nurture these opportunities while simultaneously maintaining an all-important oversight responsibility over your young faculty. And like Fletcher Seagull know when it is time to let Jonathan Livingston Seagull take his first solo flight. Take special pride in his accomplishment. Our distinguished colleagues Walt Decker, Ed Kenzelock, Joe Veltri, Ted Tong, and Tony Managuerra did this exceedingly well. “Pursue the Money”. The traditional sources of money in support of poison center and toxicology work, such as state, hospital, pharmaceutical, and foundation dollars, have been critical but now will need to be supplemented to allow our work to be enhanced. New allied disciplines collaborating with toxicology will open up opportunities for new sources of funding including the following: in education (NIH training grants), in basic research (NIH and Howard Hughes Foundation funding), in
3.
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F. H. Lovejoy translational research (NIH, CDC, and Emergency Medical Services for Children funding), in quality improvement and outcomes research (Robert Wood Johnson, CORI funding through the Affordable Care Act, AHRQ and the CDC), and in Informatics Research (the National Library of Medicine and the Food and Drug Administration). Building the infrastructure and credibility to be successful in securing new funding sources, will take time but will for certain enhance future, robust collaborative efforts. Parenthetically we all rejoice and applaud the recent success of the Toxicology Investigators Consortium in garnering NIH funding support for their important work—an achievement of great importance for the field of toxicology. “It’s their Life to Live, Not Yours.” Your trainees and mentees at the end of the day must think through their decisions, make their decisions, and ultimately live with their decisions. Increasingly with my trainees I came to believe that my role was to help them to thoughtfully and fully consider the options around the decision they were about to make, with all of its pluses and minuses. But, I tried hard to not make the decision for them. Again they, not I, would have to live with the decision. My role was to be certain they had all the data necessary to make a wise decision. “Good Guys Finish First, Not Last”. I have had the chance to watch remarkable leaders over my career. Divisions and departments rise and fall based on their effectiveness. Nurturing your skills to be an effective research or administrative leader is critical to one’s success. Continually looking for ways through courses, exposures, and experiences to improve one’s skills is essential. When I assumed my current role as Associate Physician in Chief, when asked what I wanted to carry out my new role, I asked not for money or support staff, I asked for funding to take courses and mini sabbaticals to learn. From that base I added a string on my bow and also on the bow of my mentees. Select those brighter and more capable than yourself. Be generous with first and last authorship; promote your trainees to give prominent lectures; give first authorship of chapter invitations to your trainees; and actively mentor young faculty for academic promotion. Young people know who are the talented and attentive mentors. Deans and department chairs know who are the generous citizens of the department. Being a good citizen counts and pays off. These attributes have been beautifully exemplified by our colleagues Ruth Lawrence, Frank Aldrich, and Don Kunkel. Additionally Tony Temple, over so many years of faithful and generous philanthropic support, has exemplified these marvelous attributes of loyal and generous leadership.
Future Directions While clinical toxicology’s accomplishments are ones we should honor and cherish, addressing its challenges can be
energizing and exciting. As I have already suggested, now may be the time to move into new synergistic areas, while simultaneously continuing to pursue the traditional, highly successful pursuits of the past. New areas might be particularly attractive if they are closely aligned with toxicology, are compelling for young physicians, are beneficial to our organizations, and are of sufficient relevance to assure generous sources of support. Forays into these areas might commence in several arenas including the following: joint fellowship training, continuing education for faculty, new research endeavors, and clinical care initiatives. The results from joint fellowship training will take longer but will be more lasting. Joint research initiatives, either at a fellowship or faculty level, can be rapidly initiated with results evolving in a timely manner. Similarly, care and education initiatives can also have a short time frame. The results will be a more visible presence for toxicology and more shared academic endeavors. Four synergistic areas might be considered: 1.
2.
Collaborative, Translational Research. As carried out so effectively through the National Poison Data System and the Toxicology Investigators Consortium Case Registry, as tools for toxico-surveillance as well as the study of specific overdoses, these types of collaborative endeavors serve as powerful models. Alignment with other existing networks such as PECARN (The Pediatric Emergency Care Applied Research Network) and COG (The Pediatric Oncology Group), as examples, might offer new collaborations as well as new sources of both K and R NIH funding, and an enhanced academic presence. Through collaborations with a host of different clinical disciplines, new and important alignments will evolve. The critical toxicology issues of today (for example, carbon monoxide poisoning, lipid rescue therapy, oral hypoglycemics and digoxin poisoning, high-dose insulin therapy, as well as adverse drug events and disaster response) open up potential fertile research collaborations with allied disciplines in each of our hospitals (for example, with anesthesiology, endocrinology, cardiology, and clinical pharmacology). Biosurveillance and Informatics. The new informatics, epidemiology, applied biostatistics, and mathematical modeling, as applied to today’s toxicology efforts, become important basic sciences for our discipline. The mining of hospital electronic records, emergency department point of contact encounters, and poison center data allow for real time problem solving in toxicology. Syndromic temporal biosurveillance, spatial cluster detection, regional data incorporation into medical decision making, disease outbreak detection and health maps, all have potential and valuable applicability in toxicology. Joint fellowship training in informatics and acquisition of basic bio-statistical skills has great pertinence for the future for our discipline. Aligning ourselves in Clinical Toxicology vol. 51 no. 10 2013
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each of our schools and hospitals with informatics experts for collaborative research and training is a fertile future direction. Health Services and Outcomes Research. The Institute of Medicine (IOM) report, “The Quality Chasm”, with its seven elements of quality care: safe, timely, effective, efficient, patient oriented, and equitable now pursued avidly in hospitals and schools throughout the US, opens up quality and outcomes assessment opportunities for toxicology. These relate closely to earlier poison center cost effectiveness work carried out by a number of our investigators, including notably Toby Litovitz . Is poison information given correctly, is it followed, is it understood, is it patient centered, is it safe? Now these efforts can be well funded by AHRQ, the National Institutes of Health, the National Library of Medicine, the Robert Wood Johnson Foundation and PCORI. Training of a cadre of young physicians in public health and public policy schools and in epidemiology and biostatistics will help to assure quality of care research in toxicology at a time when these matters are foremost in the country’s conscience. Genetics and Molecular Biology. Collaborative relationships with aligned basic disciplines enhances important fundamental research. Toxicology has done this well in the past and these efforts with pharmacology departments and schools of pharmacy should be continued. Additionally the new sciences of molecular biology and pharmacogenetics
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open up attractive new arenas of translational research for young physicians. An understanding at a molecular level of the mechanisms of action of toxins and the variability of metabolism based on genetic variance from person to person is indeed a fertile area for the future. Collaboration with physicians trained in basic molecular biology and toxicology, as well as clinical investigators in established clinical disciplines, such as endocrinology, genetics, and cardiology, will afford important opportunities. Piggybacking with these well-funded, synergetic disciplines opens up innumerable opportunities for the future. These are only a few potential areas to pursue in the future. They all share the elements of being exciting and cutting edge and are naturally aligned with our endeavors. They are possibly worthy of your consideration as each of you position your toxicology and poison center efforts to be more robust, relevant, and impactful. In closing, thank you for allowing me to reflect with you in this address. I hope that it will prove to be useful. I close with a story that President Kennedy often told: The great French General Marshall Hubert Lyautey had returned to Morocco following World War I and was discussing one day with his gardener when to plant a new orchard. His gardener lamented that it would take at least 50 years for the trees to reach maturity. The Marshall replied, “Then we haven’t a moment to lose; we must plant tonight”. Thank you so much for this honor. Plant tonight, good luck tomorrow and best wishes.
COMMENTARY: 2012 NACCT CAREER ACHEIVEMENT AWARD LECTURE
Future directions for clinical toxicology and toxicologists FREDERICK H. LOVEJOY Jr
Clinical Toxicology Downloaded from informahealthcare.com by Northeastern University on 01/13/14 For personal use only.
Department of Pediatrics, Harvard Medical School, Boston, MA, USA
Alan Woolf, thank you for that wonderful introduction of this Career Achievement Award. Over the years our paths have crossed often in the pursuit of our callings in the vineyards of healing of the Boston Children’s Hospital, thus your words are very meaningful. I also want to thank my friend of longest duration in toxicology, Barry Rumack, who introduced me at these meetings last year as well as today. He did his usual great job then and today and my gratitude is profound. Finally I want to thank all of you for this honor. I began with you at my first toxicology meeting in Montreal 39-years ago; I departed from you for academic and pediatric labors at Harvard and Children’s Hospital; I now return and it is good to return. I have decided to offer you today thoughts that are grounded in my current work and that I hope may be useful to you as physicians, nurses, and pharmacists in your work. A word about my career to better understand the title of the talk. My career is perhaps a “Tale of Four Careers”. The first, following pediatric residency and 2 years in the Navy in Morocco as a medical officer, involved becoming deeply embedded in the care of the sickest, hospitalized patients at the Children’s Hospital coupled with administrative leadership of a residency group of 65 for 4 years as chief resident. This was followed by 18 joyous years of emersion in a second career of research and writing, administration and clinical care in toxicology, and direction of the statewide Massachusetts Poison Control System. Then came a third, a passion for medical education, through leadership for 10 years of the pediatric clerkship for Harvard medical students rotating at the Children’s Hospital and for 27 years as program director of the Children’s Hospital’s pediatric residency program and later the Boston Combined Residency Program. The fourth career has been an administrative mélange of interim department chair twice and for 20 years shepherding pediatric academic promotions at Harvard Medical School. Why do I tell you all of this? Simply because it is from these
exposures to remarkable colleagues and mentors, unending challenges, and many opportunities to witness the ingredients of excellence and success, that some lessons have been learned, far afield from the world of toxicology but perhaps with some cornels of wisdom. Hopefully a few will be useful. It has been said that anything of true value is built on the shoulders of those who go before. In that context it is useful to perhaps consider the abiding strengths of toxicology, followed by the persistent challenges, and then what might be the response to each. First, three strengths of clinical toxicology: 1) Public and professional service, 2) Information retrieval and dissemination, and 3) Collaboration across disciplines. From its earliest days in the 1950s service to the public at large as well as to a diverse and large group of professionals has allowed toxicology to stand unbounded by limitations imposed by institutions; a discipline with a wide purview able to speak at a state and federal level and on the broadest issues in toxicology. It has spoken eloquently to poisonings affecting the public, to care, education and research issues important to a broad array of professionals, and through advocacy to important public policy issues at a state and national level. Toxicology has had a bully pulpit that it has taken superb advantage of in the past and should in the future. Secondly, toxicology has had a long and rich tradition of information acquisition based upon access to large populations and subsequent useful dissemination of that information. Through highly effective cooperation, it has generated national, population-based data through poison centers. It is a long way from the 4 by 6 cards and Poisindex microfiche and CD ROM to today’s real time, automated drug and disease reporting and surveillance. This is a record to be rightly proud of. As a result of this accomplishment clinical toxicology has been an important and generous servant for the public good. Thirdly, toxicology has a rich tradition of being able to collaborate effectively within and across disciplines. This collaboration has been exemplified in 60 years of national meetings from the first in Chicago to this meeting today in Atlanta involving physicians, nurses, pharmacists, veterinarians, and public health professionals. In fact the American Academy of Clinical Toxicology, the American
Received 14 October 2013; accepted 16 October 2013. Address correspondence to Frederick H. Lovejoy, Jr, MD, Department of Pediatrics, Harvard Medical School, 300 Longwood avenue, Boston, MA 02115, USA. E-mail: [email protected]
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Association of Poison Control Centers, and the American College of Medical Toxicology and our colleagues from Canada, Europe, and Asia stand as glorious examples of effective collaboration across disciplines. These synergies in clinical research, education, and care serve as powerful models for growth in the future. Toxicology, I believe, also has three challenges that must be considered and hopefully overcome in the future . They include: first, financial challenges; second, a capacity to attract the best and the brightest; and third, the fact that the discipline still is small in number and thus its impact and influence, especially in academia, are limited. Insufficient funding has always been a challenge. Its limited supply has hampered the important work of poison centers, has hampered the education of a sufficiently large number of young trainees in our discipline, and has curtailed toxicology’s ability to carry out its important research. Outstanding basic, translational, clinical, and outcomes research must go hand in hand with robust competitive funding. Research dollars, not clinical dollars alone, should be the cornerstone of quality research programs. Investigators, support staff, and trainees all need the assurance of the opportunity for this support. Going forward this deficiency should be addressed. Secondly, attracting a constant flow of the best and the brightest into our discipline has been a challenge. Toxicology fellowships programs are limited in number and in the number of fellows they train. While many fellowships are creatively supported, training grants are few and most fellowships are funded by multiple local, clinical sources external to toxicology. Because dollars equate to time, this limits commitment of time to important research, education, and clinical work in toxicology. This is a negative for attracting the best and the brightest. Like Willie Sutton, bright, talented, young trainees go to where dollars and support reside and are found in abundance. Thirdly, the discipline has significantly grown since the 1970s and 1980s, as evidenced by the wonderful attendance at our national meetings. Still, when toxicologists return home, they stand relatively alone in their area of expertise. A significant corpus of broadly based, professional expertise is only infrequently aggregated, thereby limiting a robust research, teaching and clinical presence. Toxicology thus has not yet achieved the size sufficient to receive the institutional and departmental recognition it deserves. As a result toxicologists and toxicology are under-appreciated. And so I have been reflecting on some humble suggestions that you might wish to consider. These come in three areas: a) suggestions for young clinicians, b) suggestions for the current leaders in toxicology, and c) suggestions as to potential future directions for the discipline. My thoughts have been formed through observing successful careers and disciplines and, as applied to toxicology, I hope, may be useful. Cognizant that today is built on the shoulders of those who have gone before, I will mention toxicologists from my day, some no longer with us, who I admired greatly and who contributed importantly to our field of toxicology.
First some suggestions for young physicians; I will mention six. 1.
2.
3.
“Listen to Your Passion and Your Expertise.” Young people succeed if they have a passion for their work. They also succeed and are happy if they place themselves in a position to be successful. Young people know what they are good at and what they do not do well. Knowing one’s areas of strength and pursuing it and avoiding one’s areas of weakness is critical. Being stuck in an area which you are told to pursue, or think you should pursue and lacking the skills to be successful, is a formula for failure. We as young physicians looked upon Jay Arena and Harry Shirkey, founders of modern day toxicology, with great admiration. They so beautifully and persistently exemplified this passion. Young people need to be helped to know their strengths and their passion. I often told house officers, laboring to make a difficult career decision, to get away from the hospital and work. Go to the mountains or the seashore for the weekend. Listen to your gut and above all listen to your spouse. More than anyone they have your best interest at heart and they can be totally honest. If one wakes happily each morning with the same decision, it is probably the right decision. “Get Well Trained in Emerging, Synergistic Disciplines”. Train yourself so that you can set yourself apart. Become an expert in a smaller, circumscribed area of your discipline so that you have unique knowledge and skills. Strive to be widely sought after whether it be for your clinical acumen, your research accomplishments, or your teaching skills, but in an area that is valued and relevant. The “road less travelled” can be lonely, even ulcerogenic, but it is also less crowded with less competitors, as my prior chief, the revered Dr. Charles Janeway, suggested when I was considering toxicology versus infectious diseases as a career. By so doing you can be recognized locally and regionally earlier and as your sphere of influence enlarges, nationally. “Don’t Take Side-Trips”. Prime Minister Nehru near the end of his life was once asked what he viewed as the reason for his great success. He responded, “I didn’t take side trips”. What he was saying was, stay focused; determine your goals clearly; undertake the next lecture, research project, or invitation consistent with your goals. Dean Synder of the Harvard School of Public Health also said it well, “Remember it is not a matter of how smart you are. It is a matter of how much glue there is between the seat of your pants and the seat of your chair”. Make the excellence of your research, your lecture, your clinical care count. Focus and hard work will yield results. These attributes exhibited so wonderfully by our esteemed colleagues, Barry Rumack and John Doull, beautifully illustrate these principles. Clinical Toxicology vol. 51 no. 10 2013
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“When in Rome, do as the Romans do”. Most of us are in academics (pharmacy, nursing, medical schools, major health centers, etc.), with some in industry and a few in practice. Research, clinical care, and education are the criteria for promotion. It is important to know these criteria, the rules of engagement. They serve as your compass. Order your professional life so you have time to write, to analyze your data, and to present your work. One morning while working on a paper, my boss, Dr. Mary Ellen Avery, the discoverer of surfactant deficiency as the cause of hyaline membrane disease, entered. I rose to say “good morning”. She responded firmly, “don’t talk, write.” I wrote. Go to the library, leave your office, stay-athome, anything that facilitates the writing process. Increase your sphere of influence from local, to regional, to national as you move up the academic ladder. Obtain funding for your work. The remarkable careers of Michael McGuigan, Milt Tenenbien, Matt Ellenhorn, Carol Angle, Fred Oehme, and our late colleague Michael Shannon magnificently illustrate these principles. “Seek out Good Mentors, Good Collaborators, Good Friends”. As exciting new fields are important so also are the mentors and faculty who work in those fields. In our hospital the successful divisions who produce successful fellows and future junior faculty are clear to all. They help their fellows and junior faculty to develop their own areas of expertise and excellence; they counsel no side trips; they encourage and reward written scholarship; they know good collaborators. These are the places to train and entrust one’s career. Successful careers are built on committed mentors and collaborators whether they be in clinical care or research. Search out those who are generous, wise, and supportive. Finally maintain local and national friends. As the time passes, you can be helpful to them and they to you, especially when supportive letters are requested at the time of promotion. Our revered colleagues, Helmut Redetzki, Lewis Goldfrank, and Bill Robertson, demonstrated these halcyon attributes to the benefit of us all. “Develop a National Visibility”. In our training program for residents at the Children’s Hospital we have a rule, “You present at a national meeting; we pay”. Developing the habit of going to national meetings, both in toxicology and in one’s specialty, is essential: to see the research, to observe the leaders, to promote your work, and to become known. Ideas for future research projects are generated, collaborations are formed. Toxicology has done this well over the years, our junior colleagues have been the beneficial recipients of this effort. The many presidents of our august associations, and I would like to particularly recognize Mark Thoman, over the years have enabled, with great dedication and perseverance, this to occur and we are all grateful to them.
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Now suggestions for toxicology leaders; I will respectfully describe five. 1.
“Attract the Best and the Brightest”. The number of newly trained toxicologists remains far too small. Those elements of toxicology, the diagnosis of the unknown overdose, the untold number of opportunities for clinical research, and the lecture in an area that most are less familiar with, are attractive and powerful draws for young residents. Charismatic teachers and mentors and respected faculty and ambitious trainees are essential to create an attractive, exciting, and robust learning and research environment. Finally a willingness to send trainees away to learn the new science is essential. David Nathan, physician-inchief at the Children’s Hospital and later President of the Dana Farber Cancer Institute, as a young division chief went to the Whitehead Institute at MIT in the early 1980s to learn molecular biology himself and then sent his brightest fellows there each year. The results were palpable. Residents flocked to his fellowship. Success breeds success. Young trainees, who become successful and revered for their work, become powerful role models and powerful magnets for attracting others into their field. Chuck Becker and Alan Done did this brilliantly in days past.
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“Enhance Through Collaboration”. Remarkably fertile and productive relationships have been established between toxicology and emergency medicine, and schools of pharmacy and nursing over the years. More, however, can be done in other areas and the opportunities are many. They include involvement with schools of public health, public policy, education, and business as well as new disciplines that interface closely with toxicology: informatics and bio-surveillance, molecular pharmacology and genetics, outcomes and quality improvement research, and collaborative translational investigation. These collaborations will yield new ideas, new sources of funding, and new and enhanced visibility. Nurture these opportunities while simultaneously maintaining an all-important oversight responsibility over your young faculty. And like Fletcher Seagull know when it is time to let Jonathan Livingston Seagull take his first solo flight. Take special pride in his accomplishment. Our distinguished colleagues Walt Decker, Ed Kenzelock, Joe Veltri, Ted Tong, and Tony Managuerra did this exceedingly well. “Pursue the Money”. The traditional sources of money in support of poison center and toxicology work, such as state, hospital, pharmaceutical, and foundation dollars, have been critical but now will need to be supplemented to allow our work to be enhanced. New allied disciplines collaborating with toxicology will open up opportunities for new sources of funding including the following: in education (NIH training grants), in basic research (NIH and Howard Hughes Foundation funding), in
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F. H. Lovejoy translational research (NIH, CDC, and Emergency Medical Services for Children funding), in quality improvement and outcomes research (Robert Wood Johnson, CORI funding through the Affordable Care Act, AHRQ and the CDC), and in Informatics Research (the National Library of Medicine and the Food and Drug Administration). Building the infrastructure and credibility to be successful in securing new funding sources, will take time but will for certain enhance future, robust collaborative efforts. Parenthetically we all rejoice and applaud the recent success of the Toxicology Investigators Consortium in garnering NIH funding support for their important work—an achievement of great importance for the field of toxicology. “It’s their Life to Live, Not Yours.” Your trainees and mentees at the end of the day must think through their decisions, make their decisions, and ultimately live with their decisions. Increasingly with my trainees I came to believe that my role was to help them to thoughtfully and fully consider the options around the decision they were about to make, with all of its pluses and minuses. But, I tried hard to not make the decision for them. Again they, not I, would have to live with the decision. My role was to be certain they had all the data necessary to make a wise decision. “Good Guys Finish First, Not Last”. I have had the chance to watch remarkable leaders over my career. Divisions and departments rise and fall based on their effectiveness. Nurturing your skills to be an effective research or administrative leader is critical to one’s success. Continually looking for ways through courses, exposures, and experiences to improve one’s skills is essential. When I assumed my current role as Associate Physician in Chief, when asked what I wanted to carry out my new role, I asked not for money or support staff, I asked for funding to take courses and mini sabbaticals to learn. From that base I added a string on my bow and also on the bow of my mentees. Select those brighter and more capable than yourself. Be generous with first and last authorship; promote your trainees to give prominent lectures; give first authorship of chapter invitations to your trainees; and actively mentor young faculty for academic promotion. Young people know who are the talented and attentive mentors. Deans and department chairs know who are the generous citizens of the department. Being a good citizen counts and pays off. These attributes have been beautifully exemplified by our colleagues Ruth Lawrence, Frank Aldrich, and Don Kunkel. Additionally Tony Temple, over so many years of faithful and generous philanthropic support, has exemplified these marvelous attributes of loyal and generous leadership.
Future Directions While clinical toxicology’s accomplishments are ones we should honor and cherish, addressing its challenges can be
energizing and exciting. As I have already suggested, now may be the time to move into new synergistic areas, while simultaneously continuing to pursue the traditional, highly successful pursuits of the past. New areas might be particularly attractive if they are closely aligned with toxicology, are compelling for young physicians, are beneficial to our organizations, and are of sufficient relevance to assure generous sources of support. Forays into these areas might commence in several arenas including the following: joint fellowship training, continuing education for faculty, new research endeavors, and clinical care initiatives. The results from joint fellowship training will take longer but will be more lasting. Joint research initiatives, either at a fellowship or faculty level, can be rapidly initiated with results evolving in a timely manner. Similarly, care and education initiatives can also have a short time frame. The results will be a more visible presence for toxicology and more shared academic endeavors. Four synergistic areas might be considered: 1.
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Collaborative, Translational Research. As carried out so effectively through the National Poison Data System and the Toxicology Investigators Consortium Case Registry, as tools for toxico-surveillance as well as the study of specific overdoses, these types of collaborative endeavors serve as powerful models. Alignment with other existing networks such as PECARN (The Pediatric Emergency Care Applied Research Network) and COG (The Pediatric Oncology Group), as examples, might offer new collaborations as well as new sources of both K and R NIH funding, and an enhanced academic presence. Through collaborations with a host of different clinical disciplines, new and important alignments will evolve. The critical toxicology issues of today (for example, carbon monoxide poisoning, lipid rescue therapy, oral hypoglycemics and digoxin poisoning, high-dose insulin therapy, as well as adverse drug events and disaster response) open up potential fertile research collaborations with allied disciplines in each of our hospitals (for example, with anesthesiology, endocrinology, cardiology, and clinical pharmacology). Biosurveillance and Informatics. The new informatics, epidemiology, applied biostatistics, and mathematical modeling, as applied to today’s toxicology efforts, become important basic sciences for our discipline. The mining of hospital electronic records, emergency department point of contact encounters, and poison center data allow for real time problem solving in toxicology. Syndromic temporal biosurveillance, spatial cluster detection, regional data incorporation into medical decision making, disease outbreak detection and health maps, all have potential and valuable applicability in toxicology. Joint fellowship training in informatics and acquisition of basic bio-statistical skills has great pertinence for the future for our discipline. Aligning ourselves in Clinical Toxicology vol. 51 no. 10 2013
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each of our schools and hospitals with informatics experts for collaborative research and training is a fertile future direction. Health Services and Outcomes Research. The Institute of Medicine (IOM) report, “The Quality Chasm”, with its seven elements of quality care: safe, timely, effective, efficient, patient oriented, and equitable now pursued avidly in hospitals and schools throughout the US, opens up quality and outcomes assessment opportunities for toxicology. These relate closely to earlier poison center cost effectiveness work carried out by a number of our investigators, including notably Toby Litovitz . Is poison information given correctly, is it followed, is it understood, is it patient centered, is it safe? Now these efforts can be well funded by AHRQ, the National Institutes of Health, the National Library of Medicine, the Robert Wood Johnson Foundation and PCORI. Training of a cadre of young physicians in public health and public policy schools and in epidemiology and biostatistics will help to assure quality of care research in toxicology at a time when these matters are foremost in the country’s conscience. Genetics and Molecular Biology. Collaborative relationships with aligned basic disciplines enhances important fundamental research. Toxicology has done this well in the past and these efforts with pharmacology departments and schools of pharmacy should be continued. Additionally the new sciences of molecular biology and pharmacogenetics
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open up attractive new arenas of translational research for young physicians. An understanding at a molecular level of the mechanisms of action of toxins and the variability of metabolism based on genetic variance from person to person is indeed a fertile area for the future. Collaboration with physicians trained in basic molecular biology and toxicology, as well as clinical investigators in established clinical disciplines, such as endocrinology, genetics, and cardiology, will afford important opportunities. Piggybacking with these well-funded, synergetic disciplines opens up innumerable opportunities for the future. These are only a few potential areas to pursue in the future. They all share the elements of being exciting and cutting edge and are naturally aligned with our endeavors. They are possibly worthy of your consideration as each of you position your toxicology and poison center efforts to be more robust, relevant, and impactful. In closing, thank you for allowing me to reflect with you in this address. I hope that it will prove to be useful. I close with a story that President Kennedy often told: The great French General Marshall Hubert Lyautey had returned to Morocco following World War I and was discussing one day with his gardener when to plant a new orchard. His gardener lamented that it would take at least 50 years for the trees to reach maturity. The Marshall replied, “Then we haven’t a moment to lose; we must plant tonight”. Thank you so much for this honor. Plant tonight, good luck tomorrow and best wishes.
