The 2021 Core Content of Medical Toxicology

The Medical Toxicology Subboard approved modifications to the Core Content of Medical Toxicology in March 2021. The document outlines the areas of knowledge considered essential for the practice of medical toxicology. The Core Content provides the organizational framework for the development of the Medical Toxicology Certification and Cognitive Expertise Examinations and serves as a template for the development of curricula for medical toxicology fellowship training programs.


Introduction
Contemporary medical curricula strive to "achieve a symbiosis with the health services and communities in which the students will serve" [1]. A "Core Content" document defines the essential body of knowledge for a given academic discipline and forms the basis for curriculum design, education, and testing.
In 1994, the Medical Toxicology Subboard (representing the American Board of Emergency Medicine, the American Board of Pediatrics, and the American Board of Preventive Medicine) developed the first Core Content of Medical Toxicology to inform the construction of the first certifying examination. This document consisted of 22 major content areas and was organized, in part, by toxicant classification. In 2000, and again in 2009, the Medical Toxicology Subboard convened a task force charged with updating the existing Core Content document, and to improve the framework that conceptualized the expanding body of knowledge of medical toxicology. These task forces solicited input from program directors for medical toxicology fellowship training programs and medical toxicology diplomates and established an ABEM contact and e-mail for recommendations about the Core Content from all medical toxicologists [2,3]. The resulting version of the Core Content was published in 2012.
In 2020, the Medical Toxicology Subboard convened a task force charged with evaluating, refining, and updating the 2012 Core Content of Medical Toxicology. The 2020 Medical Toxicology Core Content Task Force was comprised of four board-certified medical toxicologists with specific content expertise in medical toxicology, pediatrics, environmental toxicology, emergency medicine, occupational toxicology, preventive medicine, poison center administration, emergency/disaster management, addiction medicine, and medical education. The task force members included current and former program directors from the US medical toxicology fellowship training programs, as well as staff members from the American Board of Emergency Medicine with expertise in psychometrics and examination design and development.
The 2020 task force considered the future needs of the specialty and recognized that a shortage of medical toxicologists currently exists. Many US academic and non-academic centers alike do not have medical toxicologists performing Supervising Editor: Mark B. Mycyk, MD inpatient or outpatient consultations. As of 2020, the number of medical toxicology fellows enrolling in fellowship training programs is increasing; however, 25-33% of total positions in the country remain unfilled, and 33-50% of programs are unfilled each year [4]. The 2020 task force acknowledged that one way to encourage young physicians to consider careers in medical toxicology is to ensure that the Core Content remains current and relevant with regard to the current practice of medical toxicology.
In February 2021, the Medical Toxicology Subboard approved a revised Core Content document. The 2021 Core Content of Medical Toxicology encompasses the body of knowledge for the specialty of medical toxicology and outlines the areas of knowledge considered essential for its practice. The 2021 Core Content provides the organizational framework for the development of the Medical Toxicology Certification and Cognitive Expertise Examinations and details the knowledge to be tested beginning with the 2022 examination. In addition, the Core Content serves as a template for the development and application of curricula for fellowship training programs in medical toxicology. The current revision replaces the 2012 Core Content of Medical Toxicology.

Methodology
The methodology applied in the development of the 2021 Core Content involved detailed analysis of the previous Core Content documents and ultimate consensus among the task force members. The work of the 2020 task force was informed by the knowledge that the Core Content is used by learners to direct their study, by program directors to direct their teaching, by test item writers to determine question topics, and by test designers to assemble the Certification and Cognitive Expertise Examinations.
The American Board of Emergency Medicine surveyed, via e-mail, 201 board-certified medical toxicologists with a wide variety of years-of-practice, practice setting, academic affiliation, medical publishing/research, involvement in teaching fellows, and poison center affiliation. Medical toxicologists rated how often each aspect of the 2012 Core Content was encountered and how important each item was to their current practice of medical toxicology. Survey respondents were also able to submit additional comments to inform this process. The survey was analyzed by the task force to identify areas for expanded or restricted detail. The task force expended in excess of 250 person-hours in the analysis and re-drafting of the Core Content.
The 2020 task force analyzed the 2012 Core Content document, which was organized into six subject areas: (1) principles of toxicology, (2) toxins and toxicants, (3) clinical assessment, (4) therapeutics, (5) assessment and population health, and (6) analytical and forensic toxicology. The 2020 task force expanded the "top-level" subject areas to include (7) environmental toxicology, (8) occupational and industrial toxicology, and (9) addiction toxicology and substance use. The intent was to improve the organization of the Core Content and to acknowledge the importance of these domains within the discipline of medical toxicology. The task force further sought to create a document that reflects current medical toxicology practice.
The Core Content was divided into sections for initial review by two task force members to recommend potential edits based on the guiding principles. Each recommendation was discussed by all four task force members, and the determination of consensus among task force members was used to finalize edits. Task force members then reviewed the entire document for consistency and presented the draft Core Content to the entire Medical Toxicology Subboard. After final editing and cross-referencing, the final Core Content document was approved by the Medical Toxicology Subboard.

Discussion
The 2020 task force defined a set of "guiding principles" to be used in updating the Core Content, which included decreasing ambiguity and increasing the clarity and clinical relevance of the Core Content document.

Decreasing Ambiguity
The 2020 task force recognized that the Core Content may be used to design educational fellowship programs and to provide a guide for learners to organize their education and study. For this reason, the task force aimed to decrease ambiguities in the document. The task force drastically reduced the use of "examples" throughout the document to eliminate the implication that these "examples" were more important than other line items in a category. For example, the subsection that formerly listed "Specific radioisotopes (e.g., cesium, iodine, polonium, radon)" was updated to remove the "e.g.," and now specifically lists the radioisotopes that a medical toxicologist should be familiar with and understand. This removes the implication that cesium, iodine, polonium, and radon are more important than others but also limits the number of clinically relevant radioisotopes that a medical toxicologist must master. Similarly, the task force decreased the use of the term "others" in the document, as this may imply that medical toxicologists must know all possible aspects of a topic and that any aspect of that topic may be a potential question on an examination. For example, in the section "metals/metalloids," the metals and metalloids that are necessary to understand are specifically listed in place of "other." As practice evolves, additional items may be added in subsequent revisions to the document. The Core Content is a guideline and, while no guideline encompasses every aspect of a topic, the task force felt that it was important to be specific when possible.

Increased Clarity
Revisions to some sections were made to specify the knowledge that a medical toxicologist should have about expansive topics. For example, "Role of the Medical Review Officer" was eliminated in favor of including additional topics under "interpretation of drug testing" that encompass aspects of the medical review officer role in current medical toxicology practice. Similarly, "confirmatory test; gas chromatography" was changed to "interpretation of confirmatory test results; gas chromatography" to de-emphasize the technical aspects of the test (i.e., how the lab performs the test) and emphasize the interpretation of the test and its advantages and limitations.

Clinical Relevance
A primary goal of the 2020 task force was to reorganize the Core Content focusing on clinical relevance. Certain sections were compressed and others were expanded to be more consistent with their relative weight in current medical toxicology practice. The task force added sections that have increasing importance in medical toxicology, including QRS prolongation, QTc prolongation, neonatal abstinence syndrome, epigenetics, and extracorporeal membrane oxygenation (ECMO). "Cannabis" was removed from the category "Psychoactive Drugs and Hallucinogens" and placed into its own category, given its prominence in the United States and the increasing legalization of cannabis.
The Occupational/Industrial Toxicology section was organized according to occupation and industry, with pertinent chemicals listed as subsections, because a medical toxicologist often evaluates workers from a particular occupation or industry (e.g., welder, painter, petrochemical industry worker) rather than with a specific chemical exposure (e.g., carbon disulfide exposure).
The task force further attempted to de-emphasize certain areas of the 2012 Core Content that were prone to esoterica. For example, the section "Regulatory and legal background (e.g., HAZWOPER, SARA, CERCLA, RCRA, etc.)" was removed; while the application of these laws may be integral to the practice of medical toxicology, the specifics of the law (wording, date of enactment, etc.) are de-emphasized. The task force removed "miscellaneous toxicants" and moved those chemicals to a new "occupational/industrial toxicology" section to more specifically contextualize them. Further, the 2020 task force agreed by consensus to eliminate from the Core Content document chemicals that have been banned or unavailable in the United States for at least 50 years and are not typically used internationally. These chemicals have been placed into the section entitled "Exposures of Historical Significance." The 2020 task force added three domains to the Core Content that reflect current medical toxicology practice: Environmental Toxicology, Occupational/Industrial Toxicology, and Addiction Toxicology. The intent of adding these sections was to reorganize existing sections of the Core Content and group them to more accurately reflect the current practice of the specialty of medical toxicology. Much of the content for these sections was contained in the 2012 Core Content document, but is re-organized to maximize clinical relevance.
The 2021 Core Content is intended to be a "living document," in keeping with the evolving practice of medical toxicology. The Subboard anticipates periodic updates to the Core Content and recommends that these updates occur approximately every 5 years. adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.