Jennie Buchanan, Daniel Windels, Jeffrey Druck, Kennon Heard

1 Department of Emergency Medicine University of Colorado School of Medicine, Aurora, Denver, CO 80204, USA

2 Rocky Mountain Poison and Drug Center-Denver Health & Hospital Authority, Denver, Denver, CO 80204, USA

3 Saint Anthony Hospital, APEX Emergency Group, Lakewood, Colorado 80228, USA

INTRODUCTION

Toxicology is an often neglected component of medical school curricula; despite articles as far back as 1980 recommending the addition of toxicology to medical curricula, there is no Liaison Committee on Medical Education (LCME) requirement for specific toxicology elements as a component of medical education.[1,2]Toxicology has long been a key component of Emergency Medicine residency education listed as part of the Emergency Medicine Model of Clinical Practice, and educational interventions regarding toxicology have often focused on post-medical school graduates.[3–6]This dearth of education for medical students is present despite unintentional poisonings accounting for over 192,000 deaths in 2012, worldwide,and resulting in 392,000 deaths from intentional ingestions.[7]It is possible that a significant amount of toxicology knowledge is transmitted during clinical rotations. However, little data regarding medical student knowledge on toxicology subjects, or the influence of specialty choice or elective rotations on that knowledge exists.

METHODS

Three toxicologists developed a multiple-choice exam of 15 questions (Figure 1) focused on three domains: pharmacologic effects (PE), treatment of poisoning (TOP), and pharmacokinetics (PK). These questions were subsequently vetted through deployment to educational faculty members to assess for internal consistency, prior to deployment. The group of educational faculty and toxicology faculty combined accounted for over 45 years of educational experience.Students in this particular medical school complete pharmacology during mid-second year of a four-year curriculum. Approximately 160 students are in a class per a year with variation in retention. The survey was deployed during a final week class for 4th year medical students, with no incentive delivered with the request for completion of the survey. This deployment was repeated for a total of three years, from 2010–2012. Responses required answering questions as to selected specialty type and whether the respondent had taken a pharmacology or toxicology elective. For analysis, specialty types were grouped into pharmacologic intense (anesthesia,emergency medicine, internal medicine, pediatrics, and psychiatry), vs. less pharmacologic intense specialties(dermatology, OB/GYN, ophthalmology, pathology,physical medicine and rehabilitation, radiology, and surgery), as well as having taken a pharmacology or toxicology elective. Each year was processed, and subsequently compared between years. Data was analyzed using ANOVA and Excel (Microsoft, Redmond WA).

RESULTS

Totally 332 of 401 (83%) students completed the survey, with no significant differences in percentage of students answering per year. Mean scores were stable over the three years for all types of students. Students going into pharmacology intense specialties did better,on average, across all three tested domains. Students doing a pharmacology elective did better, on average,than the average student on the treatment of poisoning and pharmacokinetics, but were no better than the average student on pharmacologic effects. Students doing a toxicology rotation alone had higher scores across all three domains, although students doing both a toxicology rotation and a pharmacology rotation did worse than those doing just toxicology on the pharmacologic effects domain (Table 1).

DISCUSSION

It is clear to the authors that additional education around toxicology is needed in medical school. Our study, however, was designed to show differences in knowledge in three different domains based on exposure and interest. The test itself has not been validated as a general knowledge test for toxicology, and as such, may not be reflective of medical student knowledge standards.In developing the assessment instrument, it is possible that the toxicologists may have been biased towards material that is commonly taught on toxicology rotations,thereby skewing results. Similarly, students who choose to do toxicology or clinical pharmacology rotations may retain more information taught at prior time periods,as opposed to material obtained during their rotation.Similarly, students going into pharmacologic intense specialties may do better on tests. In addition, it is possible that there was a selection bias, with students with more knowledge on the subject more likely to answer the survey.

What our evaluation does show; however, is that toxicology rotations are associated with increased knowledge of three different domains, while pharmacology electives are associated with increased knowledge of two of the domains. As expected, it also showed that studentsgoing into more pharmacologic intense fields were more likely to have increased toxicology knowledge.

Table 1. Data analysis

Figure 1. Toxicology questions set.

CONCLUSIONS

The external validity of this study is limited to a single medical school with incomplete participation. The content was limited by the survey length and there is no gold standard for this knowledge area. Consistent results over the three-year period and correlation of performance with completing a toxicology rotation and intent to enter a pharmacology intensive specialty suggest this survey may correlate with toxicology knowledge specifically related to three domains studied PE, PK, and TOP. Implementation of required core courses or sections in required core courses like pharmacology focused on the field of toxicology may improve practical core content knowledge in fourth-year medical students. Further research defining standards of toxicology education in medical students needs to be studied.

Funding:This study was not funded.

Ethical approval:Not needed.

Conflicts of interest:The authors state they have no competing interests.

Contributors:JB proposed the study and wrote the first draft of this work. All authors read and approved the final version of the manuscript.

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