ABAT Exam Study Guide

ASHP Midyear 2009, I sat in a PPS interview booth pursuing my future. With each 30 minute block, I was searching for the emergency medicine residency program that was foolish enough to rank me high. As lucky as I was to have landed a position, there’s one vivid memory I still carry with me from those interviews.

It was in a meeting with a big name program where the representative asked me some standard fare questions. But one which had caught me off guard – not by its uniqueness – but by its time frame was “where do you want to be in 10 years.” Truthfully, I hadn’t thought that far down the road as every interview prep guide I read mentioned a 5-year timeline. But what I blurted out, both surprised me and also set a course for a long term pursuit: In 10 years I want to add “DABAT” to the end of my name.

There’s a long and interesting story behind why that came to mind, but that will be for another day. What I want to start describing is how I actually prepared for the exam. So hopefully you can pick apart what worked for me to figure out how to do it yourself. And “do it yourself” is somewhat of a theme here.

Allow me first to preface that I did not do a toxicology fellowship. I trained as an EM Pharmacist (PGY1 and PGY2 in EM). Nor do I work in a Poison Center. I am an EM pharmacist who happens to be completely fascinated with toxicology. My desire for the DABAT credential was also not one of the career advancements. In all truthfulness, it was just for me.

What is a DABAT?

In the late 1980’s physician toxicologists had board certification through the American College of Medical Toxicology. Similarly, veterinarians have the American Board of Veterinary Toxicology board certification. But pharmacists, nurses and PhD scientists with experience in toxicologic consultation and direct patient care did not have any such credential. However, recognizing this omission, the American Board of Applied Toxicology (ABAT) which is a standing committee of the American Academy of Clinical Toxicology (AACT) established its own Board Certification credential. These nurses, pharmacists, and PhD scientists then became eligible to complete the Credentialing process and sit for the ABAT exam. If successful in scoring a passing mark, these individuals were conferred the title Diplomate of the American Board of Applied Toxicology (DABAT).

Three decades on, there are close to 200 DABATs. While DABATs are often thought of as working in Poison Control Centers, their roles extend beyond to settings such as public health poisoning prevention, legal consultation, forensic evaluations, and practice in acute care settings as clinical pharmacists in emergency departments or ICUs.

So you want to be a DABAT?

Before even thinking about beginning to prepare for the exam, the first hurdle you need to pass is the credentialing. This process is to validate your candidacy for the exam itself. This is a very detailed process that deserves its own discussion. But being the Tarantino fan that I am, I usually start in the middle/end of the story.

In the process of completing the credentialing document, you by now should have become familiar with the ABAT study guide available on the AACT website. As far as descriptions go, this detailed outline is completely accurate of the depth and detail of knowledge required to be successful on the exam. The guide is very long and somewhat daunting. But there are elements of it that are perhaps more important than others.

Time must be on your side

Just before beginning the exam, one of the proctors was giving us a pep-talk of sorts. While it was in pure good intention, they mentioned that if by chance you aren’t successful this time around, many diplomates are successful a second time. While this is no surprise when speaking to other diplomates, it was something I had prepared myself for. 

In approaching the material for the exam, I made myself comfortable knowing that this may be a 2-year commitment. Turns out that I was correct in that. For my first time taking the exam, I studied for about 6 months, most days of the week – and did not pass. I was disappointed but realized that this was part of the process. The other thing that kept me going for the next year was how close I was to passing: 2 points.

In reflecting on what I did well, and what didn’t work, I made changes to my studying habits for the second year. The first time around, I began studying on an ad-hoc schedule and tried to shoot for 5 days per week of at least some dedicated studying time. I approached the material for studying with Goldfranks as the basis but chose to focus on the things I didn’t really know: metals, insecticides/pesticides/herbicides. I barely touched on the topics I felt I knew: acetaminophen, salicylates, antidepressants, etc.

But because there was still so much material to go through, I decided to eliminate other ‘distractions’ in my life. I stopped playing video games, and I stopped reading anything other than tox. One thing that I would not compromise on, however, was my family. I did not want to study to take any time away from being with my wife and daughter.

After getting the result of my first time through the exam, I re-evaluated this studying process and made two major observations and subsequent changes to this process. The first was the studying material: it wasn’t nearly enough. I vastly expanded the resources I used to study from as well as the content. Let’s put it this way: how well you think you need to understand acetaminophen toxicity is how you should understand sodium monofluoroacetate, and your understanding of acetaminophen toxicity should be that order of magnitude above your existing knowledge.

In order to step up my knowledge, this meant more studying of more material. Starting 6 months out the first time around became starting 10 months out this time around. Furthermore, I created a detailed daily schedule for studying goals to achieve. A typical day had 3-4 chapters in a core toxicology textbook, with 2-3 days per week with primary literature review. The primary literature review consisted of reading pretty much every case report from ClinTox and JMT I could get my hands on.

The second, more surprising change I made was that I realized by not reading anything other than toxicology related material, my mind became fragile or weakened somehow. Also, there were a lot of books I wanted to read. So for the second time around I made a point of emphasis to continue reading as much as I pleased. This simple change had a surprising change in my ability to retain information and make additional connections.

Patient cases – ABAT exam style

Practical experience is fundamental for credentialing, and being successful on the exam. Not being in a poison center, I knew I had to seek out each and every tox case and get involved. Since there is no formal consult where I practice, this meant being at the bedside for anything and everything tox related. By gaining practical experience, this keeps your ability to think critically, apply knowledge and make connections with patient cases and what I had been studying.

In other words, you have to learn how to think like a toxicologist and approach each case like a toxicologist. In my prior professional experience, I was incredibly lucky to have been in the right place at the right time to develop this through process and perspective. 

My first job out of residency was at NYU. The ED is staffed in somewhat of a unique way with the attending physicians and residents working both the NYU ED and the Bellevue ED. And of course, if you know anything about Bellevue and Tox, the NYCPCC is right across the street. 

On the first Thursday of every month, the NYCPCC holds a consultants’ conference where cases are presented from around the city, as well as neighboring PCCs. While the discussion and presentations are incredible, its the format of the discussion which teaches the evaluation of a potentially poisoned patient. 

The format goes along these lines: A patient complaint and general demographics are presented, with some triage vital signs and limited history. Then the audience is asked, “what would you like to know/what do you want to order/what’s the next step, etc.” Next, more information about the initial ED course with additional labs and some basic initial interventions are performed. Then again, the audience is asked: “what would you like to know/what do you want to order/what’s the next step, etc.” This process continues until the punchline of the case followed by a brief description of the topic and then more discussion among the members of the audience. 

I continued attending the conference after I left NYU and took a position at Rutgers. But the regular attendance for about 4 years ingrained in my mind, not just the knowledge gained from the various discussions, but more importantly the thought process and problem-solving methods of toxicologists.

You’ll be interested to find that the written component of the exam is very similar to these types of case conferences. But being prepared to think in this context and with this method of problem-solving, will increase your chances of gaining maximum points. And you’re going to need those points when you get to the multiple-choice section.

What to study

Exclusively studying a tertiary toxicology reference is insufficient to pass the exam. You could read Goldfranks cover to cover and still not pass the exam. The reason being, as comprehensive as Goldfranks is, there are areas in which it does not go into sufficient detail for your knowledge needed for the exam. The ABAT exam study guide explains this and makes it no secret. 

One excellent example of the topics that require additional resources includes environmental and occupational related toxicology. I was speaking with a toxicologist and asking for recommendations for textbooks, they suggested Occupational and Environmental Medicine. While some of this information is available in core toxicology books, the detail and depth from this book helped me to be successful on questions related to this topic. I consider this book an essential component to what made me successful on the exam.

Some free resources are equally beneficial. One example of this is the Agency for Toxic Substances and Disease Registry (ATSDR) website. While it’s a terrific resource to make yourself familiar with, it also has a section of Case Studies in Environmental Medicine. I would consider this site essential for studying for a successful exam.

Reading, Reading, and Listening… then more reading

As I mentioned previously, I read every case report I could get my hands on from major toxicology journals. While these cases may represent rare occurrences or things perhaps not likely to be on the exam, they almost always reference something that will. Similarly, the thought process for assessing a poisoned patient in these case reports is maintained. In the process of collecting these case reports, I came across old recordings of the JMT podcast. Lo and behold I heard some familiar voices when I started listening to these episodes from as far back as 2011.

Before they were the Dantastic Mr. Tox and Howard, Dan Rusyniak and Howard Greller were the hosts of the JMT podcast. I attribute much of my success to these two, not because of the content they provide itself, but the perspectives, the connections and the infectious passion for toxicology that helped me understand what I was studying better. It also helped me accomplish daily studying goals during the time that I would otherwise have not been able to study: driving, and running.

Another terrific resource is the https://mtcc.peaconline.org/ from Andrew Stolbach. While these cases and modules are geared for the physician audience, I still found them extremely helpful. The in-depth discussion of the pharmacology and toxicology of numerous xenobiotics, in addition to exam-style questions, helped me train and test my knowledge. While these modules can be structure-heavy (and you aren’t tested on structures per se in the ABAT exam) learning structures is extremely helpful in recognizing similarities among certain classes that may not be obvious.

While the ABAT website does provide a link to the Goldfrank’s self-assessment quizzes that accompanied each chapter, the link no longer works. In essence, it dumps you to the McGraw Hill page where you can purchase the book. When it was available, I found these questions tremendously helpful and were as close to the exam questions in terms of difficulty and style as I could get. But again, it’s no longer available (unless I’m not aware of its new location).

Other aspects of the exam and how I prepared for them are worthy of their own post, and that’s what I hope to do. To give you an idea of what I mean, here is a picture of my studying methods:

Since writing is an essential element to the exam, I also had to work on my penmanship. Because my handwriting looks like Bart Simpsons’ attempt at forging his mother’s hand for a school excuse note. 

The depth and breadth of the knowledge required to pass the ABAT exam is exactly the kind of challenge I felt I needed in my professional career. I would encourage anyone who shares a love for toxicology to at least begin the process of credentialing and perhaps even sitting for the exam. If fear of failure is stopping you because of the embarrassment you may feel, I’ll repeat again that I failed my first attempt. But if you’re truly committed to achieving your goal of those magical little letters at the end of your name, that feeling of embarrassment is fleeting. Trust me.

 

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