Medical Toxicology — Specialty Profile

Exploratory, not prescriptive. This profile blends hard data (pay, match, burnout, demographics — each sourced and dated) with generalizations and synthesized online opinion about culture and "who fits." It's here to help you get curious and go find out for yourself — not to tell you who to become. Numbers marked ⟳ verify change every year; check the linked source before you quote one. Last reviewed: 2026-07-25.

Multidisciplinary subspecialty fellowship, entered mainly from Emergency Medicine, and also from Pediatrics, Preventive and Occupational Medicine, and IM.

Also called: med tox, tox. A 2-year fellowship you enter after a base residency, not straight from medical school. Organ system: none in particular, since it's the specialty of drugs, chemicals, venoms, and poisons acting on the whole body.

The 30-second version

Medical toxicology is the pharmacology-and-poisoning detective niche of medicine, the person the whole hospital calls when a patient is altered, crashing, or mysteriously sick and the answer might be a drug, an overdose, a chemical, a snakebite, or an occupational exposure. Toxicologists reason from receptors and toxidromes to a diagnosis and an antidote, run poison-control centers (much of it by phone), staff inpatient consult services, teach, research, and, for most of them, keep working clinical shifts in their base specialty, overwhelmingly Emergency Medicine. Its defining draw is being a genuinely fascinating cerebral field that also carries less overnight-shift burden than full-time EM, which is why it's so often called an EM career-longevity "off-ramp." The honest catch: it usually means a pay cut versus full-time EM and a small job market, so most toxicologists blend it part-time with their clinical shifts rather than doing tox alone.

Quick dashboard (details and sources below)


Training after med school	Base residency + Medical Toxicology fellowship (2 yrs)
Total from college start	~13–14 yrs (4 undergrad + 4 med school + 3–4 base residency + 2 fellowship)
Competitiveness	Small, niche field — not hyper-competitive, but tightening ⟳
Typical total pay	~$350,000–$430,000, mostly EM-anchored ⟳
Pay reality	Pure/full-time tox is usually a pay cut vs full-time EM (~$300k–$360k academic) ⟳
Lifestyle	Consult/academic + poison-control (much by phone) + usually part-time EM shifts
Burnout	No tox-specific figure exists; generally lower than EM's #1-ranked ~63% ⟳
Demographics	107 fellows nationally: 39.3% women, 15.9% DO, 6.5% IMG (ACGME AY2024–25) ⟳

What they actually do

Medical toxicologists diagnose, manage, and prevent harm from drugs, overdoses, chemicals, venoms, environmental and occupational exposures, and drugs of abuse. The core skill is cognitive rather than procedural: reading a toxidrome (the fingerprint pattern a class of poison leaves on vital signs, pupils, skin, and mental status), reasoning from pharmacology and physiology to what's causing it, and choosing the antidote, decontamination, or supportive strategy that reverses it. They're the experts the rest of the hospital consults when a case gets weird, the "physician's physician" for anything poison-related.

The work has three usual pieces, and most toxicologists do some of each.¹ First, a consult/academic role: bedside and phone consults on poisoned or complex-medication patients, plus teaching and research. Second, poison-control center medical direction, much of it by phone and telehealth, advising clinicians and the public on exposures and overdoses, often paired with center leadership. Third, for the majority, continued clinical shifts in the base specialty (usually EM). Purely non-clinical "0% EM" tox jobs exist but are hard to come by.

Representative work (mostly cognitive): interpreting drug levels and nomograms · recognizing toxidromes · selecting and dosing antidotes and antivenoms · managing overdoses, withdrawal, and severe drug interactions · guiding decontamination and enhanced elimination (e.g., dialysis for certain poisons) · poison-center phone/telehealth consultation · occupational/environmental exposure workups · public-health surveillance of drug-of-abuse and exposure trends · expert-witness and forensic case review.

A day in the life: less "pick up the board mid-code" than EM, more "the phone and the pager." A toxicologist might round on the inpatient consult service, take poison-center calls from EDs across a region, staff a resident teaching session, work on a research project or a case series, and, on shift days, still cover the ED floor. The rhythm is more plannable and more daytime than full-time EM, but call still exists; it's largely phone/telehealth call rather than in-house "come stabilize a trauma at 3am" call.¹

The training path & time to completion

Medical school (4 yrs) → a base residency → 2-year (minimum 24-month) ACGME medical toxicology fellowship → subspecialty certification through your primary board.²³

This is a multidisciplinary fellowship, one of the few subspecialties co-sponsored by three primary boards. You can enter from essentially any ACGME residency, but in practice the pipeline is heavily skewed:

Emergency Medicine supplies the vast majority. Toxicology is intellectually and operationally adjacent to EM (overdoses and poisonings present to the ED), so EM residents get the most exposure and the strongest recruitment pipeline. "Currently, emergency medicine is the primary specialty of the vast majority of board-certified medical toxicologists, fellows, and applicants."⁴
The minority entries: Pediatrics, Internal Medicine, Preventive/Occupational Medicine, and Family Medicine (and occasionally Psychiatry). ACMT and the field are actively trying to broaden non-traditional recruitment.³⁴
Certification follows your primary board rather than one unified exam sponsor: EM-trained (and most other ABMS) physicians certify via ABEM's MedTox subboard; Pediatrics-trained via ABP; Preventive Medicine-trained via ABPM. The subspecialty exam is offered annually (October).²³ Completing the ACGME fellowship alone isn't automatically sufficient, and you must meet your primary board's criteria.³

Total from the start of college: roughly 13–14 years: 4 undergrad + 4 med school + 3–4 years base residency (EM 3–4, Peds/IM 3, Preventive Med shorter) + 2 years fellowship.²³

The part premeds miss is that most toxicologists blend tox with their base specialty. Med tox is rarely a full-time job on its own. The large majority keep a meaningful clinical EM FTE (the part that pays the most per hour) and layer poison-control, consult, and academic work on top. Even in fellowship, most programs cap ED shifts (often ~12 hrs/week) or drop the requirement, moving fellows into "a more regimented academic schedule peppered with ED shifts."¹ The mental model to carry: base specialty (usually EM) ± part-time tox, not "quit the ED to become a toxicologist."

How competitive is it?

Bottom line: a small, niche field, not hyper-competitive but tightening. Most applicants who apply match, and some programs and positions go unfilled in some years, though demand has been rising to record levels.⁵⁶

32 ACGME-accredited fellowship programs, ~50 first-year positions/year, ~100 fellows in training total, typically 1–3 fellows per program per year.³⁷ ⟳
2024 cycle: 56 applicants for 53 positions; ~89% of applicants matched; ~91% of programs filled. Applicants roughly equal to positions, most matched applicants got a top-3 choice, and ~9% of programs went unfilled. The signature of a field that's selective at the program level but not broadly competitive.³ ⟳
Demand is rising, but positions still outnumber applicants. A Journal of Medical Toxicology analysis found demand for fellowship training "at an all-time high." The match has not caught up to that: in the 2026 appointment year, 30 programs offered 54 positions and filled 42 (77.8%) against 45 applicants, so ten programs ended the match with an empty seat.⁶⁸ ⟳
Match mechanism: NRMP Specialties Matching Service (some programs also use ERAS). Application needs a CV, 3+ letters (ideally one from a toxicologist), and a personal statement.³

The honest read: matching is achievable for most committed applicants, but the same EM burnout and job-market pressure that makes tox attractive as an off-ramp is also what's pushing more EM physicians toward the fellowship, so it's more competitive than it used to be.

Compensation — the robust version, honestly caveated

Start with the single most important framing: there is essentially no large, standardized "medical toxicologist salary" survey. The field is tiny (~600–800 board-certified, actively practicing physicians nationally), so the big datasets of Doximity, Medscape, MGMA, and BLS don't break it out. What they do measure robustly is the base clinical specialty most toxicologists carry, overwhelmingly Emergency Medicine. So a toxicologist's income is best modeled as:⁹

EM (or IM/Peds) clinical base salary ± the effect of trading paid clinical shifts for lower-paid tox work (poison-center direction, inpatient consults, academic/research, teaching).

The direct figures (thin, so use with caution). The only sources that name the subspecialty are low-confidence:⁹¹⁰

SalaryDr: median $390,000, average $359,333, 25th pct $268,000, 75th pct $420,000, but based on only 3 verified submissions (statistically meaningless; notable that 67% were academic and the median tracks EM).
Marit Health: average ~$356,000 for an "EM toxicologist," effectively an EM-anchored blend.
⚠️ Do NOT use ZipRecruiter's "medical toxicologist" ~$115,369. That job-title scrape captures mostly non-physician toxicologists (lab scientists, PhD/industry), a completely different labor market. It's listed here only to show why title-based data misleads.

All the credible direct figures cluster right around the EM average, consistent with the "EM base plus part-time tox" model.⁹ ⟳

The real anchor is EM base pay. Because most toxicologists keep working EM shifts, these drive the income: Medscape 2026 EM average total comp ~$421,000 (up ~8% in 2025); Medscape 2025 ~~$388,000; Physician Side Gigs' self-reported survey (2023–24) overall $398,000, full-time $437,000, part-time $372,000 (~~$236/hr median); BLS mean annual wage $317,480, on a median of $335,550.⁹ ⟳

The trade-off, made concrete. Doing tox means cutting clinical shifts, and EM pay scales almost linearly with hours worked (Physician Side Gigs 2023–24):⁹

21–25 hrs/wk: $321,000 · 26–30: $359,000 · 31–35: $395,000 · 36–40: $420,000 · 41–45: $482,000

A toxicologist who drops from ~40 to ~25–30 clinical EM hours/week to make room for poison-center, consult, and academic duties slides down this ladder — roughly a $60,000–$100,000 give-up in clinical income — which the lower-paid tox work only partly backfills. That's the mechanism behind "tox is usually a pay cut."⁹

How the tox pieces pay (data is scarce, and flagged where estimated):⁹

Poison-control medical direction. Usually a part-time / fractional-FTE stipend layered on a clinical or academic job, covering 24/7/365 consultation availability. Public stipend figures aren't reported; commonly a modest add-on, not a full salary. ACMT formally advocates that health systems fund this work, reflecting that it's often under-compensated relative to effort. ⟳
Inpatient/ED tox consult service. Usually folded into an academic or hospital-employed package; consult RVUs are modest next to procedures. No standalone national figure. ⟳
Academic toxicology. The most common home for full-time-ish toxicologists. Academic EM is already the low end of EM (~$365,000, 2023–24), and protected research/teaching time trims clinical earnings further, so academic toxicologists generally sit at or below the academic-EM figure, offset by protected time and lifestyle.⁹
Occupational / industry / government (pharma drug-safety, CDC, FDA) varies widely, and industry medical-director roles can meet or exceed clinical EM, but specialty-specific public figures don't exist. ⟳
Expert witness / medico-legal. A common, well-paid supplemental stream (general physician rates ~$356/hr record review, ~$448/hr deposition, ~$478/hr trial). Per-hour episodic work, not a salary.⁹

Bottom line on the number. Best national estimate of a practicing toxicologist's total income: roughly $350,000–$430,000/yr, driven mostly by the EM (or IM/Peds) base plus part-time tox pay. Realistic spread: ~$260,000 (heavily-academic, reduced clinical) to ~$480,000+ (mostly full-time clinical EM with tox on the side, or industry). Pure, full-time toxicology, academic work plus a poison center plus consults, with minimal shifts, generally lands below full-time EM (~$437k), often ~$300k–$360k. Choosing full-time tox over full-time EM is, in most cases, a pay cut.⁹

Lifestyle & the off-ramp bargain

The defining lifestyle feature is less overnight-shift burden than full-time EM, and that's the whole point.¹ Poison-control and consult work is more plannable than the ED floor, much of it can be done by phone or telehealth, and post-fellowship many toxicologists dial back their EM overnights and weekends because a chunk of income now comes from consult/academic/poison-control work. For an EM physician worn down by circadian chaos, that shift toward "a more regimented academic schedule peppered with ED shifts" is exactly the draw.¹

But the upgrade is partial rather than total. Reported average hours land around ~43/week in SalaryDr's panel — which is three physicians, so read it as an anecdote — moderate and importantly less nocturnal than full EM, but not light.¹¹ Call still exists, since poison-control coverage and inpatient consults come with it, though it's largely phone and telehealth call rather than in-house resuscitation call. And for most people the reality is EM-plus-a-cerebral-niche with fewer nights, not quit the ED: pure non-clinical tox jobs are scarce.¹

Lifestyle rating: 4/5. Good schedule control and a real reduction in overnight/circadian load versus full-time EM, tempered by ongoing (phone) call and the fact that most toxicologists still work some clinical shifts.

Wellbeing — the part to take seriously

There is no clean, stand-alone burnout figure for medical toxicology. The field is too small to appear separately in the big surveys, so treat any specific "toxicologist burnout is X%" number as fabricated.¹² What is well-established is the comparison point: Emergency Medicine sits at or near the top of physician burnout (~63%, Medscape 2024, #1 of all specialties), driven heavily by shift work, overnight/circadian disruption, and boarding/throughput pressure. Toxicology's appeal is precisely that it lets an EM physician swap some of that grind for consultative, plannable, more daytime work, so "lower burnout than full-time EM" is a reasonable, sourced inference, not a measured tox-specific statistic.¹²¹³ ⟳

Satisfaction runs high, with a sample-size caveat. The small SalaryDr sample reported 4.3/5 satisfaction and 100% saying they'd choose the specialty again, citing case variety and patient relationships as rewards and on-call demands and administrative burden as the main frustrations. The direction matches the field's reputation, but the sample is single-digit, so read it as flavor, not proof.¹¹ ⟳

Career longevity is the headline wellbeing benefit. The most consistent theme across every source: toxicology is a way to make an EM-adjacent career last. Adding consult work, poison-control direction, academics, and industry/government options gives an aging or burning-out EM physician somewhere to go besides the night shift, extending a career that might otherwise end early. In a field (EM) with one of the youngest attrition profiles in medicine, that durability is the real prize.¹¹³

Who's in the field (demographics)

The ACGME Data Resource Book carries a medical toxicology row in three of its demographic tables, so the figures below are measured rather than inferred. The cohort is 107 active fellows nationally, which is small enough that one person moves any of these percentages by about a point.⁷

Base-specialty composition: predominantly Emergency Medicine ("vast majority"), with a minority from Pediatrics, Internal Medicine, Preventive/Occupational Medicine, and Family Medicine.³⁴
% women: 39.3% of active fellows in academic year 2024-25, 42 of 107 (ACGME Table C.21).⁷ ⟳ (A Data USA "Toxicology" profile showing ~70% female is the graduate-education CIP field of PhD and academic toxicology rather than the physician subspecialty, and the measured physician figure is nowhere near it.)
% IMG: 6.5% of active fellows attended an international medical school, 7 of 107 (Table C.15). NRMP puts combined IMG at 7.2% of the 2026 entering class, 3 of 42, so the two populations agree closely.⁷⁸ ⟳
% DO: 15.9% of active fellows, 17 of 107 (Table C.15), against 23.8% of the 2026 matched class, 10 of 42.⁷⁸ ⟳
URiM: about 11% of active fellows, 12 of 107: 9 Hispanic or Latino, 2 Black or African American, and 1 Native Hawaiian or Pacific Islander (Table C.23).⁷ ⟳

Read all four as the shape of a small cohort rather than as stable rates. AAMC's specialty-demographic reports still cover only the ~48 largest specialties and carry no medical toxicology line, so the ACGME book is the only place these figures are published.

Culture, personality & the online stereotypes

Who gravitates here: intellectual-detective types who genuinely love pharmacology, physiology, and the puzzle of "what is poisoning this patient and how do I reverse it." There's a strong public-health streak: poison prevention, surveillance, drug-of-abuse trends, occupational and environmental exposure, policy. Overwhelmingly these are emergency physicians who want a cerebral niche of their own and a partial escape from a lifetime of shift work, people who want to keep doing acute medicine but need a more sustainable shape to it. A minority come from pediatrics, internal medicine, or preventive medicine. Plenty of toxicologists don't fit any single mold.¹¹⁴

The online reputation (reputation rather than fact, with a kernel of truth): toxicology is affectionately known online as roughly "the coolest niche nobody makes real money in." The recurring framing is a great EM off-ramp / academic add-on, with poison-control work and genuinely fascinating cases as the reward and a modest pay ceiling and small job market as the honest price. It carries a "physician's physician" prestige, the person the whole hospital calls when a case gets weird, paired with a running joke that the field's most valuable service (free phone advice to poison centers) is exactly the part that's hardest to bill for.

What people say online (synthesized and paraphrased from public discussion in trainee and physician forums, not quoted):

The dominant thread is toxicology as a response to EM's rough job market and burnout, with more EM docs eyeing it as an escape route or longevity play, and a widespread sense that the fellowship is harder to get than it used to be. The match data does not yet show that: positions still outnumber applicants.
Realists caution that fellowship rarely eliminates shifts and that pure non-clinical tox jobs are scarce, so most people still do "a few shifts" and take consults. The lifestyle gain is real but is usually fewer and better shifts rather than no shifts.
Value-capture is a live worry: because a lot of core tox work (poison-control phone advice) is provided free, the specialty can feel undervalued and exposed to cost-cutting, a structural reason the pay ceiling stays modest.
The upside people keep returning to: it makes an EM career more durable and more interesting, with side doors into academics, addiction medicine, occupational/environmental medicine, industry, and government.

Voices from the field. Paraphrased from public writing, with links to the originals:

Dr. Lewis Nelson, via ALiEM, frames the fellowship as most worthwhile for people who love having niche knowledge with real practical implications and who lean toward academic careers, describing the transition from pure shift work toward a more regimented academic schedule still seasoned with some ED shifts.¹
ACMT's "Becoming a Medical Toxicologist" materials lay out a deliberately broad career surface across EDs and inpatient units, poison-control centers, occupational clinics, academia, industry, government, and clinical and forensic labs, with the diversity itself being the selling point.¹⁴
Dr. Natasha Khalid, on KevinMD, captures the emotional pull: the curiosity-driven, detective satisfaction of unmasking a mysterious poisoning behind an unexplained altered patient, and a public-health empathy for who tends to be poisoned and why. (She writes from outside the US, so read it for the why-people-fall-in-love-with-tox sensibility rather than US job specifics.)¹⁵

Why people choose it / why people leave

Why choose it: you love pharmacology, physiology, and diagnostic puzzles and want a niche where you're the hospital's go-to expert · you want to keep doing acute medicine but survive it long-term, with fewer overnights and more plannable, consultative work · a broad career surface (clinical consults, poison control, teaching/research, addiction or occupational medicine, industry, government) · a public-health streak (prevention, surveillance, policy, drug-of-abuse and environmental work) · schedule control and phone/telehealth-friendly work alongside reduced shifts.

Why leave or avoid it: you want maximum income, since for most tox means a pay cut against full-time EM and a modest ceiling · you need a big, flexible job market, when the field is small and now competitive and pure non-clinical roles are rare · you want to fully quit shifts, when most tox jobs still bundle some EM · you dislike academic/administrative work (grant-writing, teaching, poison-center admin are common) · you want procedures and continuity clinics, when this is mostly cognitive, consultative medicine.

Best fit if: you're an intellectual-detective type who loves the pharmacology-and-poisoning puzzle and public health · you want a cerebral niche of your own · you're looking for a way to make an EM-style career more sustainable and interesting over decades · you're at peace with earning somewhat less than a full-time EM doc in exchange.

Not for you if: you're chasing top-tier pay · you need a large, easy-to-enter job market · you want to stop doing shifts entirely · you dislike academic/consultative work · you want a procedure- and continuity-heavy practice.

The FLI angle — Medical Toxicology for first-gen, low-income & immigrant students

The pitch, honestly stated: medical toxicology is a cerebral niche and an EM-career-longevity off-ramp, a way to keep practicing acute medicine with fewer nights and more intellectual variety, which can protect earning capacity over a whole career by heading off the early burnout that ends many EM careers.

But be clear-eyed about the trade-offs, which matter more for FLI students:

It usually costs money in the near term. Fellowship is 2 more years at trainee pay, and the destination job typically pays less than full-time EM (roughly mid-$300Ks to ~$390K, versus higher full-time EM). For a student carrying heavy loans or supporting family, delaying a full attending salary by two years and then landing below the EM pay peak is a real cost to weigh.⁹¹¹
The job market is small and competitive. You can't count on landing a tox-heavy job wherever your family is; most people blend it with clinical EM, and pure non-clinical roles are scarce, so geographic flexibility is narrower than for general EM.¹⁶
The realistic framing: treat toxicology as an add-on that makes an EM career more durable and interesting, rather than as a standalone income strategy. EM itself is already relatively FLI-friendly (no fellowship required to earn well, shift-based, no clinic inbox); toxicology is the option you reach for if you love the intellectual niche and want to build in longevity, accepting a modest pay trade for a career you can sustain longer.

Bottom line: the honest FLI read is earn first, specialize for love and longevity. Med tox rarely raises your income, often lowers it, and adds two years, but for the right person it turns a high-burnout EM career into one you can still want to be doing at 55. Weigh that against your loans and your family's near-term needs before committing.

Career directions within toxicology

None is a separate board; these are the ways toxicologists actually build a practice, usually in combination.¹⁴

Poison-control medical direction. Advising clinicians and the public on exposures/overdoses, largely by phone/telehealth; often paired with center leadership.
Inpatient/bedside toxicology consult service. Managing poisoned, overdosed, and complex-medication patients in the hospital.
Academic toxicology. Teaching, research, fellowship/program leadership (comes with grant-writing).
Addiction medicine. A common adjacent path, treating substance-use disorders and withdrawal.
Occupational & environmental medicine. Workplace and environmental exposures; noted online as one of the more financially viable tox-adjacent niches.
Industry / regulatory. Pharmaceutical drug-safety, product safety, and government roles (CDC, FDA).
Clinical & forensic laboratory. Designing and interpreting toxicology testing.

Sub-subspecialties & fellowships

There are no separate boards under medical toxicology. What varies is the blend of settings a toxicologist works across, and most build a practice from several at once: poison control, which is the population-facing core of the field; inpatient consultation for the poisoned and overdosed patients admitted to somebody else's service; and academics, where a large share of the specialty sits.

Beyond those three, addiction medicine is an adjacent board that many toxicologists also hold, and occupational and environmental medicine covers exposure work rather than acute poisoning. Industry, government and laboratory roles, including regulatory and forensic toxicology, are not bedside at all.

Fun facts

It's one of the few subspecialties you can enter from several different residencies, whether emergency medicine (most), pediatrics, internal medicine, or preventive medicine, and be board-certified through ABEM, ABP, or ABPM depending on where you started.³¹⁴
A large share of the core work, poison-control medical direction, happens by phone and telehealth, advising other clinicians and the public, which is part of why the lifestyle differs so much from the ED floor.¹
The field's own running joke is that its most valuable service is the part it can't easily bill for, namely free poison-center advice, a real reason its pay ceiling stays modest despite the expertise involved.¹⁶
It's genuinely tiny, small enough that it doesn't appear as its own line in the big Medscape burnout and comp surveys, which is why any "toxicologist burnout is X%" figure should be treated as made up.¹²
Career exits run everywhere from CDC and FDA to industry drug-safety, addiction, occupational and environmental medicine, and poison-center leadership, unusually broad for a subspecialty its size.¹
Toxicology still offers more fellowship positions than there are applicants for them — 54 against 45 in the 2026 cycle — even as EM physicians increasingly talk about it as an off-ramp.⁸

Sources

The three-part job, reduced overnight burden / off-ramp framing, fellowship shift caps, career longevity, and Dr. Lewis Nelson's perspective. ALiEM, "Considering a Medical Toxicology Fellowship?" (https://www.aliem.com/considering-a-medical-toxicology-fellowship/); ACMT, "Becoming a Medical Toxicologist" (2025) (https://www.acmt.net/becoming-med-tox/). ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹
Fellowship length (2 yrs / min 24 months, ACGME), certifying boards, and exam frequency. ABEM Medical Toxicology Eligibility Criteria (2024) (https://www.abem.org/wp-content/uploads/2024/07/medtox-eligibility-criteria.pdf); ABEM, Medical Toxicology (get certified, 2026) (https://www.abem.org/subspecialty-get-certified/medical-toxicology/); ACGME Medical Toxicology FAQs (updated 09/2025) (https://www.acgme.org/globalassets/pdfs/faq/118_medicaltoxicology_faqs.pdf). ↩ ↩² ↩³
Training pathway, multi-entry model, program/position counts, 2024 match outcomes, application requirements, and co-sponsored certification. ACMT, Applying for a Medical Toxicology Fellowship (accessed 2026) (https://www.acmt.net/applying-for-a-medical-toxicology-fellowship/); ABP, Medical Toxicology Certification (https://www.abp.org/subspecialties/medical-toxicology); ABPM, Medical Toxicology (https://www.theabpm.org/become-certified/subspecialties/medical-toxicology/). ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰
EM-dominant entry ("vast majority"). Entering Medical Toxicology Fellowship from a Non-Traditional Residency Background, J Med Toxicol (2024) (https://link.springer.com/article/10.1007/s13181-024-01028-7); Factors Affecting the Choice to Specialize in Medical Toxicology, J Med Toxicol (2023) (https://link.springer.com/article/10.1007/s13181-023-00965-z). ↩ ↩² ↩³
2024 cycle: 56 applicants / 53 positions; ~89% applicant match; ~91% program fill. ACMT (URL in ³). ↩
Rising demand for fellowship training. Demand for Medical Toxicology Fellowship Training Is at an All-Time High, J Med Toxicol (2022/2023) (https://link.springer.com/article/10.1007/s13181-022-00920-4 | https://pubmed.ncbi.nlm.nih.gov/36469243/). (Granular per-year counts sit behind a paywall; the headline finding is in the abstract.) ↩ ↩²
Program count (32) and fellow demographics. ACGME, Data Resource Book, Academic Year 2024-2025 (https://www.acgme.org/globalassets/pfassets/publicationsbooks/2024-2025_acgme_databook_document.pdf), which carries a medical toxicology row in three demographic tables. Table C.21, active residents by sex: 32 programs, 107 fellows, 42 female (39.3%), 65 male (60.7%), 0 not reported. Table C.15, active residents by medical school type: 107 fellows, 82 US LCME-accredited (76.6%), 7 international (6.5%), 17 osteopathic (15.9%), 1 Canadian (0.9%). Table C.23, active residents by race and ethnicity: White 74, Asian 14, Hispanic or Latino 9, Black or African American 2, American Indian or Alaska Native 0, Native Hawaiian or Pacific Islander 1, multiple 5, other 1, unknown 1, which puts URiM at 12 of 107, about 11%. AAMC's specialty-demographic reports cover only the ~48 largest specialties and carry no medical toxicology line: AAMC Table B3 (https://www.aamc.org/data-reports/students-residents/data/report-residents/2024/table-b3-number-active-residents-type-medical-school-gme-specialty-and-gender). Corrected 2026-08-17: this page asserted in six places — the dashboard, four demographic bullets, this footnote and the closing sentence of the section — that %women, %IMG, %DO and URiM were not publicly broken out for medical toxicology, and named this book as the authority for that absence. All four are in it, in the three tables listed above. The closing sentence also said a hard percentage "would have to come out of the underlying AAMC or ACGME data files"; these are published tables in a public PDF. A second refutation sat on the page already: ⁸ prints the 2026 matched class as 69.0% US MD, 23.8% US DO, 2.4% US IMG and 4.8% non-US IMG, which contradicts the DO and IMG bullets on its own. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶
NRMP, Results and Data: Specialties Matching Service, 2026 Appointment Year (Feb 2026), Tables 1A and 2 — Medical Toxicology: 30 programs, 54 positions offered, 42 filled (77.8%), 45 applicants, 10 programs left unfilled. Of the 42 matched, US MD 69.0%, US DO 23.8%, US IMG 2.4%, non-US IMG 4.8%. https://www.nrmp.org/wp-content/uploads/2026/02/SMS_Results_and_Data_Report2026.pdf ↩ ↩² ↩³ ↩⁴ ↩⁵
Compensation — the EM-anchored model, direct tox figures and their caveats, EM base data, hours-worked ladder, and pay-by-model. Medical Toxicology comp research memo (mid-2026), drawing on: SalaryDr Medical Toxicology Physician (Apr 2025 data) (https://www.salarydr.com/specialty/medical-toxicology); Marit Health, EM Toxicologist (2026) (https://www.marithealth.com/o/-/emergency-medicine-toxicologist/salary); Medscape EM Compensation Report 2026 (https://www.nuaxia.com/post/medscape-emergency-medicine-compensation-report-2026); Physician Side Gigs, Average EM Physician Salary 2023–24 (https://www.physiciansidegigs.com/average-emergency-medicine-physician-salary); BLS OEWS 29-1214 Emergency Medicine Physicians, May 2025, mean $317,480 and median $335,550 (US Bureau of Labor Statistics, Occupational Employment and Wages — May 2025, Table 1 (https://www.bls.gov/news.release/archives/ocwage_05152026.htm)), superseding the May 2023 mean of $306,640 this note carried until 2026-08-18; ACMT Poison Center Medical Director job description (2024) (https://www.acmt.net/wp-content/uploads/2024/04/Medical-Director-Job-Description.pdf); ACMT Position Statement on poison-center medical direction (https://pmc.ncbi.nlm.nih.gov/articles/PMC3614117/); Expert Institute, Expert Witness Fees (https://www.expertinstitute.com/resources/expert-witness-fees/). SalaryDr panel size: n=3. A self-selected physician panel; the n is disclosed here because it is what the figure rests on. On Marit Health: it publishes a panel of self-reported physician salaries, and displays MGMA and AMGA benchmarks beside them that are masked unless you create an account. The figure quoted here comes from the self-reported panel, not from either benchmark. Read it as crowd data: unweighted, of unstated sample size, and directional. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹
Why title-based data (ZipRecruiter ~$115k) is not physician comp. ZipRecruiter, Medical Toxicologist Salary (Jul 2026) (https://www.ziprecruiter.com/Salaries/Medical-Toxicologist-Salary). ↩
Small-sample lifestyle/satisfaction (~43 hrs/wk, 4.3/5, 100% would choose again — single-digit sample). SalaryDr, Medical Toxicology Physician Salary (2026) (https://www.salarydr.com/specialty/medical-toxicology). SalaryDr panel size: n=3. A self-selected physician panel; the n is disclosed here because it is what the figure rests on. ↩ ↩² ↩³
No tox-specific burnout figure exists (field too small for the major surveys) — any specific number should be treated as fabricated. Medical Toxicology life/wellbeing research memo (mid-2026). ↩ ↩² ↩³
EM burnout anchor (~63%, #1) used as the inference baseline. Medscape Physician Burnout & Depression Report 2024 (https://www.medscape.com/sites/public/lifestyle/2024), via Med School Insiders (https://medschoolinsiders.com/pre-med/every-doctor-specialty-ranked-by-burnout/) (2024). ↩ ↩²
Career surface / directions and multi-entry certification. ACMT, "Becoming a Medical Toxicologist" (2025) (https://www.acmt.net/becoming-med-tox/); ALiEM (URL in ¹). ↩ ↩² ↩³ ↩⁴
The emotional/"why people fall in love with tox" perspective. Natasha Khalid, KevinMD, "From a doctor's journey in the ICU to unveiling poisoning mysteries" (2023) (https://www.kevinmd.com/2023/07/from-doctors-journey-in-icu-to-unveiling-poisoning-mysteries.html). (Non-US author — read for sensibility, not US job specifics.) ↩
Synthesized online sentiment (job-market and off-ramp pressure, value-capture worry, broad exits). Student Doctor Network forum thread (https://forums.studentdoctor.net/threads/any-recent-toxicology-fellows-on-here.1471933/) and Reddit r/emergencymedicine, r/medicine — paraphrased and synthesized, accessed 2026, no quotes. These are forums, and are cited here only for what physicians say they are thinking about, never for a number. ↩ ↩²

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