The Attending Transition

Where the money goes

A single physician starting at $300,000 in 2026 with no pre-tax deferrals pays roughly $11,400 in Social Security tax, about $5,250 in Medicare tax, and about $68,100 in federal income tax after the $16,100 standard deduction, leaving about $17,900 a month before state tax. The same physician took home about $4,950 a month as a resident. The difference, about $13,000 every month, is money you have never had and do not yet miss. Lifestyle expands to meet it within months if nothing is decided in advance.

The first-year withholding surprise

When an attending job starts mid-year, payroll often withholds as if the new salary applied all year or ignores the resident income already earned, and signing bonuses are withheld at a flat 22 percent, well below an attending’s marginal rate. The result for many new attendings is a four- or five-figure balance due the following April, plus a penalty. Complete a new W-4 with the IRS estimator when you start, add extra withholding or make one estimated payment in the fall, and have the first attending-year return prepared professionally.

Live like a resident, on purpose

Not austerity: sequencing. Hold a resident’s budget for two or three years, give yourself a defined and meaningful raise, and route the rest of the gap automatically the month the first paycheck arrives. The order of operations: emergency fund to three to six months; full employer match; protection sized to the new income, including own-occupation disability, umbrella liability, and term life if anyone depends on you; the loan strategy from lesson two; every tax-advantaged account, including the Backdoor Roth; then a taxable account. Rent the first year in a new city. Buy the house when the job is proven and the budget, not the lender, says yes.

The documents no one wants to write

Four documents make up a basic estate plan: a will, a durable power of attorney, a healthcare directive, and, if you have children, a guardianship designation. Physicians with young children and a growing balance sheet need them more than most, and most do not have them. Alongside the documents, review every beneficiary designation on retirement accounts and life insurance; they override the will, and the ex-partner or the parent named at 26 is a common mistake. Title assets deliberately, and add an umbrella liability policy; for a few hundred dollars a year it protects future earnings from a judgment that exceeds your underlying limits.

Repeat

Fellowship, the first contract, partnership, practice ownership, a second child, a move: each one reopens most of these lessons. The point of the curriculum was never to finish it. It was to make you the person in the room who can explain it, so that over time you need help with the hard questions and not the routine ones. Watch, do, teach, repeat.