New Attending Financial Checklist: Orthopedic Surgery

The transition from fellowship to attending is the highest-stakes financial moment of your career. Your income will roughly triple in 12 months. Several windows — disability insurance, PSLF eligibility, financial underwriting — close permanently once you're past them. Most new ortho attendings miss at least two of the six decisions on this list.

Why year one matters more than any year after it

The financial decisions you make in your first 90 days as an attending have outsized long-term impact for two reasons:

1. Time-limited windows. Disability insurance specialty ratings, PSLF-qualifying payment history, and the sign-on bonus tax timing window are not available later. They require specific action at a specific time.
2. Compounding anchors you. Whether you set up a backdoor Roth in year one, or in year five, or never — those four years of contributions ($30K–$35K at 2026 limits) compound tax-free for 30 years. At 7% real return, starting year one instead of year five is worth roughly $175,000 at retirement, on a $30K annual contribution alone.

New attendings are also at the highest risk of lifestyle creep. Income goes from $70K–$80K in fellowship to $500K–$700K in year one. The financial structure you set up in year one tends to persist. Set it up well and the savings rate sustains itself; skip it and you're still "meaning to get organized" at year eight.

The 6 decisions to make in your first 90 days

1. Buy individual disability insurance immediately — before the fellowship window closes

This is the one item on this list with the hardest deadline.

Major individual disability carriers (The Standard, Principal, Ameritas, Ohio National) offer residents and fellows the ability to purchase own-occupation specialty-specific disability coverage under a "guaranteed standard issue" or simplified underwriting program — without a full financial underwriting review, because income is expected to increase dramatically. The window to buy under these programs typically closes 6–18 months after starting attending-level practice.¹

Why it matters for orthopedic surgeons specifically:

• Your income is procedural. You cannot work at a desk if your hands, shoulders, or back are compromised. "Own-occupation" coverage pays full benefits if you can no longer perform your surgical specialty even if you could theoretically do other work. "Any occupation" coverage — which most employer group plans use — requires you to be unable to work at any job before benefits kick in. Group LTD through a hospital employer is almost never own-occupation for surgeons.
• The disability risk for orthopedic surgery is real. Musculoskeletal injury to the operating surgeon is an occupational hazard, and it accelerates in the mid-career years. Getting locked in at a preferred-class policy while you're healthy and newly attending is the lowest-cost moment you'll ever have to buy this coverage.
• The individual policy you buy as a new attending stays with you when you change jobs — a hospital-employed surgeon who moves to private practice keeps it. Group employer coverage disappears the moment you leave.

Target coverage: $20K–$30K/month in own-occupation individual policies, stacked on top of employer group LTD. Work toward $40K–$50K/month total as income grows. See the full analysis in the disability insurance guide.

2. Make the student loan decision before it's made for you

Fellowship graduation is the last moment when both PSLF and private refinancing are live options simultaneously. Once you take your first attending position, that fork closes in one direction.

If you're joining a nonprofit hospital system (501(c)(3)) or academic medical center: PSLF eligibility continues. Your residency and fellowship payments already count toward the 120-payment requirement if you were on an IDR plan throughout training. Many academic spine surgeons, trauma surgeons, and subspecialists taking academic attending roles enter year one with 4–7 years of qualifying payments already on the clock. If you're 4 years into a 10-year PSLF track, completing it saves a significant amount — model the remaining balance before refinancing.

If you're joining a private practice, a for-profit hospital, or any employer that doesn't qualify under PSLF: The PSLF door closes. Future payments will never count. At this point, private refinancing almost always makes sense — medical school debt at 7%–8% federal rates sitting against a $600K–$700K attending salary is a drag on net worth, not a strategic instrument.

The 2026 IDR landscape: SAVE was discontinued in March 2026. IBR (Income-Based Repayment) is the current income-driven option. The Repayment Assistance Plan (RAP) is expected to launch July 1, 2026 — confirm current program availability at StudentAid.gov before selecting a plan. See the student loan repayment guide for the full PSLF vs. refinancing decision framework.

3. Manage your signing bonus tax exposure before the check arrives

Signing bonuses are taxable as ordinary income in the calendar year received — 37% federal rate at ortho attending income levels, plus state, plus FICA on the bonus up to the Social Security wage base.²

Two things to do immediately:

• Set aside 40–45% of the bonus before spending any of it. Many new attendings receive $50K–$150K in signing bonuses. A $100K bonus creates roughly $41K–$46K in federal and state taxes owed in April. Put that amount in a money market or short-term T-bill immediately.
• Check whether you need to make a Q3 or Q4 estimated tax payment. If you start July 1 and receive a $100K bonus in August, your total 2026 income will be significantly higher than your 2025 income as a fellow. The IRS estimated tax safe harbor is 90% of current-year tax or 110% of prior-year tax (for prior-year AGI above $150K).³ For most new attendings, prior-year AGI is below $150K (fellowship), so the 100% prior-year safe harbor applies and covers you from underpayment penalties — but this only means you avoid penalties, not that you don't owe a large bill in April. Model this explicitly.

Note that signing bonuses in most contracts come with 12–24 month clawback provisions. If you leave before the vesting date, you repay the gross amount — not the after-tax amount. If you leave after 12 months and repay $100K that you received and paid $45K in taxes on, you can claim the repaid amount as a deduction (IRC § 1341), but the timing of the tax benefit is awkward. Understand the clawback mechanics in your contract before treating the bonus as permanent income.

4. Set up your retirement accounts in month one

Most new attendings are in a hurry and skip or delay this. The compounding cost is significant.

Employer 401(k) or 403(b): Enroll immediately, even if the employer match vesting is delayed. Set your deferral to at least $24,500 for 2026 — the annual employee limit per IRS Notice 2025-67.⁴ If you start mid-year and want to max the annual limit in the remaining pay periods, recalculate the per-paycheck deferral accordingly.

Backdoor Roth IRA: Your attending income will exceed the Roth IRA direct contribution income limit in year one ($236,000 for MFJ, $161,000 for single, 2026). Use the backdoor: contribute $7,500 (under 50) to a non-deductible traditional IRA, then convert to Roth immediately before earnings accumulate. Set this up in January of every year going forward. The annual contribution is small in absolute terms, but tax-free Roth growth over a 30-year surgeon career is asymmetrically valuable. Confirm you have no pre-existing traditional IRA balance that would trigger the pro-rata rule before executing.⁴

HSA (if on a high-deductible health plan): $4,400/self or $8,750/family in 2026. Invest it; don't spend it. Every dollar used for medical expenses now costs you the tax-free growth that dollar would have compounded at. Save receipts and reimburse yourself from the HSA in retirement — IRS allows reimbursement for any qualified medical expense regardless of how old the expense is, as long as the HSA existed at the time.

If you're in private practice from day one: You're likely eligible for a solo 401(k) with $72,000 total annual contribution capacity (employee + employer), or eventually a cash balance plan stacked on top. This is where the private practice vs. hospital employment retirement gap begins. A hospital-employed surgeon capped at $24,500/year in employee deferrals compares unfavorably to a private practice surgeon running $72,000/year into a solo 401(k) — and dramatically unfavorably to a late-career private practice surgeon stacking $72,000 + $200,000+ in a cash balance plan. See the retirement planning guide for the full stacking model.

5. Review your life insurance and umbrella coverage

Fellowship stipends rarely justify robust life insurance. Attending income does — especially if you have a spouse, children, or are cosigning on a mortgage or student debt (though federal loans are discharged at death, private refinanced loans are not always).

Level term life insurance in year one:

• A 30-year-old new attending in excellent health qualifies for 20- or 30-year term at very competitive rates. Rates climb with age and health complications; buy while young.
• Coverage target: 10–15× annual income if you have dependents. For a surgeon earning $600K, that's $6M–$9M in coverage, which costs roughly $3,000–$5,000/year for a healthy 30-year-old in a 20-year term policy.
• Some surgeons use employer-provided term insurance as a base and supplement individually. Be aware that employer group life coverage ends when you leave — individual coverage follows you.

Umbrella liability insurance: Add a $2M–$5M personal umbrella policy over your auto and homeowners coverage. Cost is $300–$700/year. This is inexpensive leverage against personal liability claims — relevant for high-income professionals whose assets make them a more attractive target in litigation separate from their malpractice coverage. Your malpractice policy covers professional acts; it doesn't cover a car accident or an incident at your home.

6. Build a physician-appropriate emergency fund

Standard personal finance advice says 3–6 months of expenses. For new ortho attendings, the practical minimum is 6 months; 12 months is defensible given:

• Early-career income ramp: the first 12–24 months in private practice often involve a production ramp period where volume and collections are below the steady-state. Unexpected early expenses or a lower-than-projected bonus create real cash flow risk.
• Malpractice tail exposure: if you leave your first position within 2–3 years, a tail payment of $30K–$100K arrives simultaneously with the career transition. Hospital employers typically cover tail on departure; private practice agreements vary. Have capital available.
• Student loan decisions: if you're pre-payoff refinancing, you may be making significant principal payments. Ensure emergency cash is segregated from the loan payoff account.

Keep the emergency fund in a high-yield savings account or short-term T-bills. Do not invest it in equities. The function of this money is liquidity, not growth.

Year-one milestones by quarter

The two financial mistakes most new ortho attendings make

Mistake 1: Buying the house in year one

The attending income arrives and, for the first time in your adult life, a mortgage is accessible. The instinct to buy immediately — after 13+ years of training deferral — is understandable and nearly universal.

But year one is the worst year to make a large, illiquid purchase for several reasons:

• You don't know yet whether you'll like the practice, the city, or the patient population. Mobility in years 2–3 is common. Selling a home you bought 18 months ago at full transaction cost is expensive.
• Down payment cash competes directly with the financial windows described above. $200K into a down payment is $200K not establishing an emergency fund, funding a backdoor Roth, or buying disability insurance.
• Physician mortgage loans (zero-down, jumbo, no PMI) are available regardless. If you decide to buy in year two or three when you're certain you'll stay, the mortgage product is still accessible.

One exception: if you've already committed to a specific hospital system or practice in a city where you intend to stay long-term, and you're certain of that commitment, the calculus changes. But the first six months is generally too early to be certain.

Mistake 2: Delaying the financial planning setup because you're too busy

Year one as an attending is clinically demanding. This is real. But "I'll get to it next year" is how new ortho attendings end up at year five having made none of the above decisions — still on a default IDR plan, still with no individual disability policy, still missing the backdoor Roth annual contribution.

The high-leverage version of this: engage a fee-only financial advisor who works with orthopedic surgeons specifically in your first 90 days — not to hand off the decisions, but to have a structured framework for making them quickly. An advisor who understands your specific situation (subspecialty, practice type, existing debt load, whether PSLF is in play) can help you work through the six decisions above in 2–3 sessions. The cost of the advice is an order of magnitude less than the cost of the five-year delay.