Physician Salary After Taxes (2026): How Much Doctors Actually Take Home, by Salary, Specialty, and State

Every physician asks this question at least three times: once as a medical student staring at debt, once as a resident comparing job offers, and once as an attending trying to understand why the paycheck feels smaller than the salary suggested.

The problem is that most existing answers are outdated or vague: examples built on old salaries, brackets from before the 2025 tax law, or forum threads that end at "it depends" without giving you the numbers you actually came for.

So here's what this piece does: four realistic 2026 physician incomes, calculated line-by-line — federal income tax, Social Security, Medicare, Additional Medicare Tax, and state tax — with the results shown for three states that cover the range: Texas (0% state tax), Georgia (moderate at 4.99% flat), and California (13.3% top bracket). Every number uses the 2026 brackets and standard deduction from IRS Revenue Procedure 2025-32, the 2026 Social Security wage base of $184,500, and the Additional Medicare Tax threshold that hasn't moved since the tax began in 2013.

Then it goes further than any comparable resource on the internet: the resident-to-attending transition, the married-filing-jointly numbers, dual-physician households, practice owners, the career-lifetime state tax gap in real dollars, and the specific deductions that move real money.

Locate yourself in the scenarios. Adjust for your specifics. Then use the later sections to understand what you can actually change.

The primary scenarios assume: single filer with the standard deduction ($16,100 for 2026), no dependents, no itemized deductions, and W-2 employment. Georgia tax is its 2026 flat rate of 4.99% after its $15,000 standard deduction. California tax uses the FTB's 2025 rate schedules, $5,706 standard deduction, and $153 exemption credit, because the 2026 schedules aren't published until late in the year (the FTB's own 2026 estimated-tax worksheet uses the same 2025 tables), plus State Disability Insurance at 1.3% of all wages, which California withholds from every paycheck with no wage cap. Real physician tax situations vary — married-filing-jointly numbers shift meaningfully (covered in its own section), kids and mortgage interest reduce liability, and 1099 income adds self-employment tax (covered separately). The point isn't precision to the dollar. It's realistic ballpark figures that tell you what to expect.

One assumption worth naming up front: these calculations show gross-to-net before pre-tax retirement contributions. A physician actually maxing their 401(k) at $24,500 reduces federal taxable income by that amount and takes home slightly less cash — but keeps $24,500 of retirement savings that would otherwise have been taxed. That trade is covered in the section on what actually moves take-home.

The July-1 attending. Fresh out of residency at $70,000, now writing scripts and getting paid about 3.6 times as much for it. Salary reflects starting-attending primary care or hospital medicine; also lines up with year-one internal medicine, family medicine, pediatrics, or emergency medicine.

Federal income tax (2026):

Taxable income after standard deduction: $250,000 − $16,100 = $233,900. Running the 2026 brackets (single filer):

• 10% on first $12,400 = $1,240
• 12% on next $38,000 ($12,400–$50,400) = $4,560
• 22% on next $55,300 ($50,400–$105,700) = $12,166
• 24% on next $96,075 ($105,700–$201,775) = $23,058
• 32% on remaining $32,125 ($201,775–$233,900) = $10,280

Federal income tax: $51,304

Payroll taxes (FICA):

• Social Security: 6.2% × $184,500 (wage base cap) = $11,439
• Medicare: 1.45% × $250,000 = $3,625
• Additional Medicare Tax: 0.9% × ($250,000 − $200,000) = $450

Total FICA: $15,514

State tax (three scenarios):

The Texas–California difference at this salary: $22,255/year ($19,005 of California income tax plus $3,250 of SDI). Enough to notice, though not yet enough to dominate the job-choice decision.

One nuance worth highlighting at this income level: the Additional Medicare Tax doesn't appear on your pay stub the day you become an attending. Your employer starts withholding the 0.9% only once the wages it has paid you pass $200,000 in the calendar year, so a July 1 start usually means none in the transition year, and at $250,000 it shows up in the last few months of your first full year. It often surprises new hires who assumed FICA would decrease as they got closer to the Social Security wage base.

Related reading for this stage: The New Attending Playbook, PGY-1 Financial Checklist, Physician Salary by State.

Established family medicine, internal medicine, or pediatrics attending. Also lines up with mid-career hospitalist, employed OB-GYN in many markets, or academic subspecialties like general endocrinology or general rheumatology. A bit below the $386,000 average total compensation in Medscape's 2026 Physician Compensation Report.

Federal income tax (2026):

Taxable income: $350,000 − $16,100 = $333,900.

• 10% × $12,400 = $1,240
• 12% × $38,000 = $4,560
• 22% × $55,300 = $12,166
• 24% × $96,075 = $23,058
• 32% × $54,450 ($201,775–$256,225) = $17,424
• 35% × $77,675 ($256,225–$333,900) = $27,186

Federal income tax: $85,634

FICA:

• Social Security: $11,439 (capped)
• Medicare (1.45%): $5,075
• Additional Medicare Tax (0.9%): $1,350

Total FICA: $17,864

State tax:

The Texas–California gap at $350K: $33,008/year. Now genuinely material to career decisions. And note the effective tax rates — Texas: 29.6%; Georgia: 34.3%; California: 39.0%. Every physician who says "I'm in the 35% bracket" is describing their marginal rate, not what they actually pay.

Related reading: Family Medicine Salary, Physician Tax Planning, Backdoor Roth IRA.

Cardiology, dermatology, gastroenterology, radiology, general surgery, anesthesiology in most markets. Also senior hospitalist with partnership distributions, established employed subspecialists, or mid-career surgeons in employed positions.

Federal income tax (2026):

Taxable income: $500,000 − $16,100 = $483,900.

• 10% × $12,400 = $1,240
• 12% × $38,000 = $4,560
• 22% × $55,300 = $12,166
• 24% × $96,075 = $23,058
• 32% × $54,450 = $17,424
• 35% × $227,675 ($256,225–$483,900) = $79,686
• Note: the 37% bracket starts at $640,600 in 2026; this filer doesn't reach it.

Federal income tax: $138,134

FICA:

• Social Security: $11,439 (capped — no additional tax on income above $184,500)
• Medicare (1.45%): $7,250
• Additional Medicare Tax (0.9%): $2,700

Total FICA: $21,389

State tax:

The Texas–California gap at $500K: $50,621/year. This is the range where high-earning California physicians start seriously running the arbitrage math. Effective tax rate: Texas 31.9%, Georgia 36.7%, California 42.0%.

Related reading: Cardiology Salary, Dermatology Salary, Mega Backdoor Roth.

Orthopedic surgery, plastic surgery, private cardiology or GI partners, established interventional radiology, urology partners, procedurally heavy dermatology, and the higher-earning end of most surgical subspecialties.

Federal income tax (2026):

Taxable income: $700,000 − $16,100 = $683,900.

• 10% × $12,400 = $1,240
• 12% × $38,000 = $4,560
• 22% × $55,300 = $12,166
• 24% × $96,075 = $23,058
• 32% × $54,450 = $17,424
• 35% × $384,375 ($256,225–$640,600) = $134,531
• 37% × $43,300 ($640,600–$683,900) = $16,021

Federal income tax: $209,000

FICA:

• Social Security: $11,439 (capped)
• Medicare (1.45%): $10,150
• Additional Medicare Tax (0.9%): $4,500

Total FICA: $26,089

State tax:

The Texas–California gap at $700K: $75,821/year. Over a 20-year career, roughly $1.5 million pre-investment — enough that many high-earning physicians genuinely reshape their job search around it. Effective tax rate: Texas 33.6%, Georgia 38.5%, California 44.4%.

At this income level, the Net Investment Income Tax (3.8% on investment income above the $200K/$250K threshold) also becomes relevant for physicians with taxable brokerage accounts or real estate cash flow — not covered in the wage calculations above but adding another few thousand for physicians with meaningful non-wage income.

Related reading: Orthopedic Surgery Salary, Plastic Surgery Salary, Physician 457(b) Plan.

Two observations. First, the take-home percentage falls as income rises — a Texas physician nets 73.3% at $250K but only 66.4% at $700K, because the higher brackets and Additional Medicare Tax progressively bite. Second, the state tax gap grows in absolute dollars faster than salary does, which is why the geographic-arbitrage argument gets stronger the more you make.

The July 1 salary jump is the largest single income change most physicians will ever experience — and it's also the moment when tax reality changes character. A resident earning $70,000 has nearly all of their taxable income in the 10% and 12% federal brackets (only the top $3,500 reaches 22%), pays full Social Security tax on all wages, and owes little or no state tax. The same physician becoming a $250,000 attending three months later crosses into an entirely different tax structure.

The resident baseline (PGY-3, $70,000, single filer, 2026):

• Taxable income after standard deduction: $53,900
• Federal income tax: ~$6,570 (about 9.4% effective)
• FICA: ~$5,355
• State tax (Texas $0 / Georgia ~$2,745 / California ~$2,375 income tax plus ~$910 SDI)
• Net take-home: $54,790–$58,075 depending on state

Note something unusual: California's income tax on a $70K resident is actually lower than Georgia's, because California's lower brackets are gentler than Georgia's flat 4.99%. Add California's 1.3% SDI and the total edges past Georgia. At attending income the gap opens wide, and California becomes the highest-tax state on the physician's list.

The July 1 transition to $250K attending:

The salary rises about 3.6 times. The take-home rises only about 3 times. Here's why, in the physician's mental model:

• The 12% bracket you lived in as a resident is a distant memory — most of your new income falls in 22% and 24% brackets.
• Social Security tax stops at $184,500. Above that point, the 6.2% ends — a subtle bonus.
• The Additional Medicare Tax starts at $200,000. Above that point, 0.9% joins your regular Medicare deduction. Net effect: FICA looks almost identical between $184,500 and $250,000.
• State tax jumps hard. A California physician sees their state income tax increase roughly eightfold between PGY-3 and first-year attending, from about $2,375 to about $19,005.

Practical implication for the first-year attending: the "why does my paycheck feel small" phenomenon is real. Your take-home rises significantly, but your effective tax rate climbs too — from about 17% (Texas) to 22% (California) as a resident to about 27% to 36% as a first-year attending. Every physician benefits from adjusting their W-4 withholding and, critically, projecting quarterly whether they'll owe additional tax at filing time given the transition-year mixing of resident and attending income.

Two moves that reshape the transition math:

Timing the transition itself. Physicians whose new attending job starts July 1 often have a partial-year attending income for their transition year — meaning that transition year, with roughly half resident and half attending income, has a lower cumulative income than their first full attending year. Many high-tax-state physicians see effective rates jump upward in year two, because year one was cushioned by six months of resident-tier income.

Starting the retirement stack immediately. The $24,500 401(k) contribution limit is per calendar year, not per employment period. A physician starting attending work on July 1 has six months to contribute the full $24,500, which is aggressive but possible with front-loading. Every dollar deferred is a dollar not taxed at the newly attending marginal rate.

The four scenarios above assume single filer status. For most physicians who are married, the numbers improve substantially — sometimes dramatically.

Married filing jointly (MFJ) 2026 brackets:

• 10% on income up to $24,800
• 12% up to $100,800
• 22% up to $211,400
• 24% up to $403,550
• 32% up to $512,450
• 35% up to $768,700
• 37% above $768,700

Standard deduction: $32,200 for MFJ (double the single amount).

Comparison at $500,000 gross:

Single filer: federal tax $138,134, effective federal rate 27.6%.

MFJ (single earner, spouse doesn't work): taxable income $500,000 − $32,200 = $467,800. Federal tax approximately $102,608 — roughly $35,526 less than the single filer.

Why the difference: MFJ brackets are wider — the 22% bracket for MFJ extends to $211,400 versus $105,700 for singles. More of the income sits in lower brackets. For a one-earner couple at the incomes in this guide, that saves roughly $14,000–$38,000 a year in federal tax before considering other MFJ-specific items (child tax credits, dependent care, spousal IRA contribution eligibility).

Roughly $14,000–$38,000 more take-home than the single-filer baseline in Texas, and $18,500–$48,000 more in California. The Additional Medicare Tax threshold moves to $250,000 for a joint return (versus $200,000 single), which is worth $450 a year at any income above $250,000.

The marriage penalty question: does a dual-earner physician couple ever pay more taxes married than they would filing single? Yes, in narrow scenarios. Every 2026 joint bracket is exactly double the single bracket except the top one: the 37% rate starts at $768,700 for a couple versus $640,600 for a single filer. Two physicians earning $400,000 each (about $767,800 of joint taxable income) pay the same federal income tax married as single. Two earning $700,000 each pay about $10,250 more married, plus $1,350 more Additional Medicare Tax (a $250,000 threshold for the couple versus $200,000 each), and itemizers also lose because the SALT cap isn't doubled for joint filers. Marriage penalties for physicians exist but are rarely more than about $10,000–$12,000/year — and they're outweighed for most couples by benefits like spousal IRA access, filing efficiency, and estate planning.

Two physicians filing jointly is one of the more complex tax scenarios in medicine, and the numbers are worth working out.

Scenario: two physicians each earning $350,000 (combined $700,000), MFJ, no kids, standard deduction.

Federal tax: taxable income $700,000 − $32,200 = $667,800. Running MFJ brackets: federal tax approximately $171,269. Compare this to a single filer earning $700,000: federal tax $209,000. The dual-earner MFJ couple pays roughly $37,700 less than a single filer at the same combined income — because their income is split across brackets more efficiently.

But now FICA gets interesting. Each spouse pays Social Security tax up to $184,500 individually — meaning a two-physician household pays SS tax on up to $369,000 combined, versus $184,500 for a single filer. Additional Medicare Tax kicks in at $250,000 MFJ, not $200,000, but applies to the household's combined wages above that threshold.

Per-spouse FICA in this scenario:

Each spouse earning $350,000: Social Security $11,439 (capped), Medicare $5,075, Additional Medicare Tax portion — this is where it gets nuanced. Employers withhold Additional Medicare Tax on wages above $200,000 individually, but the actual liability is calculated on combined MFJ income above $250,000. In this scenario, combined wages of $700,000 minus the $250,000 threshold means $450,000 subject to the 0.9% surtax = $4,050 total.

Total combined FICA: $37,078 ($22,878 Social Security, $10,150 Medicare, $4,050 Additional Medicare Tax) — significantly more than a single filer at the same $700,000 income (who paid $26,089), because the dual-earner household stacks two Social Security taxable bases.

State tax on combined $700,000 MFJ:

• Texas: $0
• Georgia: approximately $33,433 (4.99% flat, after the $30,000 joint standard deduction)
• California: approximately $66,016 ($56,916 of income tax using joint brackets, plus $9,100 of SDI)

Net take-home, dual-physician household earning $700,000 combined MFJ:

• Texas: ~$491,654
• Georgia: ~$458,221
• California: ~$425,638

Compare to a single filer at $700,000: the dual-earner couple keeps roughly $26,700 more in Texas and $36,500 more in California — the MFJ federal bracket structure more than offsets the higher combined FICA.

Practical implications for dual-physician couples:

• Coordinate retirement stacks. Each spouse can max their own 401(k)/403(b) ($49,000 combined at $24,500 each), each can contribute to a Backdoor Roth ($15,000 combined at $7,500 each), and each has independent 457(b) access if applicable. A serious dual-physician household can shelter $80,000–$120,000+ of income pre-tax annually.
• HSA family limit is combined. Only one $8,750 family HSA contribution per household, not one per spouse.
• The Additional Medicare Tax underwithholding trap. Employers withhold based on individual wages above $200K. If one spouse earns $180K and the other $220K, the second spouse has 0.9% withheld on $20K ($180), but the household's actual liability is 0.9% on $150K (combined $400K minus $250K threshold), or $1,350, so the couple owes about $1,170 at filing. Overwithholding results in refund; underwithholding results in owing at filing.

Physicians who own their practices — solo practitioners, partners in group practices, or shareholders in professional corporations — face a fundamentally different tax picture than employed W-2 physicians.

The pass-through structure. Most physician practices are organized as S-corporations, LLCs (except in California, where the Professional Medical Corporation is required), or partnerships. Practice income flows through to the physician-owner's personal tax return as either W-2 wages (reasonable compensation from the S-corp) or pass-through distributions (K-1 income).

The reasonable compensation requirement. S-corp physician-owners must pay themselves a "reasonable" W-2 salary reflecting the fair market value of their clinical work. The remainder can be taken as distributions, which are exempt from self-employment tax (FICA/SE) but still subject to full federal and state income tax.

Worked scenario: solo practice owner taking $600,000 out of an S-corp: $350,000 of reasonable W-2 compensation and a $250,000 distribution.

W-2 portion ($350,000):

• Federal income tax: taxed together with the distribution at ordinary rates
• FICA (employer + employee): Social Security $11,439 (capped on employee side, employer matches), Medicare $5,075, Additional Medicare Tax $1,350 employee-side
• The S-corp also pays the employer's matching share of FICA (about $16,500: $11,439 of Social Security and $5,075 of Medicare), a practice expense on top of the $600,000

Distribution portion ($250,000):

• Federal income tax: subject to standard brackets, but no FICA or SE tax
• Savings vs. paying it as W-2 wages: 2.9% Medicare tax + 0.9% Additional Medicare Tax on the $250K distribution portion = approximately $9,500/year in payroll tax savings

The QBI deduction (Section 199A). Pass-through income from certain businesses qualifies for a 20% deduction against qualified business income — but medical practices are specified service trades or businesses (SSTBs), and for 2026 the deduction for an SSTB phases out between $201,750 and $276,750 of taxable income (single) or $403,500 and $553,500 (MFJ), per Rev. Proc. 2025-32. Most attending physicians who own their practices are above that range and get no QBI deduction.

The 1.5% California problem. California levies a 1.5% franchise tax on S-corp net income ($800 minimum), which materially erodes the payroll-tax savings that make S-corps attractive elsewhere. The break-even income for S-corp benefits in California sits meaningfully higher than in Texas or Florida. See our California PMC guide for the full analysis.

Practical take-home for the practice-owner physician:

In Texas, that physician-owner keeps about $409,000 of the $600,000 after 2026 federal income tax (about $173,100 on $583,900 of taxable income, with no QBI deduction at this income) and employee-side payroll tax ($17,864), versus $340,000 for a W-2 physician earning $500,000 salary — but the practice owner also carries practice-related expenses (malpractice, staff, overhead) that the W-2 physician doesn't. Direct comparison requires knowing your practice's actual expense structure.

The retirement plan advantage that reshapes practice-owner economics. Practice owners can establish defined benefit plans, cash balance plans, and Solo 401(k) plans with much higher contribution limits than employed physicians. How much depends on age, pay and the actuary's assumptions: in the worked example in our cash balance plan guide ($300,000 salary, benefit at 62, 5% interest crediting rate, the 2026 benefit limit held flat and an assumed lump-sum conversion factor of 12.5), the level yearly pay credit is about $228,000 for a physician-owner who starts at 50, on top of a 401(k) — far more than the $32,500 employee-side limit (age 50 and up) W-2 physicians face. This is the single largest tax advantage of practice ownership and rarely appears in take-home comparisons because it's a savings decision, not an immediate cash-flow decision. Our cash balance plan guide shows how the contribution is set and what the plans cost to run.

Texas, Georgia, and California anchor the range. Here's how the other states cluster by the rate that applies to physician-level income in 2026 (from the Tax Foundation's 2026 state rate tables, with Georgia updated for its May 2026 cut):

No tax on wages (highest take-home): Alaska, Florida, Nevada, New Hampshire (its interest and dividends tax ended in 2025), South Dakota, Tennessee, Texas, Wyoming, and Washington (which taxes only capital gains).

Under 4%: Arizona (2.5% flat), North Dakota (2.5% top), Indiana (2.95% plus county income tax), Pennsylvania (3.07% flat), Kentucky (3.5% flat), Iowa (3.8% flat), North Carolina (3.99% flat).

4–5%: Michigan (4.25%), Colorado (4.4%), Utah (4.5%), Nebraska (4.55% top), Illinois (4.95% flat), Georgia (4.99% flat for 2026), Massachusetts (5%, plus a 4% surtax on income above $1,107,750 in 2026).

5.75–9%: Virginia (5.75%), Delaware (6.6%), New York State (6.85% on taxable income from $215,400 to $1,077,550), Connecticut (6.9% from $250,000 and 6.99% above $500,000 for single filers), Maine (7.15%), Wisconsin (7.65% top), New Jersey (6.37% up to $500,000, 8.97% to $1 million, 10.75% above).

9% and up: Minnesota (9.85%), Oregon (9.9%), Washington, D.C. (9.25%–10.75%), Hawaii (up to 11%), California (9.3%–13.3%, plus 1.3% SDI), and New York City residents, who add city income tax of up to 3.876% on top of New York State's rate. See the full comparison in our Physician Salary by State guide.

One caveat that reshapes several of these rankings: some low-headline-tax states lean harder on property and sales taxes, and Texas is the usual example. California's Proposition 13, by contrast, limits the general property tax rate to 1% of assessed value plus voter-approved local debt, and caps annual assessment increases at 2% until the home sells. Physicians earning above $200K–$300K typically care most about income tax because it's the largest single levy, but price the property tax on the house you would actually buy. The total-tax math tightens the gap somewhat, though rarely enough to close it.

Two states with structural surprises worth flagging. California's State Disability Insurance (SDI) is withheld at 1.3% of all wages in 2026, with no wage cap since 2024, which is why the California figures in this guide include it. And New York City physicians pay city income tax (top rate 3.876%, reached at $50,000 of taxable income for single filers) on top of New York State's 6.85%, a combined marginal rate of about 10.7% on most physician incomes, in the same range as California's 10.3%–11.3% plus SDI.

The state tax gap between high-tax and low-tax states looks large in a single year. In career terms, it becomes structural.

Twenty-five-year career projection: Texas vs. California, physician earning $500,000/year with 3% annual raises:

Cumulative 25-year Texas advantage: approximately $2.0 million pre-investment.

Invested at a 7% annual return, the compounded advantage over 25 years comes to about $4.5 million (before any tax on the investment returns). Even factoring in higher property taxes and cost-of-living differences (which don't scale as steeply as income), the state tax gap compounds into life-changing money for high-earning physicians who stay in the same state for decades.

Two caveats worth acknowledging:

The projection holds today's brackets, rates, and 1.3% SDI constant for 25 years, which is unlikely — California may raise or lower rates; Texas may introduce new taxes; federal brackets will change. The direction of the gap is more reliable than the specific dollar figure.

Physicians rarely make career decisions purely on tax arbitrage. Family, spouse's career, specialty market, patient population, and lifestyle preferences all matter — often more than the tax number. The point of quantifying the gap isn't to say every physician should move to Texas; it's to make sure the number is honestly on the table when the decision is being made.

One legitimate hybrid strategy: several physicians build careers in high-tax states for career-defining years (fellowship, academic reputation, family stability) and then time a move to a low-tax state for the second half — capturing the higher-earning peak years under lower tax. Whether this works depends on specialty portability, but for cognitive specialties with broad geographic demand, it's a real strategy that saves seven figures over a career.

The four calculations above show what the tax system takes. Here's what you can actually change.

Pre-tax retirement contributions — the largest lever. For 2026, the employee 401(k)/403(b) contribution limit is $24,500, plus an $8,000 catch-up for age 50+ ($11,250 at ages 60–63). Contributing the full $24,500 at a 35% federal + 5% state marginal rate saves roughly $9,800 in taxes — meaning your take-home only drops by about $14,700 to shelter $24,500 of savings. The physician making $500,000 who maxes contributions increases retirement savings while reducing tax at a rate no other deduction touches.

For physicians with access to a 457(b) — public university employees, VA physicians, some hospital-employed physicians — the 457(b) space is separate from the 401(k) space, meaning another $24,500 of pre-tax savings on top. Combined ~$49,000 of pre-tax deferral at physician marginal rates saves roughly $19,600 in taxes. See 457(b) Plans for Physicians for the detailed mechanics, including the risks of a non-governmental plan.

HSA contributions — the triple tax advantage. If you have an HSA-eligible health plan, the 2026 family HSA limit is $8,750 ($4,400 for self-only), and contributions made through payroll are pre-tax at both federal and FICA levels (unlike 401(k), which still owes FICA). For a family contribution at a 32–37% federal bracket plus 2.35% Medicare tax, that saves roughly $3,000–$3,450 a year, more with state tax (California doesn't exempt HSA contributions). See Physician HSA Strategy.

Mega Backdoor Roth — where plan documents allow. This is the mechanism covered in detail in our Mega Backdoor Roth guide: post-tax 401(k) contributions converted to Roth, potentially adding up to $47,500 of tax-advantaged savings in 2026 (the $72,000 combined limit minus the $24,500 employee deferral), less any employer contributions. This doesn't change your immediate take-home — it changes what happens to money you'd otherwise save in a taxable account.

Backdoor Roth IRA — the annual $7,500 contribution. For 2026, the IRA contribution limit is $7,500 (individual) or $8,600 (age 50+). Above certain income thresholds, direct Roth contributions phase out; the Backdoor Roth mechanic preserves access. Effect on take-home is neutral (the contribution is post-tax), but every dollar sheltered from future tax growth compounds meaningfully across a career.

PSLF for eligible physicians. Not a tax deduction, but for PSLF-eligible physicians, the balance forgiven after 120 qualifying payments is tax-free under federal law — meaning the effective compensation from PSLF-qualifying employment is far higher than the salary line suggests. For a physician at an FQHC, VA hospital, or academic center, this reshapes the take-home comparison against private practice.

One thing that does NOT move take-home much: itemizing. Under current standard deduction levels ($16,100 single / $32,200 MFJ for 2026), the physicians who benefit from itemizing are those with substantial mortgage interest on expensive homes, significant charitable giving, and — following OBBBA's raise of the SALT cap to $40,400 for 2026 — meaningful state tax deductibility, at least until modified AGI passes $505,000, where the cap starts shrinking back toward $10,000. For most physicians without a large mortgage or charitable footprint, the standard deduction wins. Model both, but don't assume you'll clear the threshold just because you're a high earner.

Physicians hear about "tax deductions" abstractly and often overestimate how much they actually change take-home. Here's the honest accounting for a $500,000 attending in California.

Mortgage interest on a $700,000 mortgage at 7%: approximately $48,600 in interest paid in year 1, decreasing over time. Deductible against state and federal income tax if you itemize. Value at physician marginal rate: approximately $21,000/year in year 1, dropping as the loan amortizes. This is real money but requires meeting the itemization threshold ($32,200 MFJ / $16,100 single).

Property tax deduction (SALT cap $40,400 for 2026 under OBBBA): for a physician paying $12,000 in California property tax plus about $44,100 in state income tax and $6,500 of SDI (which counts as a deductible state income tax), the total state and local taxes exceed the cap. Only $40,400 counts as itemized deduction, and only because a $500,000 salary sits just under the $505,000 modified-AGI line; above it, the cap shrinks by 30% of the excess and bottoms out at $10,000 (for a single filer, at about $606,000 of modified AGI). Value: approximately $14,000/year at marginal rate — but only when combined with mortgage interest or other itemized items pushing the total above the standard deduction.

Charitable giving: deductible if itemizing, but starting in 2026 only the amount above 0.5% of AGI counts federally ($2,500 at a $500,000 AGI). A California physician donating $20,000/year captures roughly $8,400 in combined federal and state tax savings at the marginal rate — meaning the effective out-of-pocket cost of giving $20,000 is closer to $11,600. Donor-advised funds and appreciated-stock donations can improve this further.

Health insurance premiums (pre-tax through employer): if $8,000/year is deducted from your paycheck pre-tax through your employer's plan, your taxable income is reduced by $8,000. Savings: approximately $3,500/year in combined federal and state tax at physician marginal rate. This one runs silently — you never see it as a "deduction" because it never appears in your taxable income.

Dependent Care FSA: up to $7,500/year pre-tax for 2026 (raised from $5,000) for childcare expenses. Savings: roughly $2,800/year in federal income and Medicare tax at a 35% bracket, more with state tax.

Student loan interest deduction: up to $2,500/year — but for 2026 it phases out between $85,000 and $100,000 of modified AGI (single) / $175,000 and $205,000 (MFJ). Essentially all practicing attendings have already phased out. This deduction exists on paper; it doesn't reach physician incomes.

The aggregate effect: a typical high-earning physician with a mortgage, moderate property taxes, employer health insurance, and modest charitable giving can reduce taxable income by $40,000–$70,000 through legitimate itemized and pre-tax mechanisms — reducing tax owed by approximately $14,000–$25,000 at physician marginal rates. Meaningful but not transformative, and requiring the effort to actually track and file properly.

What's more valuable than itemizing for most physicians: maxing pre-tax retirement contributions ($24,500 401(k) + $8,750 HSA + potentially another $24,500 in 457(b) space) delivers larger tax savings than any itemization strategy, without any of the documentation burden.

Everything above assumes W-2 employment. Physicians earning 1099 income face a different math and one specific problem: self-employment tax.

Self-employment tax is nominally 15.3% (both the employer and employee halves of Social Security and Medicare), applied to 92.35% of net self-employment earnings. But the 12.4% Social Security portion applies only up to the Social Security Wage Base ($184,500 in 2026), and W-2 wages count against that base first. This creates the counterintuitive result our Locum Tenens Salary and Tax Guide covers in depth: an attending whose primary W-2 salary already exceeds $184,500 pays essentially no Social Security tax on 1099 income — only the 2.9% Medicare portion (plus the 0.9% Additional Medicare Tax above $200K/$250K).

Practical translation: for a typical attending, 1099 side income carries about a 3.5% payroll-tax load (3.8% on 92.35% of the earnings) instead of 15.3%. That isn't cheaper than extra W-2 wages above the wage base, which cost you 2.35% while the employer pays the other 1.45%; what makes side work cheaper than it first looks is the missing 12.4% Social Security charge. That is the payroll-tax point our AI Training Side Gig guide makes too.

Worked example: attending earning $350,000 W-2 plus $75,000 in moonlighting 1099 income.

The $75,000 in 1099 income is subject to:

• Federal income tax at the 35% marginal rate, after deducting half of the Medicare portion of SE tax = about $25,900
• Medicare tax (2.9% on 92.35% of the 1099 net earnings) = $2,009
• Additional Medicare Tax (0.9% on the same base, all above the $200K threshold, which the W-2 income already crossed) = $623
• Social Security tax: $0 (W-2 income already reached the SSWB cap)
• State tax at physician marginal rate

Total federal tax on the 1099 portion: approximately $28,500 — about 38% of the $75,000, close to the 37.35% the same dollars would cost as extra W-2 wages (35% + 1.45% + 0.9%). The 12.4% Social Security charge a 1099 worker below the wage base would owe is what drops out.

The trade-off: 1099 income requires quarterly estimated taxes (no employer withholding), no automatic retirement plan participation (though it opens Solo 401(k) eligibility — see the Mega Backdoor Roth guide), and — in California specifically — legally cannot be earned through an LLC (see our California Professional Medical Corporation guide).

Solo 401(k) leverage. A physician with 1099 income can open a Solo 401(k) with total contributions up to $72,000 for 2026 (the physician acts as both employee and employer). Employee contributions are limited to $24,500 combined across all 401(k)-type plans, but the employer profit-sharing portion is separate and can absorb up to 20% of net self-employment earnings (25% for W-2 owners of S-corps). This shelters substantial 1099 income from immediate taxation.

A full-time 1099 physician — locums doctor, independent contractor, or newly established practice owner without employees — faces a fundamentally different tax picture from the W-2 scenarios above. Self-employment tax applies to the entire $184,500 Social Security base if no W-2 income exists, essentially doubling payroll tax burden. Health insurance is purchased individually. Retirement plans require self-establishment. Quarterly estimates are mandatory to avoid underpayment penalties.

The four primary scenarios cover established-attending life. Two additional stages deserve attention.

The mid-career catch-up years (ages 50–60). Physicians aged 50+ can add catch-up contributions to retirement accounts. For 2026:

• 401(k) catch-up: +$8,000 → total limit $32,500 (+$11,250 → $35,750 at ages 60–63)
• Governmental 457(b) catch-up: +$8,000 → total limit $32,500 (separately); the age-50 catch-up doesn't apply to the non-governmental 457(b) plans many hospitals offer
• HSA catch-up: +$1,000 for age 55+ → total limit $9,750 family
• IRA catch-up: +$1,100 → total limit $8,600

A physician age 55 with 401(k), governmental 457(b), HSA, and Backdoor Roth access can put about $83,350 a year into these accounts — but only about $58,750 of it is pre-tax. Starting in 2026, anyone whose prior-year FICA wages topped $150,000 must make 401(k), 403(b), and governmental 457(b) catch-ups as Roth, and Backdoor Roth money is after-tax. At a 40% combined marginal rate, the pre-tax portion reduces immediate tax by approximately $23,500/year.

Cash balance / defined benefit plans for practice owners in this age range can multiply the effect. The amount depends on age, pay and the plan actuary's assumptions; under the assumptions in our cash balance plan guide ($300,000 salary, benefit at 62, 5% interest crediting rate, the 2026 benefit limit held flat and an assumed lump-sum conversion factor of 12.5), a practice owner who starts at 55 gets a level pay credit of about $312,000 a year, building toward a projected maximum lump sum of about $2,538,000 at 62. Those figures are illustrations, not quotes; an actuary sets the real ones. It is a meaningful lever for physicians whose careers didn't front-load the wealth-building years.

Late-career pre-retirement (ages 60–65). This stage introduces Medicare timing decisions and Roth conversion planning. Physicians who plan to retire between 65 and 70 sometimes benefit from Roth conversions during their 60s — converting traditional 401(k) balances to Roth in the years between retirement and Required Minimum Distributions (which start at age 73 for those born 1951 through 1959 and age 75 for anyone born in 1960 or later, which covers physicians now in their early 60s), taking advantage of lower marginal rates during the earning gap.

The retirement bracket gap. A physician earning $500,000 in their peak years and retiring on $150,000/year of withdrawals faces marginal rates that drop dramatically at retirement. This is the exact scenario where late-career Roth conversions genuinely add value: paying 22–24% tax on converted amounts at retirement, versus 32–37% during working years. See Physician FIRE and Physician Net Worth at Retirement for the full analysis.

Social Security taxation for physician retirees. Once collecting Social Security in retirement, up to 85% of benefits become taxable depending on total income. For a physician retiree with $80,000 in Social Security and $150,000 in portfolio withdrawals, most Social Security is taxable — but at the retiree's now-lower marginal rate. This is meaningfully different from the "Social Security tax" the pre-retirement physician pays via FICA.

If you're a physician who has verified take-home figures against this article, corrections and additions make future editions better — editorial@medmoneyguide.com.

Related reading: Physician Salary by State (2026) · Physician Tax Planning Guide · The OBBBA Physician Tax Guide · Mega Backdoor Roth for Physicians · Physician 457(b) Plan · The Backdoor Roth IRA · Locum Tenens Salary and Tax Guide

Specialty income references: Family Medicine · Internal Medicine · Cardiology · Dermatology · Orthopedic Surgery · Plastic Surgery

Employer decisions with tax implications: PSLF vs. Refinancing · The VA Physician Money Guide · FQHC Physician Playbook · California Professional Medical Corporation

Life-stage planning: The New Attending Playbook · PGY-1 Financial Checklist · Physician FIRE · Physician Net Worth at Retirement