Your First Attending Bill Shouldn't Be Your Worst Surprise.

Some do. W-2 physicians benefit from backdoor Roth conversions, tax-loss harvesting, charitable strategies like donor-advised funds, and real estate investments with cost segregation. If you also have 1099 moonlighting or side income, additional strategies like S-Corp election become available for that income stream.

Moonlighting income reported on a 1099 is subject to self-employment tax unless structured properly. Setting up a single-member LLC with S-Corp election for your moonlighting allows you to pay yourself a reasonable salary and take the rest as distributions, avoiding 15.3% SE tax on that portion. This is one of the highest-value strategies for physicians with side income.

Owning your practice space through a separate entity and leasing it to your practice creates rental income, which can be offset by depreciation. A cost segregation study on a $1M medical office typically reclassifies 22-34% of the building to shorter depreciation schedules, generating $65K-$100K in first-year deductions. This is one of the most overlooked strategies for practice owners.

A cash balance plan is a type of defined benefit retirement plan that allows significantly higher tax-deductible contributions than a 401(k). For physicians over 45, contributions can reach $100K-$400K+ per year, all tax-deductible. It is particularly effective for high-earning physicians who want to shelter substantial income while building retirement wealth rapidly.

Multi-state practice creates filing obligations in each state where you have nexus (physical presence, patients, or income). Without proper apportionment, you can end up paying tax on the same income to multiple states. We handle state-by-state allocation, credit calculations, and reciprocity agreements to ensure you are not double-taxed.