Priya and David: A First Year Hospitalist Household, Scored

Priya finished internal medicine residency and took a hospitalist job in a large Northeast metro at about $260,000. David works as a software engineer at $140,000, which puts the household near $400,000 in her first attending year. They have been married four years and have one toddler. It is a strong start by any measure: two professional incomes, a reviewed contract, and no spending fires.

The debt picture is one big decision and small clean edges. The federal student loans stand at about $200,000, which is the median balance for the class of 2025 in the AAMC data, and they sit on the standard repayment plan because the plan was never chosen on purpose. The credit cards are paid in full every month. Car loans run about $25,000. Total debt of about $225,000 against about $400,000 of income is a ratio of about 0.56 to 1, a light anchor for a first year attending household.

The savings machinery exists and runs small. The emergency fund holds about $20,000, roughly a month and a half of the new lifestyle. Saving runs at about 10 percent, the 403(b) up to the match and automated, and nothing beyond the match. Investable net worth is about $80,000. The household is in the 32 percent federal bracket, a fact Priya did not know, and no deliberate tax moves have been made: no backdoor Roth, no pre tax against Roth comparison, nothing aimed.

The protection stack is where the residency shape shows. Health coverage is in place. Disability coverage is the hospital group long term disability policy and nothing else. Life insurance is a $500,000 twenty year term policy bought in residency. There is no umbrella policy. The malpractice coverage is the employer's claims made policy, and the tail was never arranged or priced. The estate shelf is empty: no will, no powers of attorney, no health care directive, with a toddler in the house and no guardian named anywhere.

The Financial Health Assessment grades a household on 21 measures across seven frameworks, 20 measures for an attending household and 19 for a resident household, and lands the total in a band. Priya and David score 42, in the Corrections band: nothing here is in crisis, and several core systems still need to be built. The episode scored the household in four groups.

The zero boxes tell the story faster than the points do. The emergency fund sits below its first waypoint. The two written goals carry no numbers, no dates, and no funding. There is no umbrella and no estate document. No loan decision has been made. The Roth against pre tax choice was never examined, the bracket is unknown to the household, and no deliberate tax move exists. Each zero is a decision nobody made, which is fixable, and none of them is a mess, which is the good news.

This is the Protection Stack framework applied to a first year hospitalist, and it shows a stack built for a resident's income guarding an attending's. Start with disability, the highest rung for any physician household. Priya's only coverage is the hospital group policy: capped, written on the plan's definition rather than hers, and gone when the job is. Her work is cognitive and shift based, and the events that end it are the ones a group definition handles worst. The individual own occupation policy is not an upgrade here. It is the missing structure, and it heads the prescription below for exactly that reason.

Life insurance shows the same sizing problem in miniature. A $500,000 term policy was a reasonable resident purchase. Against a $400,000 household income with a toddler, it covers a year and a quarter of earnings. The malpractice line is quieter and just as open: the employer policy is claims made, and nobody has established who buys the tail when she leaves, in a specialty where first contracts are often short and employer changes are normal. The umbrella rung is simply absent. Health coverage, the one fully built rung, holds its 4 points and shows what finished looks like.

The framework's point is sequence. Every later step in this household's plan, the loan payoff, the savings rate, the investing, is built on Priya's income, and the stack that protects that income is the thinnest part of the picture. The Protection Stack framework page lays out the rungs in order, and the internal medicine insurance page works the hospitalist definitions in full.

The second deep dive is the Lifestyle Guardrails framework, and the finding is the most common one in first year attending households: nothing went wrong, and the money still disappeared. Saving runs at about 10 percent. Spending was never assigned a ceiling, so it set itself against the new income, and the emergency fund stopped at about a month and a half because nothing told the surplus where else to go. The household did everything casually right and nothing deliberately.

The Double Up Rule exists for exactly this year. Live on double the resident net, and every dollar above that line flows the waterfall in order until taxable investing opens the exit. Priya and David never drew the line, so the raise spread across the whole lifestyle instead of down the order. The fix in the prescription is mechanical, not moral: automate 20 percent on payday, before spending sees it, and let the automation hold the guardrail the household has not held by attention.

Notice what this dive does not say. It does not say the spending is foolish, and it does not prescribe cuts. A household at $400,000 with clean cards and a reviewed contract has earned its lifestyle. The guardrail question is narrower: does the surplus have orders, or does it wander? For one year, it wandered. The new attending guide lays out the order the surplus should have marched in.

Five moves, in the order the episode gave them.

One: Buy the individual own occupation disability policy now. Specialty specific language, sized to her income, bought at 33 and healthy while pricing favors her. This is the missing structure under the whole plan.

Two: Put a $2 million umbrella policy in force. The cheapest rung in the stack, bought before the assets compound into a target.

Three: Sign the estate documents. A will, financial power of attorney, and health care directive for each of them, with a guardian named for their toddler. One attorney engagement closes the emptiest shelf in the house.

Four: Automate saving at 20 percent on payday. Past the match, through the waterfall order, with the automation carrying the discipline the first year proved attention would not.

Five: Make the loan call. Price forgiveness at her employer against payoff and refinance with real numbers, choose one, and run it. Any of the three is better than the standard plan chosen by nobody.

Run all five and the episode's arithmetic is 42 plus 22, a score of 64, into the Corrections band. None of the five requires a raise, a refinance closing, or a windfall. Each one is a decision and an afternoon.

A first attending year can be well run and unfinished at the same time. Priya and David did the visible things right: the contract reviewed, the cards clean, the match captured. The score comes from the invisible list, the decisions that do not announce themselves. The loan plan nobody chose. The coverage still wearing residency sizes. The documents nobody signed. Attending money does not fix those by itself, because each one waits for a decision, not a deposit.

The second lesson is the order of operations. Protection before payoff, automation before willpower, the loan decided once and then left to run. Households that run the order finish the list in a year. Households that run on urgency spend the same year paying extra principal on a loan they have not decided about, uninsured in the ways that matter, wondering why the score never moves.

Ryan Inman is a retired financial planner who worked with about 500 physician families. He created the Financial Residency podcast (about 3 million downloads) and is no longer affiliated with it. Financial Fellowship is his sole focus. This guide is educational. Last updated October 2026.