New Attending Emergency Medicine

Start here: three steps, in this order

Disability: sized to attending income, in the first ninety days

The coverage problem in this specialty is mechanical. The income depends on a body that can intubate, reduce, suture, and stay sharp at hour eleven of a night shift. An injury to a hand, a back, or an eye does not reduce that income gradually. It ends the shifts, and the shifts are the income.

Size an individual own occupation disability policy to attending income inside the first ninety days, targeting the 60 to 70 percent of pre disability income that carriers will issue in total coverage (Medical Economics), with the definition written to your own occupation and the benefit period running to retirement age.

This section is built around Jimmy Turner, MD, the physician behind Money Meets Medicine and the disability voice this site trusts. His frame for new attendings is simple: the group policy is not your policy. Group coverage, whether a hospital plan or a staffing company plan, is capped, tied to the job, written to the group definition of disability, and gone when the contract is.

The individual policy is the one that follows you from group to group and job to job, and the resident policy you placed in training, if you placed one, now gets exercised: raise the benefit to attending income on the increase right you bought, without a new medical exam. If you did not place one in training, this is the quarter to fix that, while the attending health record is still the resident health record. Read Jimmy and the assessment path at the Jimmy Turner page, and the definition itself at own occupation disability.

Term life follows the same first quarter logic, sized to the household rather than the group maximum, and the umbrella policy goes on once the attending income makes you worth suing: it is the cheapest million dollars of protection in the stack. The full build is on the insurance topic page and in the protection stack framework.

Worked math: whether an emergency physician needs own occupation disability insurance, how much term life insurance an emergency physician needs, and how much disability insurance an emergency physician needs.

The first contract: a tale of three structures

The $421,000 average is the least informative number in this hub. The specialty pays three different ways, and the averages blend all of them. The democratic group holds its own hospital contract, bills for its own work, and shares what is left with partners: the top of the self reported market, with self employed physicians averaging $497,500 (Marit Health). The national staffing company holds contracts at hundreds of hospitals and pays a rate: steadier recruiting, thinner benefits, and a margin the company keeps between what the hospital pays and what reaches you.

The hospital employs directly, at a $428,500 average in the Marit data: a salary, a real benefits package, and the flattest ceiling of the three. None of the three is automatically right. All three are priced wrong if you only read the first year rate, because the partnership distributions, the benefit loads, and the exit terms live in years two through ten.

Inside each structure, the pay formula needs the same read. Marit puts the median rate at $31 per wRVU, with the middle half of physicians running from $27 to $45 per wRVU, and average annual volume at 11,662 wRVUs. An hourly offer and an RVU offer are the same offer only after you multiply the rate by the volume your department actually generates, at the schedule you actually work.

Hours are the other half of the formula: at 2,000 clinical hours a year, $421,000 of income is about $211 an hour, because $421,000 divided by 2,000 hours is $210.50. At 1,700 hours the same income is about $248 an hour. The physician working fewer, harder hours at a better rate often out earns and out lasts the one stacking shifts. The depth, the benchmarks slot, and the full comparison live on the contracts and income topic page. This section links there. It does not copy it.

Two clauses get read before any of the money. If the malpractice policy is claims made, know today who pays the tail when you leave, because that clause was priced at signing and collected at exit. And read the restrictive covenant against a map of where else you could work, because in a one hospital town a broad covenant is a move out of town written into your first job.

Worked math: the hourly rate offer compared against the RVU offer, tail coverage and restrictive covenants, checked, and the signing bonus priced against a higher hourly rate.

The waterfall: the resident to attending jump

Compare net to net, never gross to gross. That is the rule the whole first year runs on. The attending gross looks enormous next to the resident gross, and the comparison lies: taxes, benefits you now buy yourself on a contractor paycheck, and the lifestyle the gross invites all take their cut before the money is yours.

The Double Up Rule frames the jump honestly. You lived on the net of a resident salary. As a new attending you live on double that net, a resident net of $65,000 becomes a $130,000 lifestyle, and every dollar above it flows the waterfall. You may not leave the rule until you reach the taxable account at its end.

1. Capture the full employer match, and nothing past it. The match is a guaranteed return. A contractor has no match, which is one more cost the 1099 rate has to clear.
2. One month of reserves, sized at the new lifestyle. The reserve is priced at the attending month, not the resident one.
3. Credit cards to zero. Nothing else gets a dollar until consumer debt is gone.
4. Coverage. Disability above all, sized to attending income, plus term life, plus umbrella, per the disability section above.
5. The student loan plan runs in parallel. If forgiveness is live, minimums and recertify, never a dollar extra. The employer question decides whether it is live: employed by the nonprofit hospital or a public system, the count runs. Employed by a for profit staffing company inside that same hospital, the count stops, with one narrow exception where state law bars the hospital from employing physicians directly and the facility identification number goes on the certification.
6. Backdoor Roth IRA, $7,500, before debt above 7 percent. The space is tiny, it closes every year, and tax free compounding is scarce at attending income.
7. Max retirement. Health savings account first inside the tier, at $4,400 self only or $8,750 family for 2026, then the 401(k) or 403(b) to the $24,500 elective deferral limit, then a governmental 457(b) where one is offered, then mega backdoor last where the plan allows. A contractor runs the solo 401(k) version of this tier.
8. Add two more months of reserves, three in total.
9. Extinguish remaining debt above 7 percent. Forgiveness track loans are excluded. They are on the parallel plan, not this one.
10. Finish the reserve before the first taxable dollar. Six months of expenses on W2 income, up to twelve months on 1099 or sporadic income, because a contractor schedule can vanish with a contract. The endpoint is set by employment type only, never by specialty.
11. Taxable brokerage, alongside written goals. Reaching this step is the exit from the Double Up Rule into established attending life.

The sign on bonus, if your contract carries one, runs through the same order rather than around it: reserves first, cards, coverage premiums, then down the list. A bonus spent on the lifestyle in month one is the raise spent twice. The three bucket framework is the map underneath all of it: bucket one is the Safety Net you finish at step ten, bucket two is the Wealth Engine of retirement accounts, and bucket three is the Accelerator that only opens once the first two are funded.

One more household shape belongs in this section: the physician in uniform. This site has assessed an emergency physician serving in the military, James, with Emily, at this stage, carrying a scholarship instead of loans and the military version of every protection question on this page. The order still applies. The loan step simply runs at zero, and the pension math joins the retirement tier.

Worked math: the order to fund retirement accounts, how many months of expenses to keep in cash, and forgiveness against fast payoff, priced.

Questions new attendings ask

Twenty questions written for the first attending years, grouped by topic.

Contracts and income 8 questions

1. How do I compare an hourly rate offer against an RVU based offer in emergency medicine?
2. What should I check in an emergency medicine contract about tail coverage and restrictive covenants?
3. Is democratic group partnership worth more than a higher hourly rate at a large staffing company?
4. How should a large night shift differential change my savings plan?
5. Is a signing bonus better than a higher hourly rate for an emergency physician?
6. What happens when your emergency group loses the hospital contract?
7. Should a new emergency physician join a democratic group partnership track?
8. How many shifts a month should an emergency physician work?

Student loans 3 questions

9. Should I use PSLF if my hospital is a nonprofit, or pay the loans off fast on an emergency medicine salary?
10. Should I refinance my student loans in my first attending year in emergency medicine?
11. Rural emergency medicine loan repayment vs. metro pay: how do I price both offers whole?

Insurance 3 questions

12. Does an emergency physician need own occupation disability insurance?
13. How much term life insurance does an emergency physician need?
14. Occurrence vs. claims made malpractice for emergency physicians: which policy form do I have?

Retirement and the reserve 3 questions

15. What order should an emergency physician fund retirement accounts?
16. How many months of expenses should an emergency physician keep in cash?
17. How do I stack a 403(b) and a 457(b) at a hospital emergency medicine job?

Ownership, documents, and the W2 or 1099 fork 3 questions

20. Should I take the 1099 contract or the W2 job in emergency medicine?

Topic pages for this stage

The depth lives at the generic level. These are links, not copies. Loans at attending scale are worked on the student loans topic page, where the employer question gets its full treatment. Coverage beyond the disability section is on the insurance topic page. The retirement menu, employed and contractor side by side, is on the retirement topic page. The partnership track is priced on the ownership topic page, and the first documents are listed on the estate planning topic page. The contractor fork itself, priced whole, is the W2 or 1099 topic page.

Worked math: stacking a 403(b) and a governmental 457(b) at a hospital job and the partnership track decision.

Red flags from the case studies

The pattern this stage signs is a claims made policy with no tail arranged. The contract looks complete, the rate is right, and the malpractice clause leaves the tail premium with the physician at exit, where it arrives as a five figure surprise in the gap between jobs. It belongs in the signed document: who pays, in what share, on what trigger.

Beside it sit the two companion flags of the first contract. A restrictive covenant read without a map, in a market with one hospital system, is a move out of town waiting for a trigger. And a sign on bonus spent before anyone reads its clawback is a loan the household has already consumed.

Worked math: tail coverage and restrictive covenants, checked clause by clause and occurrence against claims made, priced.

If your situation is different

1099 instead of W2: there is no match to capture, no group coverage floor, and a reserve endpoint of up to twelve months. Start with the full 1099 setup.

Planning part time from the start: the schedule is the income here, so price the shifts first and build the waterfall at the part time net. The shift count is worked in how many shifts a month to work.

Two physician household: run one waterfall for the household, coverage on both incomes, and the loan plans read together, because forgiveness on one side changes the payoff math on the other.

In uniform: a scholarship replaces the loan step and a pension joins the retirement tier, as the James and Emily assessments on this site work through. The order still holds.

The new attending checklist

One page, in order. Print it and work down.

• Contract read on structure: who holds it, hourly against RVU, partnership track or none
• Tail responsibility and the restrictive covenant in the signed document
• Employer of record verified, and the PSLF count confirmed running or stopped
• Lifestyle set at double the resident net, in writing, before the first paycheck
• Full employer match captured
• One month of reserves at the new lifestyle
• Credit cards at zero
• Disability sized to attending income on an individual own occupation policy
• Term life sized to the household, and the umbrella policy placed
• Loan plan running in parallel: minimums and recertify if forgiveness is live
• Backdoor Roth IRA funded at $7,500
• Retirement tier running: HSA, then the workplace plan to $24,500, then a governmental 457(b) if offered
• Will, power of attorney, and health care directive signed