Attending Account Funding Waterfall

Who this is for

Attending physicians with steady W-2 or 1099 income and the cash flow to fund retirement accounts beyond the employer match. Not a fit for residents and fellows (use the Resident Account Funding Waterfall instead). Assumes the foundation is already in place: high-interest debt cleared, three to six months of cash, and disability insurance in force.

The decision this chart helps you make

Most physicians earn more than they need to spend during attending years and have to make a sequential decision about where each saved dollar should go. The wrong order can cost seven figures over a career. The waterfall answers a single question: given the choice, which account type fills first? The chart follows a strict cascade through seven tiers. Tier 0 confirms the foundation is in place. Tier 1 captures the employer match (a typical match returns 25-100% on contributed dollars). Tier 2 fills the most tax-advantaged accounts available to attendings: the HSA (pre-tax in, tax-free growth, tax-free out for medical expenses) and the backdoor Roth IRA. Tier 3 maxes the 401(k) or 403(b) deferral and a governmental 457(b) if available. Tier 4 captures the mega backdoor Roth if the plan allows it. Tier 5 handles kids' accounts (529 first, UTMA last). Tier 6 covers charitable strategies, taxable brokerage with asset location, and reassessment triggers. Two land mines are flagged with warnings. The pro-rata trap can ruin the backdoor Roth if any pre-tax balance sits in a traditional, SEP, or SIMPLE IRA. The SECURE Act forces a 10-year drain on inherited IRAs received after 2019, which can pile ordinary income onto attending earnings every year for a decade.

Essentials vs Ultimate

Essentials covers the waterfall in its cleanest form: the seven tiers in order, the 2026 contribution limits, and the foundation check up front. Ultimate adds the warnings (pro-rata cleanup, inherited IRA drain), the spouse-by-spouse rules (each spouse needs their own HSA for age-55 catch-ups, each spouse runs their own backdoor Roth), the age-based catch-up contributions (50+, 60-63), the HSA "shoebox" reimbursement strategy, the Roth-vs-traditional default for the 401(k), and asset location guidance for the taxable brokerage. Use Essentials to establish the sequence. Use Ultimate when sequencing it in your situation.

How to read this chart

This is a waterfall, not a decision tree. Read top-to-bottom. Each tier flows to the next only after the previous one is filled. The chart uses five box types: • Dark green diamond boxes are gating questions (e.g., "is the foundation in place?", "any pre-tax IRA balance?") • Pale red boxes with ⚠ are land mines (pro-rata trap, inherited IRA, UTMAs) • Pale orange boxes flag reassessment triggers • Pale cream boxes with green headers are the action steps with contribution limits • Pale parchment boxes are context (mechanics, common defaults, edge cases) Stop reading when a tier does not apply to you and skip to the next. Most attendings reach Tier 3 or Tier 4 in any given year. Use the toggle above to switch to Essentials if the Ultimate view is too dense.