Roth conversion advice is usually written for retirees near the IRMAA threshold, not for surgeons earning seven figures. At your income level, Medicare surcharges are often already maxed out, which means IRMAA isn’t the variable that should drive your decision. Instead, the real leverage comes from understanding where today’s 37% tax bracket meets your expected retirement tax rate and how the SECURE Act’s 10‑year rule changes what your heirs inherit. In this article, we walk through a practical framework—and a worked example—for deciding when conversion, deferral, or partial conversion makes the most sense for high‑income physicians.

Many surgeons reflexively defer income every year, assuming next year’s tax bill will somehow be lower. This post breaks down when income deferral genuinely saves tax—and when it quietly backfires—by looking at real‑world scenarios like gap years, practice sales, and state moves. Use it to ask sharper questions with your advisor before the calendar locks in your 2026 tax outcome.