For years, “just do the backdoor Roth” was default advice for high‑earning surgeons. But after 2025’s OBBBA changes, that rule of thumb can quietly cost you money. This article walks through a simple three‑branch framework to decide when Roth still wins, when traditional and cash balance contributions create more value, and how your state‑to‑state tax trajectory can flip the answer. Before you fund another backdoor Roth on autopilot, model both paths and let the math—not the calendar—drive the decision.