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.

Most surgeons track collections, not what they actually keep per clinical hour. In this article, I walk through a real‑world style example of a 2.4M orthopedic practice and show how overhead, tax structure, retirement plan design, and debt service combine to create a much lower effective hourly rate than most surgeons expect—and how targeted structural changes can raise that rate without adding a single additional case.