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.