Money · for people who take call
The Cardiologist's
Investing Workup
One clear plan to build durable wealth in healthcare and beyond — while your day already runs from the first cath-lab case to the last clinic note.
If you trained for a decade, took call for years, and still chart at 9 p.m., the last thing you want is a second full-time job managing money. Good news: the evidence is overwhelming that busy high earners do best with a simple, mostly automated plan — not a screen full of blinking tickers.
This is the whole thing in one place: the accounts to fill, the order to fill them, the funds to put inside, and where a healthcare and biotech tilt fits if you want one. Two ideas carry the entire piece — your savings rate beats your stock-picking, and the account matters as much as the investment.
Differential · 01
Treat the cause: save first, pick stocks later
Here's the uncomfortable truth nobody selling a hot biotech wants to admit: a doctor who saves 20% of a $400K income into plain index funds will smoke a doctor who saves 5% into the world's cleverest picks. So the protocol is: save aggressively → fill tax-advantaged accounts in the smartest order → fill them with cheap, diversified funds → leave it alone.
The single habit that has made more physicians wealthy than any stock tip: live like a resident for a few years after training and bank the difference. The compounding does the rest. Everything below is just plumbing on top of that one decision.
The workup · 02
Every account a high earner can use
Think of this as a waterfall. Fill the top bucket, let it spill to the next. Not everyone has every bucket — it depends on your employer and whether you have 1099 / self-employed income. All figures are 2026.
Employer match → then the HSA
Capture the full employer match first — an instant 50–100% return no investment can beat.
Then the Health Savings Account, the only triple-tax-free account in the code: $4,400 self-only / $8,750 family, plus a $1,000 catch-up at 55+. Pay medical bills out of pocket, let it grow as a stealth retirement account, reimburse yourself decades later.
401(k) / 403(b) + governmental 457(b)
Employee deferral: $24,500. Catch-up +$8,000 at 50+, or a SECURE 2.0 super catch-up of +$11,250 at ages 60–63.
If you have a governmental 457(b) (many hospital/academic docs do), it stacks with its own $24,500 — the most underused doubling move for employed physicians.
Backdoor Roth IRA
Direct Roth contributions phase out long before attending income — so use the back door: contribute to a nondeductible Traditional IRA ($7,500, no income limit), then convert to Roth. Do it for your spouse too. Mind the pro-rata rule (Form 8606): clear old pre-tax IRA balances into your 401(k) first.
Mega Backdoor Roth
The hidden gem. The total §415(c) annual-additions limit is $72,000 ($80,000 with catch-up; $83,250 for ages 60–63). If your plan allows after-tax contributions with in-plan Roth conversion, you can funnel the gap between your deferral + match and $72K straight into Roth.
Solo 401(k) · SEP-IRA · Cash-Balance Plan
Moonlighting or locums? A Solo 401(k) lets you add employer profit-sharing up to the same $72,000 cap. A cash-balance / defined-benefit plan is the heavy artillery for high-earning practice owners — actuarial contributions can reach $100K–$300K+ pre-tax in peak years.
Taxable brokerage · 529 · I-Bonds
The taxable account has no limit, full liquidity, favorable long-term capital-gains rates, and tax-loss harvesting — for high earners this is where most money eventually lives. Add 529 plans for tuition (state deductions vary) and I-Bonds at $10,000/person/year for inflation-protected safe money.
| Account | 2026 limit | Catch-up | Notes |
|---|---|---|---|
| 401(k) / 403(b) deferral | $24,500 | +$8,000 (50+) +$11,250 (60–63) | High earners' catch-up must be Roth if prior-year FICA wages > $150,000 |
| Governmental 457(b) | $24,500 | +$8,000 | Stacks on top of your 401(k)/403(b) |
| HSA (with HDHP) | $4,400 / $8,750 | +$1,000 (55+) | Self-only / family · triple-tax-free |
| IRA / Backdoor Roth | $7,500 | +$1,100 (50+) | No income limit on the nondeductible → convert path |
| §415(c) total additions | $72,000 | $80,000 / $83,250 | Employee + employer + after-tax (enables mega backdoor) |
| SEP-IRA / Solo 401(k) | up to $72,000 | — | Up to 25% of comp; Solo 401(k) preferred for backdoor users |
| Compensation cap | $360,000 | — | Max comp counted for plan formulas |
| Filing status | Full contribution | Phase-out | No direct contribution |
|---|---|---|---|
| Single / HoH | < $153,000 | $153K–$168K | > $168,000 |
| Married filing jointly | < $242,000 | $242K–$252K | > $252,000 |
| Married filing separately* | — | $0–$10K | > $10,000 |
*If you lived with your spouse at any point in the year. Above the ceiling, the backdoor Roth is still open to everyone.
The prescription · 03
Example portfolios to fill them
Once the accounts are set, the investments can be genuinely simple. The evidence favors low-cost, broadly diversified index funds. Here are five model allocations from simplest to most tilted — substitute your brokerage's equivalent funds for the tickers.
A · One-Decision
- VT / target-date100%
B · Three-Fund
- VTI · US60%
- VXUS · Intl30%
- BND · Bonds10%
C · Mid-Career Tilt
- VTI · US45%
- VXUS · Intl20%
- AVUV · SCV10%
- VNQ · REIT5%
- BND · Bonds20%
D · Near Retirement
- VTI · US35%
- VXUS · Intl15%
- VNQ · REIT5%
- BND · Bonds30%
- SCHP · TIPS15%
E · Core + Satellite
- Broad core (A–D)85%
- Healthcare sleeve15%
Portfolio A is a one-fund answer that even rebalances itself — there's no shame in it; it beats most professionals. The small-value tilt in C is optional and only worth it if you'll hold through the years it underperforms (and it will). Near retirement, the point of bonds and TIPS is sequence-of-returns protection — enough safe assets that a bad first year doesn't force you to sell stocks low.
The secret sauce: asset location
Same funds, smarter placement, free after-tax return. Run your allocation as one portfolio across all accounts — not fund-by-fund:
Tax-deferred 401(k)
- Bonds (BND)
- REITs (VNQ)
- Anything that throws off income taxed at your high rate
Roth (back / mega)
- Highest-growth assets
- Small-cap value
- Your most aggressive sleeve
Taxable brokerage
- Broad index (VTI / VXUS)
- Foreign tax credit
- Tax-loss harvesting
The specialty consult · 04
If you want a healthcare & biotech sleeve
You understand this sector better than almost any other investor. The lowest-effort way to express that is a diversified healthcare or biotech ETF, which spreads single-company risk across dozens or hundreds of names. Keep the whole sleeve to ~10–15% of the portfolio.
| Ticker | Fund | Type | ~Expense | Profile |
|---|---|---|---|---|
| VHT | Vanguard Health Care | Broad healthcare | ~0.09% | ~400 holdings, cheapest & broadest |
| XLV | Health Care Select SPDR | S&P 500 healthcare | ~0.08% | Mega-cap: Lilly, UNH, J&J |
| FHLC | Fidelity MSCI Health Care | Broad healthcare | ~0.08% | VHT-like, Fidelity platform |
| IBB | iShares Biotechnology | Biotech (cap-weighted) | ~0.45% | "Tamer" — Amgen, Gilead, Vertex |
| XBI | SPDR S&P Biotech | Biotech (equal-weight) | ~0.35% | Higher-octane, small-cap heavy, M&A upside |
| ARKG | ARK Genomic Revolution | Active / genomics | ~0.75% | Speculative CRISPR & gene-editing tilt |
If you'd rather own specific companies, the table below lists names carrying Strong Buy or favorable analyst consensus in mid-2026 (per Morningstar, Zacks, Morgan Stanley, Citi, and William Blair). The two highlighted rows sit squarely in your clinical wheelhouse. Ratings and prices move constantly — verify before acting.
| Ticker | Company | Focus | Signal |
|---|---|---|---|
| CYTK | Cytokinetics | Aficamten for HCM — your ACACIA-HCM read | Strong Buy · Citi top pick |
| LQDA | Liquidia | Pulmonary hypertension | Zacks #1 Strong Buy |
| IONS | Ionis Pharmaceuticals | Antisense; lipid franchise | Strong Buy · Citi pick |
| JAZZ | Jazz Pharmaceuticals | Neuro / oncology | Strong Buy consensus |
| ASND | Ascendis Pharma | TransCon endocrine | MS Overweight |
| BMRN | BioMarin | Rare genetic disease | Undervalued (Morningstar) |
| EXEL | Exelixis | Oncology | Consensus Buy |
| EYPT | EyePoint | Retinal disease (pre-readout) | ~85% Strong Buy* |
| KRYS | Krystal Biotech | Gene therapy | William Blair 2026 |
| NTLA | Intellia | CRISPR (speculative) | High risk |
*Clinical-stage names are call-options-on-science. No single one should be large enough that a failed trial changes your retirement date.
The plan · 05
Putting it together
A married attending couple — one $400K income, employer 403(b) + governmental 457(b), an HDHP, and some 1099 moonlighting — could fill, in order:
- 403(b) to full match, then max $24,500
- Governmental 457(b) → $24,500
- HSA → $8,750 family
- Backdoor Roth → $7,500 × 2 (self + spouse)
- Mega backdoor (if the 403(b) allows after-tax) toward $72,000
- Solo 401(k) on the 1099 income · then taxable brokerage in VTI/VXUS · then 529s
That's potentially $100K+ into tax-advantaged space before the taxable account even starts — exactly how high earners build a portfolio that funds an early, comfortable retirement.
The five rules that matter more than any ticker
- Save 20%+ of gross. Savings rate is the engine.
- Capture every match, max every tax-advantaged account in the order above.
- Own the whole market cheaply — expense ratios under ~0.10%.
- Locate assets tax-smartly and rebalance once or twice a year.
- Write the plan down and stop tinkering. Boring discipline wins.
The doctor who automates a diversified portfolio and ignores it usually retires more comfortably than the one chasing every "strong buy." Your time is worth more in the cath lab than in a brokerage app.
References & further reading
- IRS — 2026 contribution limits (IR-2025-111), catch-up rules & §415(c) COLA notice
- Vanguard / Fidelity — Roth IRA income limits & 401(k) limits 2026
- Bogleheads — three-fund portfolio & tax-efficient fund placement; The White Coat Investor
- Morningstar, Motley Fool, U.S. News, Zacks, Citi & William Blair — 2026 healthcare/biotech coverage
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