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Doctors frequently juggle two separate income streams: a steady salary from a hospital or academic setting, and revenue from a private practice or consulting engagements.

Even though the two income streams are taxed differently, the overall tax picture can be complicated, especially when including self‑employment tax, health‑insurance premiums, retirement contributions, and state‑specific rules.

This guide outlines essential tax considerations for balancing salary and practice income, providing actionable strategies to reduce your tax bill and boost your take‑home earnings.

Comprehending the Two Income Streams

Wage Income

If you work as an employed physician—whether at a hospital, clinic, or university—you obtain a salary that is subject to payroll deductions.

Included are federal income tax, Social Security tax, Medicare tax, and, if applicable, state and local taxes.

Your employer usually withholds the appropriate amount regularly, and you receive a W‑2 by year‑end.

Self‑Employment Income

In contrast, income from a private practice, consulting, or other self‑employment activities is reported on Schedule C (or a partnership return if the practice is a partnership) and is subject to self‑employment tax in addition to income tax.

Self‑employment tax includes both employee and employer shares of Social Security and Medicare, amounting to roughly 15.3% of net earnings.

Nonetheless, you may deduct the employer portion (7.65%) in computing your adjusted gross income, thereby lowering taxable income.

Key Distinctions to Remember

Tax Withholding: With salary income, taxes are automatically withheld; with practice income, you might have to make quarterly estimated payments.

Deductions: Practice income offers more opportunities for business deductions (office rent, equipment, supplies, mileage, professional liability insurance, continuing education).

Retirement Contributions: Salary income may be funneled into employer‑sponsored plans (403(b), 401(k), etc.), whereas practice income can be channeled into a solo 401(k), SEP‑IRA, or SIMPLE IRA.

Health Insurance: For premiums paid out of practice income, you might be able to deduct health insurance on your personal return.

Self‑Employment Tax: Only practice income is taxed for self‑employment, yet deductions help offset some of it.

Planning for Quarterly Estimated Taxes

Because salary taxes are withheld, you typically need to worry less about quarterly tax payments unless you have significant practice income that isn’t fully withheld.

Estimate your total tax liability for the year by adding your expected salary and practice income, then subtracting any deductions and credits.

Should your practice income be substantial enough that you expect to owe over $1,000 in tax at year‑end, quarterly payments will probably be necessary.

The IRS provides a worksheet (Form 1040‑ES) to help calculate these payments.

Maximizing Deductions on Practice Income

Office Space
• Rent, utilities, and office supplies can be fully deductible if the space is used exclusively for business.
• If you work from home, a suitable part of your home expenses (mortgage interest, property taxes, utilities, internet) can be deducted as a home office.

Mileage and Transportation
• Track all business mileage in a logbook or use an app. The IRS standard mileage rate is $0.655 per mile for 2025.
• Or, deduct actual expenses (gas, maintenance, depreciation) if they surpass the standard rate.

Professional Development
• Continuing medical education (CME) courses, conferences, and certifications are deductible.
• Keep receipts and confirm that the courses are needed or useful for your practice.

Equipment and Technology
• Computers, medical devices, software licenses, and phones used for patient communication are deductible.
• For large purchases, consider depreciation (MACRS) or Section 179 expensing.

Insurance
• Malpractice insurance premiums are fully deductible.
• Practice‑related health insurance premiums for you and employees may be deducted as a business expense.

Employee Compensation
• Hiring staff (nurses, medical assistants, billing clerks) makes their salaries deductible.
• Payroll taxes paid by the practice are also deductible.

Retirement Planning for Dual Income

Salary Portion
• If your employer offers a retirement plan, contribute up to the maximum allowed ($22,500 for 2025, plus $7,500 catch‑up if 50+).
• Employer matching contributions add benefit without tax penalty.

Practice Portion
• You can create a solo 401(k) or SEP‑IRA for practice income, contributing up to 25% of net self‑employment income, up to $66,000 (or $73,500 if 50+).
• A solo 401(k) additionally lets you take a salary from your practice, which can reduce self‑employment tax because the salary portion is subject to only the employee portion of payroll taxes.

Health Insurance Deductions
• Self‑employed individuals may deduct 100% of health‑insurance premiums on their personal return (Form 1040, Schedule 1).
• This deduction is not limited to a percentage of your income and can significantly lower your adjusted gross income.

State‑Specific Considerations
• New York and California have high state income taxes and additional physician taxes. Check whether your state imposes a separate tax on medical professionals.
• Some states grant a deduction for out‑of‑state physicians meeting residency requirements.
• State health‑insurance mandates can necessitate extra forms (e.g., California’s SDI for self‑employed).

Avoiding Common Pitfalls

Under‑Withholding
• Don’t depend solely on salary withholding for practice income; use the IRS’s Tax Withholding Estimator to adjust your W‑4 or make quarterly payments.

Improper Tracking
• Keep meticulous records of all business expenses. Digital receipts, a dedicated bank account, and regular reconciliation help avoid audit issues.

Overlooking Deductions
• Physicians often overlook deductions for student loan interest, continuing‑education tuition, or charitable contributions tied to their practice.

Ignoring Tax Credits
• The Qualified Business Income (QBI) deduction can provide up to a 20% reduction on qualified income. Ensure you qualify and claim it.

Failing to Update Your Tax Strategy
• Laws shift annually. Conduct an annual review of your tax strategy, particularly after changes in income, expenses, or life events (marriage, children, etc.).

Putting It All Together: A Sample Planning Scenario

Dr. Lee earns $300,000 in salary from a teaching hospital and runs a private practice that nets $200,000 after expenses. Here’s how the tax picture might look:
• Salary: $300,000 subject to payroll withholding. No self‑employment tax.
• Practice: $200,000 net income. Self‑employment tax on $200,000 (15.3% = $30,600). Deduct employer portion (7.65% of $200,000 = $15,300) from AGI.
• Total taxable income before deductions: $300,000 + $200,000 – $15,300 = $484,700.
• After standard deduction ($14,600 for married filing jointly), taxable income: 節税対策 無料相談 $470,100.
• Federal tax: Approximately $120,000 (using 2025 brackets).
• Self‑employment tax: $30,600.
• Total tax: $150,600.

To reduce this burden, Dr. Lee could:
• Contribute $22,500 to a 403(b) from salary.
• Max out a solo 401(k) with $66,000 from practice income.
• Deduct $15,300 employer portion of SE tax.
• Deduct health‑insurance premiums.
• Use Section 179 to expense new imaging equipment ($40,000) in the first year.

After these adjustments, the taxable income shrinks, and the overall tax bill could drop by tens of thousands of dollars.

Final Thoughts

Balancing salary and practice income involves careful taxation, deduction maximization, and financial planning.

Treating each stream per its distinct tax rules, keeping meticulous records, and using retirement and health‑insurance options helps physicians lower tax liability while maintaining healthy cash flow for both employment and entrepreneurial ventures.

Regular consultation with a tax professional who understands the medical field is also invaluable; they can spot opportunities and pitfalls that might otherwise slip through the cracks.

With the right strategy, you can keep more of what you earn and focus on what matters most—providing excellent patient care.