The offer letter said $300,000. The first direct deposit, three or four weeks after you started, is a fraction of what you divided that number into, and rent is due Friday. A resident on Reddit this week asked attendings what their first check looked like, hoping for a number worth pushing toward. The more useful question is what comes off it and when, because the month you switch from resident to attending pay is one of the money moments our guide to surviving residency keeps coming back to. An earlier post covered the cash gap between your last resident check and your first attending one. This one starts the day the first stub arrives. It is general education, not tax or financial advice; a physician-focused CPA is worth an hour once you have a signed contract and a start date.
Four payroll questions to ask before day one
Most of month one’s surprise is timing, which you can learn in advance. Email your recruiter or HR contact after you sign: “Before I start, could you confirm four things: my first pay date and whether pay runs in arrears, when the sign-on bonus is paid and whether it comes as a separate check, the date my health and disability coverage take effect, and whether retirement enrollment is automatic and at what percentage?” Ask for the employer’s legal name and EIN in the same email if you plan to pursue Public Service Loan Forgiveness. PSLF eligibility depends on which entity actually employs you, which is the one on your W-2, and a for-profit group staffing a nonprofit hospital is not the same as the hospital.
Reading the first stub line by line
Take that $300,000 salary paid every two weeks: $11,538 gross per check. Social Security takes 6.2%, about $715, and Medicare takes 1.45%, about $167. Those two never change with your W-4. A 10% contribution to the 403(b) or 401(k) takes another $1,154. The 2026 employee limit for 401(k), 403(b) and most 457 plans is $24,500, and many hospital employers offer both a 403(b) and a 457(b), so the retirement line can grow quickly once you decide how much to put away. That leaves about $9,500 before health premiums, dental and vision, group disability, and federal and state income tax. All of those still come out.
Check three things on that stub: that the salary matches the contract, that the retirement percentage is the one you chose rather than a default, and that benefits you declined are not being deducted. An error caught on the first stub costs one email; caught in April, it costs a year of corrections.
Why the sign-on bonus arrives lighter than promised
When a bonus is paid separately from salary, employers usually withhold federal income tax at a flat rate. The IRS’s 2026 Publication 15 confirms that the supplemental wage rate remains 22%, rising to 37% only on supplemental pay above $1 million in a year. Add Social Security, Medicare and state tax, and a $30,000 sign-on can land closer to $20,000. In the start year, when half your income was a resident salary, 22% may be close to what you will owe. In a full attending year, check your bracket: if it is above 22%, a bonus paid then can leave a balance due in April.
The split year: over-withheld now, a refund later
Payroll calculates withholding as if every check were one slice of a full year at that rate. For a resident who earned six months of PGY pay before switching, that tends to withhold more than the year’s actual tax, so the extra comes back as a refund the following spring. That is money you could have used in the tightest months. The IRS’s withholding guide for employers, Publication 15-T, points employees who work only part of the year to the IRS Tax Withholding Estimator. Run it with your real resident and attending figures before changing your W-4, and if moonlighting, a spouse’s income or a bonus is in the mix, let the CPA make the call.
Loan payments lag your new salary
Under the Repayment Assistance Plan, the monthly bill is based on your adjusted gross income from the previous tax year and recertified annually, and those payments still count toward PSLF. The first attending months are often billed on resident income. If you are on a PSLF track, that is a window of low qualifying payments, not a mistake to correct. If you are not, our earlier breakdown of extra RAP payments explains when paying more actually reduces the balance. Either way, calendar your recertification date so the attending-income bill does not arrive unannounced.
Your net pay changes twice in the first full year
Social Security tax applies only to the first $184,500 of wages in 2026. On $300,000 of Social Security wages paid biweekly, that cap is reached on the 16th check, and every check after it is about $715 larger. Then, once wages from one employer pass $200,000, your employer must withhold an extra 0.9% Medicare tax, starting with the 18th check, which trims about $104. The fall checks run about $600 larger than the spring ones, and they shrink again in January. Budget from the spring number. The late-year bump is not a raise.
Build the budget from the second stub
The first check is distorted by a partial pay period and one-time deductions. The second full, ordinary stub is the first honest number you will see. Before committing to a lease, a car payment or a mortgage pre-approval sized to your offer letter, wait for that stub and multiply its net by 26, or by 24 if you are paid twice a month. That figure, not the salary in your contract, is what you have to spend, and every fixed payment you sign up for in the first 90 days is measured against it.