After residency, most physicians spend several months navigating a dense checklist of licensing, credentialing, and career decisions before they start practicing independently. The transition from trainee to attending physician involves securing a full medical license, obtaining board certification, negotiating an employment contract, and managing significant financial changes, often all at the same time. Whether you plan to enter practice right away or pursue fellowship training, the months surrounding residency completion are some of the busiest of your medical career.
Choosing Between Practice and Fellowship
The first major fork in the road is whether to start working as an attending or to continue training in a subspecialty. Fellowship adds one to three years of additional training depending on the field, and applications typically run through the Electronic Residency Application Service (ERAS). The fellowship application cycle opens in early summer, with a July submission window and a second cycle starting in November. If you’re considering a subspecialty like cardiology, gastroenterology, or hematology/oncology, you’ll need to plan well before your final year of residency, since applications and interviews overlap with your last months of training.
Choosing fellowship isn’t purely an academic decision. Subspecialists often earn significantly more than generalists. The average starting salary for a gastroenterologist is $552,000, compared to $292,000 for an internist or $275,000 for a family medicine physician. But those extra years of training also mean extra years of relatively low pay and continued student loan accumulation, so the financial calculus depends on your specialty and debt load.
Getting Your Full Medical License
During residency, you practiced under a training license or permit issued by your state. To work independently as an attending, you need a full, unrestricted state medical license. This requires proof that you’ve passed all three steps of the USMLE, along with verification of your medical education, graduate training, exam scores, references, and any prior hospital privileges.
The application process takes at least two months from submission to approval, and often longer. Peak application season runs from April through September, exactly when most finishing residents are applying, so processing delays are common. International medical graduates should expect additional time. Starting your application early in your final year of residency, ideally three to four months before your expected start date, helps prevent a gap between finishing training and being cleared to practice.
Board Certification
Board certification is technically optional, but most employers and hospitals require it or expect you to obtain it within a set window after hiring. To sit for the exam, you need a completed residency with letters of attestation from your program director, an unrestricted medical license, and a medical degree from an accredited school. Each specialty board sets its own exam schedule, format, and eligibility rules.
The exam itself is typically offered in the months following residency completion. Some specialties use a single written test, while others include an oral examination or a practice-based assessment component. If you plan to pursue subspecialty certification later, you’ll first need to hold your primary specialty board certification, then complete fellowship training and pass an additional subspecialty exam.
Navigating Your First Employment Contract
Your first attending contract will likely be the most complex legal document you’ve signed, and it deserves careful review, ideally with a lawyer who specializes in physician contracts. Most contracts include a base salary plus a production bonus tied to your clinical output, measured in relative value units (RVUs). RVUs reflect the complexity and time involved in each patient encounter, and your employer will set annual benchmarks you’re expected to meet. For context, a family physician seeing about 20 patients a day over 220 working days might generate roughly 7,400 work RVUs per year.
Two contract provisions deserve special attention. The first is a non-compete clause, which restricts where you can practice if you leave the job. These clauses vary in geographic scope and duration, and they can limit your options significantly if you decide to change employers or start your own practice in the same area. The second is malpractice tail coverage, which pays for claims filed after you leave a position for incidents that occurred while you worked there. If your employer carries “claims-made” malpractice insurance and the contract doesn’t cover the tail, you could owe tens of thousands of dollars when you move on. Clarifying who pays for tail coverage before signing saves painful surprises later.
What You’ll Earn as a New Attending
The average starting salary across all physician specialties is roughly $403,000, based on recruiting data from 2024 to 2025. That number masks enormous variation by field. Some of the highest-paying specialties for new attendings include orthopedic surgery at $576,000, radiology at $551,000, and gastroenterology at $552,000. On the lower end, pediatrics averages $258,000, family medicine $275,000, and hospital medicine $279,000.
Most offers also include a signing bonus and relocation allowance, though amounts vary widely by employer and region. Beyond the headline salary, it’s worth comparing benefits like retirement contributions, loan repayment assistance, paid time off, and the productivity thresholds that trigger bonus pay. A slightly lower base salary with generous RVU bonuses can outperform a higher base with aggressive production targets.
Managing Student Loan Debt
The jump from a resident’s salary to attending-level income changes your loan repayment picture dramatically, and the decisions you make in the first year matter. If you’ve been making payments on an income-driven repayment plan during residency and working for a qualifying nonprofit or government employer, those payments count toward Public Service Loan Forgiveness (PSLF). PSLF requires 120 qualifying monthly payments while employed full-time by an eligible employer, after which the remaining balance is forgiven.
If you take an attending position at a qualifying employer (most academic medical centers, VA hospitals, and nonprofit health systems count), your residency payments carry over. You should submit the PSLF form annually and whenever you change employers so the Department of Education can verify your employment and track your payment count. Keep your own records too, and check that your count matches what the government reports. Borrowers who move to a private practice or for-profit employer lose PSLF eligibility going forward, though previously qualifying payments still count if they later return to a qualifying employer.
For those not pursuing PSLF, the higher attending salary makes aggressive repayment feasible. Many financial advisors suggest continuing to live on something close to a resident’s budget for the first one to two years and directing the difference toward loans, especially those carrying interest rates above 5 or 6 percent.
Credentialing and Prescribing Privileges
Even after you have a license and a signed contract, you can’t start seeing patients until your new employer completes the credentialing process. This involves the hospital or health system verifying your training, malpractice history, and license status. Credentialing commonly takes two to four months, and delays can push back your actual start date, so initiating the process as early as your employer allows is important.
You’ll also need your own DEA registration to prescribe controlled substances independently. During residency, you likely practiced under your institution’s DEA number. As an attending, you apply separately using DEA Form 224. The registration is tied to a specific state and practice address, so if you relocate, you’ll need to update it. Many physicians apply for their DEA number alongside their state license to avoid any gap in prescribing authority.
The Adjustment to Independent Practice
Beyond paperwork, the shift from resident to attending is a psychological recalibration. You no longer have an attending backing up your decisions. The consults you once requested are now being requested of you. Many new attendings describe the first few months as a period of heightened anxiety, even in areas where they’re clinically competent, simply because the safety net of supervision is gone.
The administrative burden also increases. You’ll be responsible for completing documentation in a timely manner to support billing, understanding how your clinical decisions translate into RVU generation, and managing your own schedule in ways residency didn’t prepare you for. Most large employers offer onboarding that covers their electronic health record system, billing workflows, and compliance expectations, but the learning curve is real. The physicians who transition most smoothly tend to be the ones who ask questions freely, lean on colleagues, and accept that the first six months feel harder than they expected.