<p>Previous research suggests that socioeconomic factors may influence a physician’s career choices, yet the link between pre-medical socioeconomic status and practice setting after graduation remains unclear. This study aims to clarify this relationship by investigating how pre-medical neighborhood income and multidimensional deprivation predict whether physicians pursue academic or community-based practice. We conducted a retrospective cohort study with students matriculating between 2011 and 2013 at a medical school in Canada. Pre-medical neighborhood income quintiles and deprivation levels, using the Canadian index of multiple deprivation (CIMD), were calculated from their high school postal codes. Practice data were sourced to compare academic versus community-based practice across different levels of pre-medical neighborhood income and deprivation. Logistic regression analysis explored average deprivation scores as predictors of practice setting. From 372 physicians with data available at both time points, we found no significant association with pre-medical income quintile and practice setting (<i>p</i>&#xa0;=&#xa0;0.587). However, higher composite deprivation scores (more marginalization) were associated with a 1.5 times greater likelihood of practicing in an academic setting. Multidimensional marginalization significantly influences pathways to academic practice, while physicians from rural high schools were significantly more likely to practice in rural settings. These findings underscore the need for a nuanced understanding of deprivation and geographic background in shaping medical career trajectories.</p>