Your medical training has been designed to prepare you for the clinical conundrums of an attending physician, but it probably hasn’t prepared you much for negotiating your physician contract before getting the job. This lack of training leads some physicians to skip negotiation completely. Unfortunately, this often means accepting subpar contract terms—like noncompetitive compensation, an untenable schedule or, perhaps worst of all, no way out of the deal. 

“I completed medical school, anesthesiology residency and two fellowships, yet I received no formal education in negotiation,” says Elisha Peterson, MD, an anesthesiologist and pain medicine physician based in Washington, D.C. “I still saw myself as a trainee. The person interviewing me was a department chair, and when I received a job offer, I didn’t feel like I was on equal footing. …The power dynamic made it feel as though negotiating wasn’t even acceptable.”

The truth is, negotiating is not just acceptable but necessary, and reasonable employers understand this. Here you’ll hear from physicians, healthcare attorneys and contract advisors who’ve navigated the contract negotiation process many times over. You’ll learn not only why to negotiate but also how and when, plus which terms are most likely to change or remain the same. Ultimately, successful negotiations are all about ensuring a contract is worth signing and, when it’s not, empowering you to confidently walk away.

When to negotiate (and when to wait)

If you’re actively in talks with an organization but haven’t yet received an offer or contract, you may be wondering at what point to broach typical negotiation topics such as salary or the path to partnership. It’s helpful to remember there are negotiations, and then there are negotiations. 

“Typically, you would not bring up the contract negotiation discussion until you have been presented with an offer from the practice, which will typically include a contract,” says Ryan Mire, MD, a Nashville-based internal medicine physician, partner of Heritage Medical Associates and physician educator for Resolve, a physician contract review company. “However, there are important considerations, such as salary, call schedule, productivity models, practice locations and external duties a candidate can inquire about prior to being offered a formal contract.” 

In other words, bring up important topics from the get-go, but save formal negotiations until you have some paperwork in hand. Whether to wait for the contract itself or to begin negotiations upon receiving an offer or letter of intent is subject to your own discretion. 

“If they are comfortable [negotiating] at an early stage like a letter of intent or offer, that is great, and if they are more comfortable getting the whole picture or all of the contract terms, negotiations can be at that stage as well,” says Jackie Crain, JD, associate contract review specialist with Contract Diagnostics, a physician contract review consultancy. 

One argument in favor of starting earlier is some employers consider any signature to be an agreement. “Many employers feel if you sign the [letter of intent], you are agreeing to all terms in that document, even if it states ‘non-binding,’” says Contract Diagnostics founder and CEO Jon Appino, “so get advisors and start questioning and asking early in the process.”

Why to negotiate—betting on yourself

If your contract looks decent from the get-go or the employer has insinuated the document is unlikely to change, it may be tempting to sign as-is. After all, this allows you to avoid the potential awkwardness of the back and forth. Experts agree, however: You should always negotiate—even if you’re fresh out of training and facing down debt. 

“The contract is intended to protect the practice and not the potential new physician,” says Neil Baum, MD, a New Orleans-based urologist and professor at Tulane Medical School. The onus is on you and your attorney to make sure the contract also protects you. Those who don’t—an alarming number—are likely leaving time, money and future prospects on the table.  

“While working in-house at a large physician practice company, I saw 95% of physicians sign their contracts immediately when the company would [have made] 20 changes when asked,” says Peter Levine, now a senior contract review specialist at Contract Diagnostics. This willingness on employers’ parts to change terms does not typically last after the contract has been signed, however; capitalize on it while you can.   

How to negotiate—and whom to involve

Work with a healthcare attorney or contract review expert.

Involving a contract expert is likely the single most important step in navigating your negotiations. Unless you’re one of the small percentage of physicians who completed an MD/JD program, you likely were not trained to decipher legal jargon. 

“Just as a lawyer is out of their comfort zone in a medical office or the operating room, a doctor attempting to negotiate a contract is a fish out of water,” says Baum. “A lawyer with experience in healthcare negotiations is worth the expense.” 

Mire, too, emphasizes every physician needs professional contract review, not simply those taking their first attending job. “You can use an independent employment agreement attorney or a company that might provide additional services outside of the employment agreement, such as access to salary data, trends in geographic regions, etc.,” says Mire, who reiterates you need an attorney experienced in employment agreements specifically.

“On average, [contract review by an attorney] is usually about a thousand bucks, maybe $1,500,” says Amanda Hill, JD, a Texas-based healthcare lawyer and owner of Guard My Practice, who estimates the review process and back and forth typically take less than a month. 

Consider what you’re leaving on the table if you don’t engage an expert. 

“If you don’t know, for example, that terminating your contract will require you to pay all the signing bonus back or purchase your own tail insurance…or if they can accelerate your last day of employment and not pay you for the full notice provided, the cost of your termination can be high,” says Laura Viozzi, JD, associate contract review specialist for Contract Diagnostics. “The cost of hiring a professional to review the agreement will save you many thousands of dollars.” 

Gather data about what’s standard at other practices

To be successful in negotiations, you likely want to gather some current, specialty-specific data about what’s typical among other employers.

“Before negotiating on salary, it is helpful for the physician to know the salaries that other physicians with similar experience and training have received. Now the new physician has a range they can use,” says Baum. 

You can access such salary data from resources like Medical Group Management Association’s annual Provider Compensation Data, Medscape’s physician compensation reports and specialty organization publications. You can also use Resolve’s free physician compensation tool in the resource center at PracticeLink.com/resource-center.

“Another ‘sticky wicket’ is the road to partnership,” says Baum. “Again, the physician should know what other practices, hospitals or private equity firms in the geographic area use for the length of time that is necessary before being considered as a partner [and] how long the new physician must wait to be vested in the practice.” 

For these types of details—or other topics such as typical schedule or time off—don’t discount how much information you can gather simply by picking the brains of other physicians. 

“Talk to physicians who’ve already accepted jobs at the institution you’re considering. Ask them what they were able to negotiate,” says Peterson. You can also ask other physicians who trained with you or reach out to connections practicing in the same city or region.  

Negotiating

Throughout negotiations, it’s tempting to rely solely on email communication—but you are likely to get a better result with a phone call or in-person meeting. After all, negotiations are less of a tennis match and more of a conversation.  

“Do not just send a redline copy [of the contract] back,” says Appino. A contract with dozens of tracked changes can signal you are trying to rewrite the agreement rather than negotiate. “Employers do not want or appreciate this,” he says. “Discussions via phone are best, followed up with documentation in an email.” 

Some physicians may hesitate to negotiate with their future employer on their own behalf, but if you’re up for it, this typically sends the best signals.

If you think you’ll be too timid and back down in the moment, however, letting your lawyer do the negotiating is a different tack you can take. 

“This is what we do for a living, so it does not bother me in the least to push back,” says Hill of handling the negotiating on a physician’s behalf. “I think sometimes doctors…feel like they’re greedy, [but] this is business. If you’re feeling uncomfortable, let your lawyer be the bad guy.” 

Share the why and practice your asks

Transparency about your requests can help employers understand things from your perspective, ensuring your asks seem anything but arbitrary. 

“I would advise physicians who are entering into a negotiation to be transparent and give the background or the ‘why’ behind the request,” says Crain. “This way, the negotiation request is really just their story of why they need additional PTO or why they believe the data or circumstances support a compensation increase, signing bonus or relocation allowance.” 

Your “why” will make it harder for employers to turn down a request without fully considering it—and may indicate you’re willing to walk if another employer can provide what they can’t. Prepare in advance by practicing the conversation with a colleague or friend, and anticipate you may be asked why you think a change to the contract is warranted.

As Anu Murthy, JD, senior contract review specialist at Contract Diagnostics, puts it, “Practice your asks before you enter into the negotiation. …Try to anticipate what their answers might be, and be prepared to justify your asks.” 

What to negotiate—from the common to the commonly overlooked

When handed a multipage document with a headache-inducing number of terms and provisions, it helps to know the most important topics to address during negotiations. These will differ for everyone, but some of the most universally important—and sticky—are compensation details and exit terms.

“[What] the doctor needs to pay attention to is, first, compensation,” says Hill. “How much are you getting paid? How are you getting paid? Is it a flat-rate salary? Is it ‘eat what you kill’ based on production? Is it a combination of the two? What are your bonuses? What is all the money that’s going to land in your pockets? And from what way? It doesn’t really matter, in my opinion, how many buckets you put it in, but at the end of the day, what are you taking out?” 

Compensation

As Hill indicates, a physician’s compensation model can differ greatly based on their employment situation, and total compensation may come from a combination of sources. Don’t make the mistake of looking at your first-year guaranteed salary and assuming it’s the number you’ll receive moving forward. 

“Compensation models are extremely critical to understand,” says Mire. “A very common mistake for physicians is to just focus on the salary and not understand the productivity model (e.g., RVU or collections). A higher salary can still cause you to leave money on the table if the productivity formula requires more work in order to achieve the productivity bonus.” 

To negotiate compensation effectively, you need to understand your total compensation, how attainable it is and what’s standard for your level of experience and area. 

“Salary, wRVUs and bonuses are all set up differently and have different salary survey medians,” says Levine. “But for each, the physician should look to be compensated at least at the median based on the data.” 

Exit terms

It may sound pessimistic to focus on exit terms when you’re joining a practice, but no job lasts forever. Protect yourself by learning—and negotiating—what might hit you on the way out. 

“No one signs a contract thinking they are going to leave, but being able to mitigate risk when the time does come is crucial,” says Selena Kanetkar, JD, senior contract review specialist at Contract Diagnostics.

Make sure not to overlook: 

Termination terms. How much notice are you required to give the employer if you decide to leave? How much notice must they give you, and for what reasons are they allowed to terminate you? 

Costs of termination. How long will you continue to be compensated if you’re terminated? How long will you continue to receive benefits? Will you have to pay back a sign-on bonus or stipend? Who will cover the cost of your tail insurance? 

Restrictive covenants, especially non-competes. How sweeping is the non-compete in terms of time and geography? Do radius restrictions apply to a specific location, or do they apply to an entire health system? Would the non-compete effectively prevent you from practicing without a major move? 

Knowing what’s negotiable and what’s not

So which contract terms have wiggle room and which are set in stone? Employers may tell you a certain topic is non-negotiable, but experts disagree with this take. 

“If [a contract term] is very important to you, you should attempt to negotiate,” says Mire. “In most instances, employers would prefer to have a standard employment agreement for all employees… [but] there is always an opportunity to negotiate components of the agreement, especially if they are deal-breaking topics that will affect your acceptance of the job offer.” 

Appino reiterates the same. “Even if the employer states it is not negotiable or states nothing will change, we always feel many, many questions should be asked when a physician conducts due diligence on an offer,” he says. “I feel all aspects of a contract should be questioned, and anything that may have room to move should be requested.” 

Typically, the most negotiable topics include start date, compensation, bonuses and stipends, schedule, call and time off. Less negotiable topics include health insurance and benefits (which tend to be standardized for an organization) and restrictive covenants, although this may be changing.

“Non-competes historically have not been [negotiable], though I am seeing a shift here,” says Kanetkar. Because laws around non-competes differ from state to state (another reason to engage an attorney), they may be more negotiable in some places than others. 

Identifying your must-haves and nice-to-haves

In addition to knowing what you can negotiate, it’s important to decide what you want to negotiate—and how much it matters to you.

“Each candidate will have to decide which topics in the negotiation are deal breakers, and if there is no ability to compromise on those terms, it may be time to consider other opportunities,” says Mire, who advises candidates to have two lists: absolute must-haves and nice-to-haves. “Typically, it will be the must-have list that would lead one to walk away from the opportunity if there is a roadblock in the negotiation.”

It could be your must-haves are related to schedule, support and workload, so an unmet salary figure isn’t a reason to walk away. As you determine must-haves versus nice-to-haves, don’t focus so heavily on present must-haves you forsake what will feel like a must-have in the future. 

“The most common mistake I have witnessed with a first employment contract is the physician only focusing on present issues, such as starting salary, call schedule, vacation, relocation and signing bonus,” says Mire. “Essential considerations also involve negotiating on topics that may not affect you immediately and will have more impact on your potential earning income such as productivity bonus models (after your income guarantee) and partnership criteria.”  

Walking forward or walking away

As negotiations wrap up, keep in mind it’s normal not to get everything you ask for. 

“Comprehensive negotiations typically result [in] mutual compromises where there is a give and take on the part of both parties involved,” says Mire.

Ideally, you’ll be able to move forward knowing you got the best possible deal—or, if necessary, walk away with confidence. After all, the whole negotiation process should give you a glimpse of the employer’s flexibility, culture and even trustworthiness.  

If an employer engages you with respect, accommodates as much as they can and clearly envisions an upward trajectory for you within the organization, you can move forward knowing you’re getting more than just a strong contract. You’re getting a supportive employer, a bright future and the added bonus of knowing you bet on yourself and won. •