Whether you’re negotiating your first contract or your fifth, you’ll need to know what to negotiate- and how.

ONCE YOU’VE LANDED A PROMISING JOB OPPORTUNITY, the contract negotiation process can sweeten or sour the deal. The key is knowing what to negotiate, how to make a compelling case and, most importantly, your own value. Here is a guide to negotiating for physicians:

Starting with the right mindset

Before starting your job search, you can cultivate the right mindset to succeed in negotiations.

“The negotiation starts in your head,” says Bradley Block, M.D., an otolaryngologist in Garden City, New York, and host of the Physician’s Guide to Doctoring podcast. “We’ve spent our whole lives as trainees, struggling for a large number of us to get into very few positions. Now we’ve got to make this switch to recognizing that there are a lot of positions for very few of us, so we hold the leverage. …You are now a fully trained physician who a lot of places are looking to hire.”

Despite having leverage, many physicians- especially new ones- skip negotiations and end up signing their contracts as is (or nearly so). In fact, Block says he didn’t negotiate well when he was first starting his career.

“I didn’t realize how to do it,” says Block. “I just went in cold. I [thought], ‘Either they’re going to hire me or they’re not, and either I’m going to take what they offer me or I’m not.’”

By the time he hired a lawyer to review his contract, the negotiations were effectively already over.

[At that point,] “the lawyer is just working out some minor points in the language so that you’re not completely taken advantage of,” says Block. “That’s not the stage that you negotiate in. You’ve basically already given up your position [by the time you’ve] agreed that you’re going to take a job.”

Failing to negotiate is a common problem, says Ethan Nkana, J.D., principal at Rocky Mountain Physician Agency, which negotiates contracts on behalf of physicians.

“It’s a common misconception that first-time attendings [or] rookie docs cannot negotiate. And unfortunately, that’s also propagated by experienced doctors as well,”says Nkana, who spent 10 years in hospital administration before pivoting to represent physicians.

This misconception is often coupled with the concern that negotiations automatically equal conflict.

”That’s another mindset shift that needs to happen,” says Block. “You can ask for more money [or] less call [or] fewer weekends … and still have it be a congenial relationship because you both want the same thing. They want to fill the spot, and you want a job. Don’t think of it as a zero-sum game.”

With this approach in mind, you can start asserting your desires as early as the first interview.

Navigating formal and informal negotiations

In fact, by that first interview, informal negotiations have already begun.

“You are trying to find out what they’re looking for and what their needs are so you can use that later on,” says Block of your earliest conversations with an employer. “[Maybe] they’re looking for people to work nights or weekends or be on committees or do research or do teaching.”

If you can fulfill any of these needs, you’ll have more leverage to make your own requests. Being transparent early on about what you can offer—and what you want— can help expedite formal negotiations and prevent either party from feeling blindsided.

Formal negotiations typically begin after an offer has been made, but whether that’s pre- or post-contract will depend on the organization.

“In large health systems, the contract is largely a template,” says Gerda Maissel, M.D., a New York-based physical medicine and rehabilitation physician, board-
certified patient advocate and founder of My MD Advisor who has hired dozens of physicians. “It is typically no longer one or two people [who] get to decide exactly the subtle things of your contract. … It’s a template, and you can’t change the contract itself very much.”

That said, she advises physicians to find out what’s negotiable and then focus on the terms that are important to them.

Block echoes this sentiment. “Being a partner in the practice, I do know [that] not everything is negotiable because we are hiring a number of people at the same time out of residency, and we have to treat them equally,” he says. “The important thing for the physician doing the negotiating is to find what levers are really important to them and find what levers are really important to the practice and try to get those in sync.”

Identifying what you want—and what’s negotiable

If you’re not sure which terms to start with, Nkana recommends considering the compensation (including base salary and volume-based compensation), contract duration, termination details, bonuses and loan assistance being offered by an employer.

Compensation: Salary, sign-ons and raises

When it comes to negotiating compensation, it’s OK to reveal if you’ve got another offer on the table- and ask if the employer you prefer can match it.

Otherwise, it’s important to research the market in order to assess whether an offer is fair and to make a compelling case to the employer.

You can do this by asking the people within your network, or finding out through online databases. Medscape’s free Salary Explorer provides average full-time physician salaries, including base salary, bonuses and profit-sharing contributions based on their annual Physician Compensation Survey. physician compensation data is also available from the Medical Group Management Association (MGMA).

When you consider a salary, you must evaluate not only the amount but also the payment method and potential for future raises.

“In some places, what you get when you’re hired may never change,” says Maissel.

At some organizations, your salary is guaranteed for a period of time. Sometimes you can negotiate the length of that guarantee, but the most important thing is to clearly understand the calculation methodology to meet the terms of the guaranteed offer.

Similarly, you must closely evaluate the terms of a sign-on bonus.

“Most docs know that they can negotiate a sign-on bonus. Some sign-ons have terms that say if you leave in under—this is a more draconian one—five years, [then] you have to pay it back,” says Maissel. “Negotiate something reasonable: a year, maybe two, if it’s a huge sign- on bonus. And if you’re going to agree to two years, maybe you only have to pay half of it back. Don’t just think about it as dollars. Think about it around what repayment would look like.”

You can also negotiate additional income based on your own productivity. “You have to maximize your own value and worth to whomever you’re working for or with,” says Mark W. Surrey, M.D., reproductive and endoscopic surgeon and fertility specialist in Beverly Hills, California.

Transition: Start date, moving expenses and transitional housing

In addition to compensation, you may want to discuss ways in which the employer can smooth your transition into the new role.

“When you start is very negotiable,” says Maissel. “…Take some time for yourself. Ask for the summer off if you want. …Negotiate a start date that’s reasonable for you and your family.”

She also recommends finding out about moving expenses and transitional housing. “You should get your moving expenses reimbursed. …It may be a corporate policy, ‘Everybody gets X dollars,’ but find out what it is,” she says. “Sometimes…health systems will pay for transitional housing for someone. Most people just assume it’s their expense. But if you are going to come up for a couple of weeks a month, maybe you get transitional housing during that period until you can move your family.”

Be aware, however, that paid expenses and reimbursements are considered taxable benefits.

If you’re relocating with a spouse or significant other, see if the organization can help them secure a job. “It’s not that a large organization can guarantee [it], but they can make introductions for you,” Maissel says. “There’s a lot more help behind the scenes for spouses, especially for the more desirable jobs, than you might think.”

Support and schedule: Staff, supervisory responsibilities and shifts

“Support is a big one that often doesn’t get articulated in the contract, but it’s a part of negotiations,” says Nkana. “Some doctors have responsibilities to supervise nurse practitioners or physician assistants. And I have some doctors who are fundamentally opposed to that. And so how do we reach a place of agreement between the employer and the doctor about your responsibilities for supervising the practice staff?”

Many physicians also find themselves working too much after-hours call, which is why it’s important to understand and, if needed, negotiate your schedule. 

“Find out about shift assignments,” says Maissel. “If you’re hired as a hospitalist, can they flip you into being a nocturnist at will?”

Similarly, you’ll want to know where exactly you’re practicing.

“Some health systems [expect] specialists to move between multiple office locations,” says Maissel. “Ask if you’re going to be expected to move between different locations, and if so, what’s the distance. You don’t want to spend an hour in the middle of the day on the road.”

Make sure that everything important is put in writing.

Exit strategy prep

Because few jobs are forever, you also need to understand your way out— and be comfortable with it.

“Make sure you’re not trapped,” says Block. “One of the big negotiating points is going to be a restrictive covenant.”

A restrictive covenant limits or prevents you from making certain movements and actions after you leave the organization. For instance, a nonsolicitation agreement could restrict you from taking your patients with you.

“Again, [in] that congenial way, [say], ‘If this relationship doesn’t work, I still need to go to practice,’” says Block. “‘I don’t want to put you in a position where you think I’m going to have all of my patients follow me next door. But I need to be able to earn a living, so how do we renegotiate this restrictive covenant into something that’s more reasonable?’”

Another way to guarantee you have a beneficial exit strategy is to sign short-term contracts. “Sometimes doctors have contracts that just go on and on and on,” says Nkana. “It’ll say a term [of] two years, and then it’ll auto-renew. …I prefer for my doctors to have short contracts and finite contracts, so two to three years max. And I want a definitive end date in there so that they can come back and have a conversation about the terms of their contract, how things are going in their practice, their pay, etc.”

You also need to make sure you have appropriate malpractice insurance coverage in the event that you leave a practice. “Make sure that the organization provides a tail or some other way that you’re not going to be stuck if after you leave there’s a claim made against you,” says Maissel.

Striking the right tone

Even as you assert your requests and your value to an organization, it’s important to maintain a congenial attitude. In the words of Maissel, “[Be] nice but firm.”

This balance is what will lead you to negotiation success—ensuring you don’t cave too easily or come across as unnecessarily competitive.

At the end of the day, both you and the employer want the same thing, and focusing on this common ground can help both parties end up happy.

“They want to fill the position, and you want to be in that position,” says Block. “Starting from that point, how do we all agree on how to get there?”