Key points

Introduction

First and foremost, congratulations on how far you have come! As an orthopedist considering jobs and contracts, you are at the end of a long and challenging road. We hope you will find life as an orthopedic surgeon, taking care of your own patients and having the autonomy to make your own decisions, tremendously rewarding. Clinically and surgically, your training has prepared you for what lies ahead—you are ready.

You may, however, feel less ready to tackle topics such as job evaluations, personal finance, and contract negotiations. Medical education and residency have prepared young doctors to focus on clinical competency, with relatively little room or flexibility to consider the details of how you personally want to practice medicine. You jumped on the conveyor belt years ago, and the goals were linear and application driven. Most trainees focus on the major milestones, such as being accepted to the best medical school possible, then to a residency in a competitive surgical subspecialty, and then potentially to a competitive fellowship. The mentality for most trainees is to put your head down and work as hard as possible to learn how to take the best care of patients.

If you are toward the end of training, now is the time to make a subtle shift and to consider what matters to you and your significant others. Career paths are most influenced by mentors and prior clinical experiences. Understanding yourself and your goals is arguably the most important first step to the job search and contract negotiation process. When considering various job opportunities and the contract negotiation process, many established surgeons recommend ranking the following topics in order of their importance to you:

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  Clinical practice

  
  
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  Research

  
  
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  Money and teaching

  
  
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  Administrative roles

  
  
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  Growth opportunity

  
  
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  Relationship with leadership

  
  
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  Work stability

  
  
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  Work-life balance

  
  
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  Location

We all have different values and priorities. Many of us would be happy with a job matching our exact clinical interests, in the perfect location, well compensating, a guarantee to make the department chair, and infinite resources. However, this is largely unrealistic, especially for graduating trainees. In fact, according to a 2019 American Academy of Orthopaedic Surgeons survey, half (51%) of the respondents left their first job before the completion of their fifth year. What is more valuable is understanding the relative pros and cons of a given job as they relate to your own priorities. As a resident and fellow, you have been climbing the proverbial ladder. Now is the time to decide which building your ladder should be placed against.

Once you have dedicated more thought to your bigger picture goals, it is time to become more informed and ask questions. We hope this article sparks this process. Maybe you have cast a wide net for your job search, narrowed down options, or even have an unsigned contract in hand. The rest of this review article offers insight and wisdom on how to approach the contract negotiation process.

Negotiation—initial stages

When it comes to your first job and contract, your primary goal is to marry your personal career and family goals with the best-fit practice. The first few contacts with a prospective practice generally do not have ample room for large-scale negotiation. Most young physicians find that it is unrealistic to expect finite numbers and details up front. Instead, focus on learning about the people and the position on a more macro level. For example, are you being hired to practice your desired specialty or subspecialty of orthopedics? If you are being hired to fill a gap in a practice, then you need to make sure its a gap you desire to fill (eg, hip arthroscopy, complex knee reconstruction, shoulder arthroplasty, etc). What is your sense of the setup and culture? Have physicians recently left the group, and what were their reasons for leaving?

Whereas residency or fellowship interviews felt more akin to being under a microscope and your primary goal may have been to put the best impression forward, interviewing for a job is more of a 2-way street. First impressions are important, and it is always best to err on the side of openness and honestly. It is in the best interest of both “sides” to be up front and honest about their desires and expectations. For example, if you are hoping to avoid trauma cases, and they are hoping for someone to take a lot of call at a level 1 center, it is best to discuss expectations up front.

Negotiation—both parties are interested

Once you are approaching the point where an offer is being presented, this is where a shift happens. Now it becomes vitally important to understand the real details of the job structure, compensation, support, partnership, malpractice insurance, and all other relevant topics. This justifies a longer, more substantial meeting, usually with multiple follow-up conversations. It is important to come prepared with questions. If you are unsure of what questions to ask, then ask your mentors or friends/colleagues who have gone through the initial contract negotiation process. Your goal should be to understand your contract as best as possible, and ideally to understand the “why” behind some of it from your employer’s perspective. For some doctors, the prospect of asking such details feels uncomfortable. For example, money can be a sensitive topic, but it is important to understand what the compensation will be for year 1, year 2, and (more importantly) year 3 and beyond. One approach is to remember that this need not be confrontational at all. In fact, it is entirely within your right, and is solely your responsibility, to understand these details. Do not be afraid to be open and transparent and to expect that from your prospective employer. For example, it is completely reasonable to ask questions like, “How does this part of the contract work? Why is it structured this way? It states the bonus will be X% collections over X; do you expect me to reach X collections?” The more questions you ask, the more you understand and the better prepared you will be to make an educated decision. You may not have much in the way of leverage in pursuing your first job, and so there may not be major concessions or adjustments based on your negotiation prowess. However, you can avoid much hardship and frustration by ensuring you understand what you are signing up for. For many early practice orthopedic sports medicine physicians, a lack of understanding of the job landscape becomes a larger dissatisfier than a lack of compensation.

Legal advice

It is strongly recommended to seek the advice of a lawyer who has familiarity with contract law as it pertains to doctors. While this is an expense, it is money well spent. Consider someone who has a strong understanding of contract law in your geographic area because some items, such as non-competes and their enforceability, vary by state. If you have an issue or question about your contract down the line, you will also have someone you can call to discuss or advocate on your behalf.

Possible specific topics to address in the negotiation process

Summary

While it is tempting to largely accept initial terms of a first contract, it is extremely important to take the time to better understand a contract when choosing a first job. Most misconceptions of a contract or job details are avoidable with appropriate due diligence. Physicians should make every effort to get all important details in writing within the contract to ensure the highest likelihood of reaching your early-career goals. While the principles outlined in this article can help prepare physicians for a successful first round of contract negotiations, seeking appropriate legal counsel is often vital to success.