Let It Go                               

Too bad you can’t negotiate your way into residency. If we could, more graduates would understand the power they hold. The realization of that power comes with experience. But if you want to tap into it early, I have one major piece of advice: If it’s not the right thing, be comfortable letting it go.

I considered a job offer with a local health system in New York City after graduating. The problem was that it was limited to adult medicine, with the option of doing care focused on survivors of 9/11. I was excited for the second part of that job, but I also wanted to see kids, prenatal patients and do women’s health. I wanted to feel like a family doctor. I was tired of looking for jobs, but mentors advised me to re-evaluate what was important to me. I did that, restarted my search and found a job where I could use my training to the fullest.

I know it’s a significant mindset change from scrambling to apply for programs or going through the Match process. But if you have the luxury of waiting a bit longer to start getting an income (and not everyone has this luxury, I know), it is worth letting the wrong things go. My own mindset change came from building up my clinical confidence, understanding my role in the organization, and choosing to do things that actually interested me instead of simply being resume boosters.

But it was a challenge to get to that point. So here’s my second biggest piece of advice: Find help.

In my case, a friend was starting a career coaching business, and I benefited from affordable career coaching. More recently, I had friends who helped me streamline my resume and reorganize it from the academic CV that we’re taught to something that would highlight my abilities for more senior roles. If there’s something unique you’re going for, consider hiring a negotiation coach (yes, they exist). With a negotiation coach, I was able to identify my non-negotiable issues and where I was willing to compromise, and what that compromise would look like. Sometimes it helps to have someone more experienced guide you through the nuanced options of employment.

So here’s my final piece of advice: Be clear about what you want.

Of course there are basic things: Make sure you have tail malpractice coverage, try to remove non-compete clauses, and figure out how much notice you have to give if you want to leave and whether or not they can fire you at will.

But maybe start dates matter to you, maybe a path for growth or getting leadership training paid for matters to you, maybe you want to have a procedure day, or you want to teach and have two precepting sessions per week. Whatever it is, be clear. Your new employer may not want to put all of it in writing (the more detail there is in a contract, the better), but at least you’re clear. That clarity makes it easier to have conversations later on, or to identify which new opportunities to take.

And of course, if it’s not the right thing, be comfortable letting it go.

Lalita Abhyankar, M.D., M.H.S., San Francisco

Seek Balance

There are two important things to keep in mind when negotiating your first contract. Maybe three. OK, maybe more. But let’s start with these two:

• Everything is negotiable (which means you have to be OK with walking away).
• Contracts are only enforced in a court of law (which means you have to really trust the handshake deal almost more than the contract because people often get sloppy with implementing contracts, and you’re unlikely to want to spend time or energy taking someone or some large hospital system to court).

With those two things in mind, it’s important to take a long, hard look at what is in your contract. Ideally, it spells out your time commitment and how you’re compensated for that time. Your work can bleed into your free time, especially in family medicine, so consider being explicit or stringent about work hours, protected time for administrative tasks and clauses or amendments for ‘overtime’ work. Some estimates lay out that for every hour of clinic/patient-facing time, you’ll have two hours of administrative work, so think about that as you negotiate!

Though I own and operate my own direct primary care practice, I also work in hospitals across the region in a locums capacity. I have enjoyed working as an independent contractor at hourly rates because it allows me to be explicit in protecting my time. When I’m scheduled and on the clock, I’m working; when I’m not on the clock, I am not working. If I have a busy day and have to work after my shift ends, I bill for those hours. I do not work for free. I don’t serve on committees for free, and I don’t attend meetings after hours or on my days off without compensation.

Last point: You really, really need to talk to several clinicians who are working in a role similar to the one you’ll be taking. Be explicit in asking them: How would they renegotiate their contract? Where do they feel as though the employer has taken advantage of terms laid out in the contract?  How can you best protect your time?

Ultimately, you are an amazing resource, and hospitals are clamoring for high-performing family medicine physicians. Stand up for yourself and negotiate for the contract that will allow you to have a long, successful career with just the right balance of compensation, protected time and the flexibility to care for yourself.  

Allison Edwards, M.D., Kansas City, Kan.

Know (and Ask for) What You Want

When I graduated residency I thought that in order to get the job I wanted, one in which I could blend public health and primary care, I was going to have to go through a second residency in preventive medicine and pursue an MPH. Before I applied to the second residency, my far-too-wise mentor told me to ask a few health systems if they were interested in such a combination. I was delighted to find several systems around the state willing to create a position focusing on primary care and public health.

This is just to say: If you know exactly what you want to do, say palliative medicine or medication-assisted treatment or public health, don’t be afraid to ask for it. I found that prospective jobs are a lot about compromises. If you are willing to work more rurally, then you are likely to have greater flexibility in scope, but if you are willing to take a more structured job then you can live exactly where you want. Your first step in the job search is to find out what you truly want, be it location or job description, and ask for that.

As for what I would recommend when negotiating, I have found that the best thing you can negotiate for is admin time or paid time off. I think it’s important to know that some systems have standard contracts with little to no wiggle room regarding salary or benefits, and that’s OK. However, if you are in the process of negotiating a custom contract, I would recommend focusing on maximizing “free time.” Time is the only resource you cannot get more of once it is gone, so I recommend getting as much as you can.

Stewart Decker, M.D., Klamath Falls, Ore.

Pause Before You Sign

My first reaction to residents asking me about employment contracts is to pause. After four years of medical school, three years of family medicine residency and potentially additional years of fellowship, many trainees are shocked by their first offer. It’s far more money than they’ve ever earned before. It’s far more flexibility than they’ve ever experienced.

But pause.

As a new graduate, you are a hot commodity, and many job opportunities are out there. I was starstruck by my first opportunity, and though I negotiated to get what I thought I wanted, I didn’t clarify enough details. In the end, it was really the wrong fit.

If you, like me, realize that your first job is not the perfect one, don’t automatically assume you’re burnt out from family medicine. It just may be the wrong job. As the writers before me stated, knowing what you want gets you further in the negotiations and toward finding the right fit. But as a graduate, all I wanted was sleep, warm meals and at least two weekends off a month. Treat yourself with a little grace, let them know you really have to think about it. Ideally, you will have a few different offers to compare, so think about which will make you happiest.

If it doesn’t work the first time, just try again. The right balance is out there.

MaryAnn Dakkak, M.D., M.S.P.H., Boston