Navigating and Negotiating Your First Job Contract

As you near the end of several years of residency and fellowship training, the job search process can be an emotional rollercoaster. We all are anxious and excited in equal measure. But once you get the job offer you’ve been waiting for, what comes next? Negotiation.

Negotiation often has a negative connotation; to some the term may imply that somehow one or both parties are not happy with the initial offer/agreement. That is not necessarily true, and the right employer will not take offense just because you have certain proposed reforms or additions. You are entitled to do this because you have worked hard to get to where you are and you have the right to make reasonable requests that reward your level of training and increase your likelihood of success.

Any employer that leaves no room for negotiation—perhaps with a “take it or leave it” attitude— probably isn’t the best place to start your job search. One that extends an offer in good faith and seriously wants you to take the position will work with you within reason to seal the deal. Negotiating a job contract can be done smoothly if you know what you want and what you’re willing to give up. That means that before you even get your first job offer, you should have a predetermined “wish list” of requests that you will ask for if/when an offer comes along.  

Once you begin the job negotiation process, you want to work to reach the ideal compromise where both parties feel like they are receiving a great deal. Ideally, you want your future employer to come out of the negotiation feeling just as enthusiastic about you joining their group as he/she did with the initial offer. Otherwise, all the good will and capital a new hire comes in with can easily be poisoned by a bitter or lengthy negotiation process. Offers can come in a few common forms:

• Verbal: You are offered the position in person or by phone with basic information communicated about the position and the compensation, and then you are asked to give an answer within a specified period of time. If your answer is yes, then you will get a brief letter of intent followed later by a formal employment agreement (EA). If your answer is no, then you never get a letter of intent or EA, and you never truly get to negotiate anything. Verbal offers are the most challenging to navigate, because they force you to ‘show your hand’ and commit in good faith before anything is even discussed or negotiated. Verbal offers weaken the negotiating position of the person being hired, and maximize the leverage for the employer.
   
• Letter of Intent (LOI): This offer is typically one or two pages, has minimal details but outlines the basic job position/title, compensation structure, and some legal jargon about what each party is beholden to by the agreement. If any negotiation is needed on the basic terms of the LOI (eg, compensation), that is typically negotiated upfront before the LOI is signed. LOI’s are almost always followed up by a formal drafted EA. Due to the fact that LOI’s are nonbinding, they serve as a way for both parties to formalize their interest in each other, but still give each side an equitable amount of room for further negotiation over terms. 
   
• Formal EA: This is typically a 10-plus page document, depending on the institution and its preferences and culture. Some institutions have very standard EAs with minimal details, but others might be more thorough. Regardless of the level of detail, these are the final and permanent form of the agreement, thus all of the negotiation happens on the front end, and all terms should be finalized before you sign the document.

The type of offer you receive can imply certain things about the employer/institution and its level of seriousness about your candidacy. A verbal offer with a condition that you will hear further details based on your response, creates significant pressure on you as the candidate, and it weakens your position to make requests later in the EA. Be cautious about offers that force you to give up your leverage before anything has been negotiated; that kind of a start may not always bode well for a good ending.

If you receive an offer by way of an LOI, then you should negotiate the compensation and other specific terms mentioned in the LOI before signing the letter. Don’t be fooled by the brevity of an LOI; even though it may be 1-2 pages, you should still take a reasonable amount of time to consult with trusted mentors, colleagues, or even contract attorneys before finalizing or signing. In other cases, an LOI may be very basic and may fulfill all of the expectations you have, in which case you may be able to sign and proceed to the next phase. However, this also means that the negotiation could later fall apart if an equitable agreement is not reached regarding any supplemental terms in the EA. Sometimes LOI’s can give you short-term comfort in exchange for medium-run uncertainty.

In my view, the best scenario is when you receive an initial offer by way of a formal detailed EA. This allows you to carefully review the terms, contemplate what additional items you will request, and consult with a mentor or attorney about specific areas or language within the agreement. As mentioned above, this mode of initial offer allows you to do all of the negotiation up front, so that once you sign you can be certain that all the important items have been covered.

So what should you negotiate? That depends entirely on your chosen subspecialty or focus within cardiovascular medicine, personal income goals/finances, and long-term career interests and goals. Regardless of your specific circumstances, here are a few key items to highlight and focus on in your negotiation for an interventional/structural heart/peripheral vascular job: 

• Compensation: Look at the Medical Group Management Association (MGMA) 50th percentile compensation in the specific geographic area of your job. Talk to other graduating fellows or early career colleagues about their compensation ranges relative to their degree of training or type of job (eg, private practice, hospital-employed, or academic practice). Compensation is a very individualized matter and you should strive to find a match between your financial goals/obligations and the sample set of jobs you have to choose from. In general, it is appropriate to request more compensation than what is initially offered. The likelihood your counter offer will be accepted depends on your professional standing, accomplishments, prior work experience, circumstances behind the available position, and negotiating leverage between the two parties. Clarify any questions you have about compensation structure (eg, base salary, bonus tiers, or compensations that are entirely RVU driven). What is the institution’s RVU conversion factor and is that in line with the industry standard? In cases where your compensation will initially be a fixed salary for 1-2 years followed by total RVU production, be certain to ascertain what the average RVUs are within the group, and will you realistically be able to reach your RVU target?
   
• Dedicated time for cath lab/interventional procedures: The employer may be reluctant to incorporate specific details as to the quoted cath lab time blocks in your weekly schedule. However, there ought to be some suggestion of what your cath lab presence will look like and what type of volume you can expect based on your initiative, referral patterns, and institutional volumes.
   
• Advertising, promotion, and building a referral base: Does the EA mention details on what types of public relations or advertising budget is given to new hires? Will the institution give you opportunities and time to meet with physicians in the area or hold community events to build your regional presence, create new referral pathways, or rejuvenate old ones? Are you inheriting the practice of a retiring colleague or building something from scratch? Where will the patients come from? Is there volume to actually support growth? What is the institutions growth plan/strategy and what terms can you negotiate to fit into that rubric?
   
• Clinic/outpatient time and support staff: Clarify how many days of clinic you will work per week and whether or not you will have a dedicated medical assistant, RN, physician-extender, or scheduler. For those practicing structural heart disease, you may also want to inquire about whether you will be starting/assisting in valve clinic, and/or other interdisciplinary clinics specific to your focus. Be sure to request that your clinic days are not interfering with dedicated procedural time that would hinder your productivity.
   
• Leadership roles: If you’re interested in leadership opportunities within your job/department, let those intentions be known at the time of negotiation. It allows both parties to discuss their interests and concerns upfront and clarifies expectations once you begin your position.
   
• Call schedule: How frequently will you be taking call? What level of support will you have when on call (eg, fellows, PA, ARNP)? For interventional cardiology, clarify whether you will also be taking general cardiology call. If the institution pays you additional funds to take STEMI/interventional call, you can negotiate those terms as well.
   
• Noncompete clause: Non-compete clauses come in different forms and the legal intricacies or relevant state-specific case laws are outside the scope of this blog. However, be sure to consult with a contract attorney if you have questions about the non-compete or if you wish to propose different conditions or terms to the language in the LOI/EA. 
   
• Miscellany: Negotiating your contract is also the time to think about all the oddball things you may need such as: moving/relocation allowance, CME allowance, paid vacation, religious holidays, cell phone allowance, desktop computer for your office with high resolution screens for viewing imaging studies, virtual disc space to store downloaded images, a 3D printer, requirements for teaching fellows/medical students, time spent rounding on the ward services, or negotiating protected weekly research/administrative time.

Negotiating your first job contract can be done tastefully, professionally, and efficiently if you have an outline of your wish list and know the areas in which you’re willing to compromise. Always be realistic and reasonable in your requests, but know that you deserve to earn the best opportunity for yourself. Don’t be afraid to ask for something you need to position yourself for success. Once you finalize and sign your contract, breathe a sigh of relief, take the appropriate vacation time before you start your job, and then be ready to deliver on the responsibilities you’ve set out for yourself. Best of luck!