Okay, so I'm going to talk about contract negotiations, and so this is applicable for any job. And when I was fellowship director at the University of Utah for seven years, I looked at all the fellows' contracts every year. So I'm not an attorney, but I've looked at a lot of contracts, and I've negotiated my own contracts as well. Okay, so the worm has turned, right? Everything is different now compared to everything prior to this moment in your experience, because prior to today, this was you guys, right? You guys were beggars, just beggars, right? Please, please accept me, right? This was you guys, right? You guys, we all remember this, right? That was it, right? But that is not true anymore, right? That's all over, right? So you have to kind of exit that mindset, right? You don't go into a job interview like that, right? That's not how this works ever again. For the rest of your lives, that's over, right? So now you're fully trained, right? You have the cognitive and the technical skills that you've acquired over all these years where all your other friends were out working all these past years, right? And you've been in school and internship and residency and fellowship and ERCP fellowship and liver fellowship, all this stuff, right? And critically, you can generate revenue, right? This is why the worm has turned. Prior to now, you didn't make any money, right? You didn't generate anything. Now you're generating revenue, and you can generate revenue for all sorts of people, right? Which is why that you're in a completely different position, right? Now you are in the driver's seat, right? But what this means is you have to negotiate, which we are not trained to do, right? We're not good at that. We all come up and like multidisciplinary, hold hands, kumbaya, right? Now you got to negotiate, right? So I always say this, in life, you don't get what you deserve. If you're looking for what you deserve, give it up now. What you get in life, what you negotiate, right? And if it's not written on that piece of paper, DNE, as they say in mathematics, does not exist, right? And remember, too, everything is negotiable. On every job, I've had three jobs, so just three. But on every job I've had, there were things I wanted that they were saying, oh, we absolutely can't do that. And I said, take care. Oh, wait, wait, wait, wait, come back, come back. Oh, let's sit down again. All of a sudden, what was not negotiable is suddenly negotiable. So just recognize if they say, you know, there's a lot of wiggle room in life. So this is the most common question I get asked all the time, right? Should I get a lawyer, right? And the answer is unequivocal. The answer is yes, get a lawyer. You must get a lawyer, right? We are not trained in contract negotiations. You also need somebody to stand in for you if you want to maybe get hard nose with them. You don't want them to see those words coming out of your mouth. Those words can come out of your attorney's mouth, right? And remember, too, the contract that you sign, which is anywhere from a, you know, three to a 50-page document, is not drawn up by the doctors you're talking to. It's drawn up by their attorneys, right? So you need an attorney to read that document and go over it with you very, very carefully. Now, a critical caveat that you guys might not have perceived is your lawyer will charge you money to do this, right? Because they are not saints, right? That's just not how it works, right? And that's okay, right? Don't be stingy. Pay the lawyer, right? And if the lawyer is expensive, pay the lawyer, right, right? No, they're trained to be aggressive. Like they're really good at this. Like, you know, like if a doctor is walking the street and they see somebody on the ground, they run over and say, can I help you? Like if a lawyer is walking on the street and they see somebody on the ground, they run over and step on their neck. Like they're really aggressive. That's what they're trained to do. My father went to law school when he was 58, and he was a hyper-aggressive person before he went to law school. And he came out of law school more aggressive. Like he didn't mellow with age, my dad. Don't use a friend. Don't use a parent. If your spouse is an attorney, none of these people can be your lawyer, none, because they're totally biased, right? And then, number two, you may go through a couple of drafts of your contract, right? And that is normal, right? And there's a, it's like a dance, right? There's a lot of backing and forcing in this process. So there's a lot of things you want to think about as you're negotiating your contract. So you have to have a realistic start date. They always want you to start right away, because the sooner you start, the sooner you start making them money, right? And this is, again, true at academics or any sort of non-academic situation, right? But you're going to need a lot of time, especially at the end of fellowship, even if you're not even moving cities, right? Some people stay in the same place, but that doesn't mean you go right into the job, right? You may have to get a new state license. I moved for all of my jobs, had to get a new state license. When I moved to Texas, I had to take that, what's that, right, and yeah, there's a test you got to take to get a license in Texas. Legal jurisprudence exam, it was terrible. You may have to sell your old house. That can take time. Maybe the market turned, and you can't sell your old house. That happened to us once, right? You got to buy a new home. That takes a lot of time, right? And then coming out of fellowship, you got to study for the boards, right? You will have very little time to study once the job begins. You're going to come home late, and you're going to be hungry and tired, and you're not going to have two hours to sit down with the DDSEP. You're just not, right? So just recognize that now is your window to take some time, right, and kind of get your ducks in a row. So a lot of people finish fellowship in June. You know, a good time to start is September, October, November, depending on your situation. And those few months without income will not matter at all in the grand scheme of things of your life. This overlaps a little bit with the prior talk, right? So you want to really, really understand your duties. And this is probably the area where the printed contract will vary the most from real life, because a lot of times the job drifts over time, right? You sign your contract for a lot of these details, coverage, how much clinic, right, how much OR or endoscopy time, right, admin time, research or protected time, right? And then in real life, there's a lot of play in that. As the years go by, you will often find that, you know, like, wow, five years in, my schedule doesn't really resemble what I negotiated. But as long as you're okay with it, that's fine. You'll probably see if you ask members of the group that their contract doesn't really reflect their work week. And for example, at the University of Utah, I had 20 percent protected time, and I often gave a lot of that up to do extra advanced cases. But I kind of felt like, well, my research was based on doing advanced procedures, so the more advanced procedures I did, it helped my research. So I did it in other ways. But just recognize that you want to really have a good understanding of things. True story, when I was coming out of fellowship, I interviewed at a big university, and I had a great meeting with the chairman and the division, blah, blah, blah, and then they sent me a blank contract, and it said, your salary will be X, and you will take Y call, and you will have Z days of endoscopy. And I said, I think you sent me the wrong document. None of this is filled in. And they said, oh, no, no, we sent you the right document. You just sign it, and we'll fill it in later. And that was actually what the chairman said to me. So needless to say, I didn't take that job. Call, right? One hospital, multiple hospitals, how far apart? A good friend of mine took a job, and the group had two hospitals that were 10 miles apart. And then between when he signed and joined, they acquired another hospital 28 miles away. And then when he was on call, he spent his entire day in the car. He'd go to hospital A, then B, and then C. Then they'd call him back to A. And then when he drove back to A, they said, oh, there's a bleeder at C. And his whole day was just driving back and forth. And that was, you know, he wasn't really savvy enough to kind of push back on that or say, like, hey, that's not what I agreed to, right? Some groups share call, which is that that can have some political and financial ramifications, right? Do you share call, right? How many weekends? How many holidays, right? Who backs you up? Like, what if you get in a car accident? What if you get sick? What if somebody is too complicated? I don't have this. Oh, I do have it up there. Are you paid to take call? I was just talking about this with Ashley. I'm paid to take call. I never got paid at the University of Utah to take call. Are you kidding? Now I get paid to take call. In my group, like, if you say, I don't want your call, who wants my call? You get 10 texts right away. I'll take your call because people want the call because it's very lucrative, right? So if you're, let me tell you, if you're paid to take it, it's a little different in your head, right? Does call stop, right? Ashley and I were talking about this earlier, too. Some groups when you're 60 or 65, which sounds like a million years away, but it's not, you know, you could say, I don't want to take call anymore, right? I'm tired of it. I've done my bit, right? Just recognize that that's out there. So you're probably going to be most focused on money, but in a lot of ways, it's not the most important thing in the contract, maybe the least. And the reason I say that is it's the part of the negotiation that's going to be the most upfront, most transparent, and most easy to check against other jobs in the region, right? So, you know, in some ways, it's the least stressful part of the negotiation. And a small amount of money up or down really isn't going to change a lot for you. Overwhelmingly, people leave jobs for non-financial issues. And I left my, the two jobs that I've had and left, I left them both for non-financial issues, right? Like I said, it's pretty easy to find out if you're getting a good deal or a raw deal. So you may get a mailer, right, that offers you a crazy salary, right, in West Cupcake. And you may be like, honey, let's move to West Cupcake. I can make a lot of money there, like a crazy amount of money, right? And the problem is if you take that job, you will make that money, but it's very hard to stay there because nobody wants to live there. And for example, one of our fellows in Utah, he took a job in North Dakota for $750 a year. Pretty good money, $750 a year, plus every year he stayed for the first five years, they'd pay 20% of his loans. And we were all like, can we join you? Like this is a great job. And he lasted one year. And his wife said, at the end of nine months, I'm going back to Salt Lake. I'm taking the children with or without you. And he had to quit. And then he had to pay back the 20% of his loans that they had paid, right? So just recognize that there's a downside to that. I've told this story before. When I was a fellow, I answered one of those ads just to kind of see. And I went, my wife and I drove out. And at the end of the day, it was a very beautiful place, beautiful hospital, beautiful facility, insane salary, just bonkers, like triple what I was seeing anywhere else, academic or anything else. And there was no town. It wasn't like the town was small. There was no town. It was just like a hospital in the middle of nowhere. And I said, I was trying to gauge, what is it like to live here? My wife and I are both bibliophiles. And I said to the division chair, I said, is there a Barnes and Noble? And he said, there's a magazine rack at the Walmart. And I was like, take care. I can't live in a town without a Barnes and Noble. You know what I'm saying? But they had just all these people cycling through that job. People would stay a year or two, and then that was it. But now you can't find it. Right, I know. That's true. Termination, right, you're going to have a termination clause in your contract, right? You can be fired if you die, right, or you become disabled and can't work. If you commit a crime, it happens. Go to your state medical board's website, and a lot of docs get involved in some shady stuff, right? It sounds crazy, but if you get caught committing a crime, meaning a felony, not a parking ticket, not a speeding ticket, but if you commit a felony and it happens, right, you may very well expect to be fired by your practice, right? If you lose your license, right, for unprofessional behavior, go to your state medical board's website, right, and see what happens. If you become uninsurable, right, or you're excluded from Medicare, right, all these things can and do happen to people, right? So you may find that you're terminated. You may also be terminated without cause, and a lot of contracts will say, like, well, within the first six or 12 months, we reserve the right to fire you without cause. Like, we just can decide we don't like you, right? And you may have to agree to that, and all the other partners may say, oh, yeah, yeah, we all signed it, and then at the end of the year, we just forgot about it. But you may find yourself, if the practice goes sour, or they find themselves in financial straits, they may reserve the right to fire you without cause. Restrictive covenants, everybody asks about this. These protect your employer. They do not protect you. This is another reason you have to have an attorney, right? The restrictive covenant is to protect them from you in case you become hostile to them, which may happen, right? And despite what you may hear, these restrictive covenants are very enforceable, right, even if you're in a right-to-work state, right? There's a general rule. The bluer the state you are in, the more enforceable a restrictive covenant, and the redder the state you are in, the less enforceable the restrictive covenant is. But they are all enforceable to varying effects, right? They usually have a time and a distance component, right? And the more crowded the place you're in, right, the shorter the distance, right? If you're in a giant city, the distance will be smaller. If you're in a smaller place, the distance will be larger. And the distance is as the crow flies, not as driven. And when I was a resident, one of the GI attendings at my hospital left, violated his restrictive covenant by about 500 yards, not a lot of space. And when he went to open, the door was padlocked and the sheriff had put a notice on it. And the other partners got wind, and they hired a surveyor, and they measured the distance. And he wasn't allowed to practice in that space. Remember, the restrictive covenant does not help you in any way, shape, or form. It helps your employer. And if they put it in, you may find that that is one thing that they will not take out. Sometimes under unusual circumstances, you can get it out, and I've done that. But sometimes you can't. You can ask for a couple of things. You can say, well, can we void my restrictive covenant if I leave in less than a year? That's fair. I haven't been here long enough to really build a practice or a reputation. I'm not really a threat to you. I'm not going to steal your business. If you're terminated without cause, you can also say, well, look, if I showed up and I did everything right and you fired me without cause, you can't hold me to my restrictive covenant. And then the most common thing is a buyout option, where let's say you're at practice A, and it's really not going well, and practice B really, really wants you. Practice B may say to practice A, we'll give a quarter million or a half million dollars to buy you out. So that's actually something that a lot of practices are very open to, because then it sort of softens the blow of having you leave and maybe go to their competitor. They're still getting a payout. Other things to ask for, relocation funds. You should not pay for your move. And remember, too, you're used to going to the supermarket and getting a bunch of boxes and throwing your stuff in it. When you move for a physician job, they should pay for your move. That means they paid a pack. You don't have to pack at this point in your life. My wife had done it a couple of times. It's amazing. A team shows up, and in eight hours, everything you own on Earth is in the back of a truck. It's the greatest thing ever, because you don't have to do it. You should ask for some educational time. You want to go to some meetings, one or two at least per year. And you want them to pay for that. You're also going to need some money to pay for your society fees. I'm a member of three societies. That's over $1,000 a year I have to pay for my license. That all gets paid out of my job. You can ask for school loan repayment. Usually, like I said, done in stages. They'll give you 20% a year for five years. But again, they will hold you to that if you leave early. For example, if they pay all of your schooling off, they may expect you to commit to 10 years. And that's fair, because it would have taken you 10 years to pay that off. So they may hold you to that. And if you leave early, be prepared to pay it all back. People, I think, make too big a deal of the signing bonus. I think it's actually more of a headache for both parties. People want these signing bonuses. They want to say they got a signing bonus to their friends. It has a lot of cachet. It has cash, but it also has cachet, as they say. The big problem with it is it's taxed at a super high rate. So if you get a signing bonus of $40,000, that's really like $22,000. And is it worth pissing them off for $22,000? Maybe, maybe not. So just recognize that if you're having a really, really, really good negotiation, and it's looking good, and you're getting what you want, at the 11th hour, don't drop a signing bonus request in. And I've known one or two fellows who lost positions because at the last minute, they asked for a big chunk of cash, and the group said no. If you're a fellow, one thing you can do is you can ask for a stipend. And this is, for example, I think more common out west, where they want to lock you in. They could say, OK, well, if we sign you in the middle of your second year, you've got 18 months as a fellow. We'll give you $1,000 a month for the next 18 months. So this encourages them to sign you sooner, and then you get a little cash up front. And that's totally legal. You can ask for a stipend. And I've seen that a lot. And $1,000 a month extra when you're a fellow is a big difference in your pocket. I'm trying to go quick, because this is a dense talk. So Depeche Mode has a song called Get the Balance Right. And there's a little verse in it that I always think is relevant for contract negotiations. I won't sing it, but I'll just say it. And it's understand, learn to demand, compromise, and sometimes lie. And just sort of recognize that both parties in the contract negotiation are kind of doing the same thing, right? Remember, they need you much more than you need them. You're the one who's bringing skills and value and growth and all this financial revenue to the practice. So don't ever, ever make them think that you're the weaker party in this negotiation. If you feel like that, then it's time to keep looking. Jobs are like buses, right? If you miss one, another will come along if you wait a little bit that will get you exactly where you need to go, right? So don't have a dream job. Don't have a dream practice, right? It doesn't work that way in the adult world. And you're probably not going to be there very long anyway, because you don't know anything, right? So most people, when they get their first job, it's not ideal or it's not perfect, right? So if you try to think about this as like, I've got to get this job for the next 40 years, that's overwhelming. If you just look at it as, I'm going to get my first job. And I think somebody earlier cited the statistic that 50% of GIs leave their first job in three years. And I left my first job three years to the day, right? And it's just like, it was great, and I had a really good time, and it was time to go. You know what I'm saying? So don't get too emotionally attached. Remember, you can fall in love with your job. Your job will never fall in love with you, right? So it's a business, right? So you have to kind of think. Whether you go to academics or private practice, it is a business. And you're smarter to think about it that way. You'll learn a lot about yourself and what matters to you in your first job. And a lot of things that you think are important really aren't so important. And other things that maybe you didn't even consider turn out to be very, very important. Most people leave jobs, right? Because they want to change their focus. They don't like their partners or don't get along with them, right? They get divorced, right? They don't like the city that they moved to, right? Somebody gets sick and they gotta move back to be near their parents, right? The practice implodes financially. One of my best friends is an IR, and he had the greatest job in the world in Vegas. And he was like, I'm never leaving, never leaving, never leaving. And the group lost one of their three hospital contracts, and the two hospitals weren't enough, and the group went bankrupt. And now he's in Miami. And all he talks about is, it's not as good as my job in Vegas. Like, you don't know what's gonna happen down the road. All right, thanks guys. Any questions? Oh, yeah. I have a question. Can you give us a second? I'll just tell a funny anecdote about signing bonus. So I got a fraction of a signing bonus that Doug was talking about, and I had already gone through several iterations of contract with a legal person who, my cousin is a, he does employment law, so in that setting I thought it was okay, but agree with him. But anyway, I was like, okay, I signed, where's my signing bonus, right? I'm at this, like, my third, and they're like, oh, no, no, that goes at your first paycheck. And I'm like, I just bought a house, I like have a, you know, got a close on my mortgage, and so signing bonus doesn't actually happen necessarily that, like, the moment you sign. So that was my naivete. And most signing bonuses come at the end of your first year. Right, like, most signing bonuses now you get at the completion of 12 months. Right? Teed, I want to rope you in. Pretty emphatic about the need for a lawyer, and if you're looking for a job in academia, especially, like, as, you know, just at a fellowship, do you really think you can make definitive change in a contract with a lawyer in an academic job? 100% I've done it. You are insane to sign without an attorney. You are insane. You're flying without a net. And then, like, the worst thing to do, and I think there's a line in there that I didn't say, do not sign the standard contract. If they say to you, this is our standard, everybody signs it, that is, to quote our president, malarkey, right? And you know what, you can just say, you know, I'd really love to come here, and this is a great job, but I need these things changed. I'm up for it. I would say that I never had a lawyer, and I would say it's hard to change my opinion, hard to change hospital contract, you know. And it's one piece of paper. You're much more able to negotiate at your position in life than they are. But I negotiated my first job contract. But you know, the hospitals these days have boilerplate contracts. I mean, I work for this huge system. You work for, you know, that's what you get. There are little points that can be negotiated, maybe dollars per RVU, you know, things like that, but huge, you know, big things are just not, not that easy to negotiate. Big things, sure, but you can negotiate. Please get a lawyer. Let me put it this way, like, I'm coming, I come up for partner now in my group, because I've been there, whatever, two years, something. And you know, they sent me the partner contract, and they said, here's our standard partner contract. And I said, I'll get back to you. And you know what, I'm negotiating with them now with my attorney. And they said, the standard partner contract can't be, guess what, they're negotiating. Do you know what I'm saying? So get a lawyer. My lawyer charges me $500 an hour, and she's worth it. I would also say, and it's a lesson I learned early, and I've only, I've interviewed for other jobs, but everybody has to be a winner in the deal. I learned that from Alan Leitner, who is Jen's old boss. And, what's that? I have his job now. And she has his job now. But you don't want to push too hard, because you got to work with these people. So everybody kind of has to be, you have to be happy, and you don't want to have them all upset with you. But at the same time, I learned this lesson in the Middle East when you're negotiating for stuff in the store. Like, if you leave and they're happy with you, you got screwed. And so, you kind of have to push a little bit, I think. And that's been my experience. That's a compromise in the Depeche Mode song. There was a hand up in the back, and you want the lawyer. Oh, in terms of finding an attorney, do you try to pick one who's an expert in GI contract negotiations? Do you pick one who's just an expert in your state law? What do you prioritize there? You just need a contract attorney. And any good contract attorney will have a lot of experience with physicians. There was a hand in the back there. Sorry, a question about negotiations with the VA. You can use your mic. We don't have one. Right here, right here. Oh, okay. Just project. I just had a question about negotiations with the VAs over here. If any of the presenters can weigh in with their experience, because it's a federal entity, so I know the negotiations could be a little bit limited. I was just wondering if anyone had some experience. Anybody have a comment on negotiating with a VA? Yep. So, no, I didn't negotiate anything. No, I actually did, because interestingly, there was a physician pay bill coming when I was starting, and the way that if you did it at university and the VA, they would basically cut your salary at the university if you got a pay increase at the VA. So if you're doing a combined thing, I would get that in writing to not let them do that, because other people do that. So I was offered a really bad salary compared to other places, but I really liked the people that I was working with, so I took it knowing that I would get an increase which worked out pretty well for me. But there are, the VA has a salary cap. You can't make more than the president, so that's something that's being worked on right now. So, that's $400,000. So, but there are some retention money out there, so you can make more than that. So that's something, it's definitely negotiable. The VA has salary ranges, and it's also, it's very, every VA independent. It's not like my VA would be the same as the VA that you're looking at. It's totally different, and it's really, really variable, but the VA is very aware right now that they're having a hard time hiring GIs because of the salary issues. So Jason Dominance, who's the national program director, and the FAC, which I just rotated off, but I've been on for eight years, you know, they're very aware of that issue because they're really having a hard time hiring. So there are ways that you can get more money through the VA, but I would just also say, you know, working at the VA, it's a great lifestyle. I have, you know, a lot of the people that I trained with work there. We have a really great group. We have, I have a great HPV surgeon. I have great IR. You know, weekends are really, you know, if you're on service, it's really light. Call is pretty light, and we're a big VA. I mean, we're one of the biggest, you know, we're in Vis and 10, which is, you know, Michigan, Ohio, some parts of Pennsylvania. We have a, you know, huge catchment area, but we're still, you know, at five o'clock, the parking lot's empty. So, you know, you may not get paid as much, but I'm just making a pitch to move to Cleveland. The cost of living is really cheap. We have no, so far, very little effects of global warming. We do not have fires, mudslides, tornadoes, generally. So, I think Cleveland's gonna be the next hot spot. And so, you know, there are good things about the VA loan repayment. There's loan repayment for if you were, you know, if you have loans, you can also talk to the VA about that. So there are a lot of really good things about the VA. Ashley, there's a famous joke about Cleveland that's actually relevant here, that like in every country, there's one city that they make fun of, and like in America, it's Cleveland. And in the former Soviet Union, it's Cleveland. That's the same. Yeah. Thanks, guys. Thank you.

contract negotiations

job contracts

negotiating

lawyer review

start date

salary

non-financial reasons