So, I just want to thank the organizers for inviting me. I'm excited to be here and I'm excited to chat with all of you, so please do catch me, you know, in between the talks and at dinner and everything, happy to chat with you. Let's see, I have no disclosures. All right, so I thought that it would potentially be most useful to start with a case. This case is of a 33-year-old Caucasian female who has a young daughter and she is married and she's searching for her first real job while she's finishing up her general GI fellowship and she's getting ready to begin her advanced endoscopy fellowship. So, her husband doesn't work outside the home, so she's the sole breadwinner of her family, which she hopes will grow more soon. She has little time, but she knows that negotiating a fair contract for her first real job is going to set her up for a future financial, professional, and personal success. Her goal, you have to have a goal, right? So, her goal is to help patients in a small to medium-sized community by bringing a new advanced endoscopy service line to that community. So, that's sort of like the mission statement, the personal mission statement, or the personal goal. Okay, that's what you go into all of this with. And she knows that this is going to require building a little program and she's already walked away, walking away, walking away from two contracts because the employer refused to honor her request to have the capital dollars that would be needed to build that new service line. So, she needs two linear EUS scopes, a radial EUS scope, double balloon endoscopy equipment, a 2T scope, and multiple new processors in addition to some other smaller things. So, these two employers said, no, we're not going to write that into your contract, but we will give it to you. It'll be here when you start, but we're just not going to write it into your contract. So, she walked away from those and then she was interviewing with another place that seemed like a good fit, but she requested to have some administrative time, half day a week, not talking about much, but she knew that she would need some time to build this new service line. It's not just going to magically happen. So, this employer said, no, we're not going to write into your contract any protected time for you to build the service. We really want this service line. We have this new cancer center. We need an EUS person. We need someone to do an EMR. We really, we're all on board. We need you and we'll make sure you're not too bogged down clinically. You'll get that time, but we're just not going to write it into your contract. Okay, so she walked away from that one too. And so, then a fourth employer she was working in talks with, they agreed to these above concessions about the capital for equipment and the protected time, a little bit of protected time. So, they proceeded beyond those initial steps. And then they asked her to go ahead and make the first salary offer. So, this is very common, especially hospitals will do this to new grads. They're basically banking on the fact that you're naive and you don't know your value. You don't know your worth, which is true most of the time. So, they think that if you throw out the first offer, that then they can just say, oh, yeah, we'll pay you that. No problem. Good talk. Because you're going to throw out a low offer, even though you think it's like a crazy high offer. So, they asked me to throw out, no, not me. This is a case study. So, they asked the woman in this case study to throw out the first offer. Okay, so that seemed a bit overwhelming with everything else she was juggling, finishing up General GI Fellowship, starting her vans. She had a little baby at home. She didn't feel that she had the time to do that proper due diligence on her own to throw out the first salary offer. And she feared that her ignorance could basically leave her vulnerable for settling and less than she was worth. So, at that point, she hired a contract review company. And that company gave her advice. It went over, you know, line by line everything that was in this contract. And they even offered representation. Meaning from here on out, the potential employer is negotiating with the representative from the contract review company that is hired. It's not me anymore doing these negotiations. So, that's nice, especially when you're talking about the money part of things. Because it's a little awkward to like, you know, sometimes be negotiating these things with your potential new employer. So, she had a, you know, about an hour-long conversation with this contract review company, which she paid like $300. It wasn't crazy. It wasn't a lawyer-based thing. It was just, you know, like a contract review company, not a lawyer that specialized in contracts. Those will be double or triple the price and may or may not have added value. So, they went over the contract with her and they decided together, you know, this young woman and the contract review representative, you know, what they wanted to negotiate and keeping in mind, you know, the value that she brought to the company. And they decided on asking for a very modest salary increase along with a couple other things. So, at that point, there was a pause in the communication. And it was like, did we offend them? Like, are they going to tell me to take a hike? Like, I don't know. There was like weeks that went by and it was like silence. So, you know, we call this a pregnancy pause and it was tolerated. You know, I didn't reach out and be like, oh, sorry, never mind, forget that last, you know, we're just going to just do whatever. But when they finally came back, not only did they agree to, you know, all of the sort of concessions that we asked for, but they also offered an additional $40,000 salary increase, which wasn't asked for. So, I was like, well, that's interesting. So, the contract review representative and this young woman, you know, they asked that potential employer, you know, out of curiosity, what prompted this additional salary increase? And they were told that the employer had decided that her salary should be commensurate with our other employed gastroenterologists. Like, you weren't going to pay me commensurate with the other employed gastroenterologists to start with? Interesting. So, obviously, this case represents my odyssey for my first real job with the employer that was before Cleveland Clinic purchased the hospital where I work. So, what happened in this scenario? I have to come back to this thing. Okay. So, just for, you know, so that this is me. I was finishing up my GI fellowship in Nashville. And this is my older daughter, Emma, when I was going through all this stuff. And so, you know, what happened? Basically, the things that went well is that I knew what I wanted. So, I had a goal. And I thought about what my must-haves and my like-to-haves were. And I walked away from several employers that weren't willing to write into my contract for the protected time or the money for, you know, capital investment. And I tolerated a pause in negotiation. So, those things were also all good. But, you know, had I not hired that professional contract negotiator, you know, I would have significantly underested my value to that potential employer. And they would not have offered me fair market value. And even with the professional contract person, they still tried to weasel their way out of not offering me fair market value. And obviously, fair market value depends on lots of things, like where you are within the country, if you're in an urban or a rural area, and these sorts of things. So, it's not a one-size-fits-all. And what didn't go well? I mean, obviously, I still undervalued myself. Especially women are very apt to do this. I should have hired probably a second contract negotiation company to get additional input. And that money would have been well spent. And meant that I would get a more fair starting salary, especially considering that all future contract amendments are based on the initial contract in your starting salary. So, it's a very big deal to make sure that you get a fair salary on that initial contract. So, I hope that you found this anecdote, you know, a little elucidating. And now, let's move on to talk about some of the items in more detail that were illustrated in that case. So, a letter of intent. What is a letter of intent? So, a letter of intent is a document that an employer provides to a physician that outlines the main elements of the employment, including usually salary. And it begins to set expectations for the negotiation process. So, it's not binding, but by signing it, you're agreeing to proceed to further negotiations and the full contract will be forthcoming. So, you think about it sort of like, you know, a gentleman or a dental person's handshake. And, you know, one thing that you can consider, the tips are going to be in red boxes, by the way. So, one thing you can consider doing is saying, you know, when you get that initial letter of intent, asking them right then and there, is this the best offer you can give me? You know, because I think just up front, you know, especially if you feel like that it's off, like it's way low, just ask them right up front, you know, is this the best offer you have? And you'll ask them again more later that same question, but like start out there. So, then you talk about a contract. So, the contract is a legal binding document that sets the expectations, right? So, what is the physician going to do for the employer? And then what is the employer going to do for the physician? So, it's a two-way street, right? We can't, you know, just look at it completely unilaterally. Let's talk about timing. So, there's no hard and fast rule here, but, you know, I would say that starting your sort of job hunt for your first real job at least a year and a half before you had planned to start the job would be, you know, a good idea. As Sarah mentioned, I think going on, you know, many interviews to gain experience and gauge your worth to the employer would be important. And to also, you know, review several contracts, even hiring, you know, contract review companies to review these contracts even though you may or may not be that interested in because you'll learn so much by just going through every line of the contract with a professional. And then when you get a good contract, hopefully moving forward, you'll be able to recognize it that much more easily or that much more. So, I think that's good. And then just practice the pregnant pause, right? Like I did, like you're like, it's like, you know, radio silence. What do we do? But just wait because you never know what they're going to come back with. So, also, this is super important, you know, literally write this down. Like, what is my goal for my first job? What's important to me? What is my vision? If I were to create a perfect job, what would it look like? And literally write it down. And then, you know, you have to decide column must-haves, column would-like-to-haves, right? And so, be prepared to walk away if your must-haves can't be met because there's a gazillion jobs out there. It's like, you know, when you were dating and your mom would always tell you, like, there's so many fish in the sea. Like, don't get so fixated on this one guy or something, you know? You're like, it's the same with jobs. Like, there's so many out there. Like, you can find one that works for you. So, then in terms of, you know, doing your due diligence, doing your homework, basically. You want to gather as much information as you can to negotiate from your best position of power. This book is mandatory reading for you guys, okay? So, this is like the Bible of physician contract negotiation. And I would recommend that you read it before you start that process that's a year and a half out from when you want to start your first job. Everything you need to know is in this book, okay? So, you also, in your information gathering odyssey, you also need to think about, you know, each individual employer that you're going to interview with and enter contract negotiations with. And what do they need? So, you kind of know what you want from them. But really, what do they want from you? Because then when you go to interview, you know, make it about them, you know? Like, I want to help you, you know, whatever, grow, have a GI hospitalist, take the call burden off of the rest of the group. So, you know, you're presenting yourself as how you can help them, not how they can help you, really. I mean, you need to know about that, so keep that stuff on the backside. But, you know, as you present yourself, it's all about how can you help them. So, we're going to educate ourselves. We're going to read books like this one, and there'll be a couple more later. We're going to read blogs. We're going to listen to podcasts. And, you know, there's lots out there on physician negotiation. Lots of good resources. Don't be afraid, too, to talk to mentors and friends about contracts, including salary. It's, like, historically been kind of taboo to talk about salary. But I think, like, we should be more transparent if we want, you know, the entire group of GI doctors, you know, to sort of raise that floor of compensation. Okay. So, we saw one kind of salary chart earlier, graph earlier. This is another one. This is from a Medscape survey from earlier this year. You know, basically, just try hard to know your worth, and then so that you can negotiate for it. There's other sources, you know, as Sarah mentioned, like, there's Doximity surveys. There's MGMA data. Just note, the MGMA data, it's all about, you know, Just note, the MGMA data is really expensive to obtain. Like, not, like, a couple hundred, like, thousands and thousands of dollars, or at least a couple thousand dollars. So, you don't have to buy that MGMA data yourself. If you hire a contract negotiation firm for $300, they have all that data. So, just spend the money, like, hiring the contract negotiation firm. Not firm, because it doesn't have to be a lawyer, but company. And they'll have all that for you. And they'll talk to you about it, like, very transparently. And they'll even show it to you. So, but in this little survey, you know, average annual earnings. So, this isn't salary. This is annual earnings, which includes, like, proceeds from ancillary stuff, like, pathology and anesthesia, whatever. So, this is, like, 512. This is for the whole country. Okay. All right. So, this one, as I alluded to, there's going to be differences based on where you practice, and in general, the Midwest, like here, reimburses, or the salaries are pretty good, and the Northeast is like, usually they're not that great, and everything else is sort of in the middle. This chart is from a Medscape survey from last year. You also want to think about the cost of living, where you're going to practice. It's really ironic that salaries are typically lower in higher cost of living areas for physicians. I know, blows your mind. You're going to make more if you go to a rural place, which is low cost of living, but maybe not super desirable to live, if that makes sense. You're going to be making a lot of money. It's crazy to think about. Consider the states that have no state income tax, like Florida, Texas, there are several others, because that's going to save tons of money over your professional career if you live in no income state, no state income tax state. If you've fallen asleep, I want you to wake up, because this is the most important point I'm going to make, and it's this, is that the intra-specialty salary, so within GI, differs much more than the inter-specialty salaries. On that last slide, I just showed you, whatever, the average GI doc was making 512, the average orthopedist was 558, so that's a difference of 40,000 or something like that. If you look at a GI doctor, so these are all GI doctors, and you look at the 10th percentile, where is everything going? You look at the 10th percentile, it's like 339, whereas the 90th percentile is like 884 for overall earnings, so that's a lot more than $40,000. We're talking about, you don't have to worry if you're interested in money that you didn't become an orthopedic surgeon. You can just play geographic arbitrage for even a couple years, right, and you can make bukus of money, save it all, invest it all, and then go practice in Palo Alto or wherever you want to go, because you already have all this money, so just play geographic arbitrage for a couple years, and then you'll have yourself set up. You don't need to be an orthopedic surgeon. So basically, geographic arbitrage is a financial strategy, it's a strategy that takes advantage of salary differences between different locations to maximize your purchase power, your savings, and your income. It's not for everyone, but it's something to think about, that's all. You have to know what every single word in that contract means, and if you don't know, you have to ask the company people that you hired, that's really important. So this was already talked about a little bit, so I'll just briefly say, you know, you can be straight salaried or you can be productivity based. If you're straight salaried, that's usually based on a minimum RVU or relative value unit, and the typical, like, I mean, this is gestalt, like, but like 8,000 work RVUs per year is pretty typical for like a core GI doc or even an interventionalist, you know, the IBD folks might be a little bit less, motility folks might be a little bit less, but that's a pretty good average, and then you have to know how much you're making per RVU. So I think Dr. Adler was sort of talking about this, basically, like, you know, an average amount of money per RVU might be like $45 to like maybe $70 per work RVU, so you want to make sure you're kind of like in this range, but then there may be bonus structures and incentive structures where, you know, the dollar per work RVU goes up after you hit certain thresholds of productivity. So this stuff is literally all going to be in your contract and it's like Greek, so you've got to figure, you've got to learn this stuff, right? You got to understand it because this is how you're paid. Oh, also, I wanted to talk a little bit about locums contracts. Those are totally different and maybe I could talk to people offline about locums contracts, but I haven't, I kind of left locums mostly out of this. So we know not to throw out the first offer, right? Because they're trying to take advantage of you and that you're naive. Also be careful of contracts with a high guaranteed, you know, one or two year salary because oftentimes what will happen is that after that guaranteed salary of $700,000 a year or something like amazingly ridiculous, they will make you hit that RVU threshold and if you can't hit the threshold, well, guess what? You make $200,000 a year. So you just moved your whole family, bought this fancy house because you make $700,000 a year and now suddenly you don't have the infrastructure, the nursing support, the APPs, the, you know, catchment area to continue, you know, making these these RVU threshold. So that's a common trick that some places will use to get you there and then it's like a bait and switch thing. So be careful if you see that structure. It can be tricky. It can work too, but it, but just be aware. This is another really good book called Never Split the Difference. I would also recommend this one, but after you read the other one, but basically this is just saying like, you know, if they offer you $400,000 but you think you're worth, you know, $500,000, don't just say, oh, let's settle on $450,000. Like that's just not a good strategy. It's a lot more nuanced than that. And this, this is an interesting book that kind of talks about that. Okay. So insurance. Okay. This was confusing to me when I was working on my first contracts. You have to know how much malpractice insurance the employer is offering you. And that's going to be in your contract. So malpractice insurance varies by state. So know in the state that you're applying what some averages or standards would be. For example, in Florida, a claims made policy, an average would be like a hundred thousand dollars per incident and like $300,000 per year. So meaning like you could, but you won't get sued like three times in a year, you know, for a hundred thousand dollars each for a total of $300,000 that would all be covered with your malpractice insurance company. So, but then you have to understand the differences between a claims made and an occurrence policy. So most policies are claims made, which basically covers incidents like lawsuits that happen during the policy period, but only, but only if the policy is still in effect. Okay. Whereas an occurrence policy covers incidents that are made when the policy is in effect, regardless of when the claim is made. Does that make sense? So like, say, you know, you work at hospital A for three years, and then you decide to take a job at hospital B. Well, hospital A said in their contract that they're not going to pay your tail insurance. Okay. And it's a claims made policy. So that means that when you leave hospital A, if you want to be insured for things that happened while you were at hospital A, but a claim, a lawsuit wasn't made until after you left hospital A, you have to have tail insurance. Does this make sense? Okay. So tail insurance is basically like a supplemental policy that is purchased to cover those claims that can be made after the policy is canceled. And who buys the tail insurance policy should be written in your contract. Okay. So your employer at hospital A could be responsible for paying your tail, or you, the individual, could be responsible for paying your tail. And this is important because these policies aren't cheap. They're typically 200% of the annual claims made premium in the state where you work. So for example, in Florida, that's about $80,000 on average for a tail policy. So you're responsible for that when you leave hospital A. Other option is to get nose coverage. That, in my understanding, is a little bit more rare. And you could talk to your hospital B, your future employer, about whether or not they'll pay your nose. Basically, that just means that they'll cover things that happened from previously before you started employment with hospital B. Oh, yeah. And to have a BANTA. A BANTA is a best alternative to negotiated agreement. So this is great because you're going to be interviewing at several different places. So if hospital A, like, you know, you have this good offer, but maybe you kind of location-wise and family-wise really want to be in B, you know, and they're similar locations, similar, like, community-type, you know, size, you know, you could say to hospital B, you know, you're going to be in B. You know, you could say to hospital B, like, you know, we'd really like to be here because my mother-in-law lives here, and we have these little kids, and we need the help, and, you know, but, like, down the road, you know, I'm getting this offer, and they're gonna, you know, pay me this, or they're giving me this much time off per year, or whatever. I'm really hoping that you guys will be able to match this because I would love to bring my services here, right? So that's a BANTA. So you're kind of using that as a negotiation strategy. Okay, so you're gonna negotiate all of these things, you know, including a scribe or an APP, CME allowance, all these things potentially are negotiable, but just remember, if it's not in writing, it's probably not going to happen. So if it's important to you, make sure it's in writing, and this goes for something that just came up in terms of, like, call, right? So call will be in call, right? So call will be in your contract, and it might be something generic, like, I will equitably share call with the associates in my group. Okay, and when you join the group, there's nine other associates, so you're one of ten, and so call's, like, not so bad, but then, like, eight of them quit, and so now there's, like, you and one other person, and your contract still says, I will share call equitably between the other associates in my group, which used to be ten and is now two, and so that's not great. So you could consider negotiating something like, I will not take more than X number of calls per year, or, you know, my percentage of time on call, given my overall clinical duties, will not be more than X percent, something like that, but you have to, you know, when you're thinking about contracts, I think you need to prepare for the worst, but hope for the best, and just think of all the things that could go wrong and try and be prepared for them. Okay, I'm almost done, so I'm not sure how far over I am, but sorry, Lisa. Okay, so all of this is great, but a lot of places, especially the VA and, like, large employers like Kaiser and stuff, they may just have a standard contract, and that's kind of easier. It's like going to shop for your car at CarMax, so there's just, like, a sticker price, and you're just, like, I like that sticker, I don't like that sticker, and that's it. There's just, like, less headache, less back and forth, you know, so there's, like, some nice things about, I think, a standard contract, but it's still important to do your due diligence, you know, there might be a little bit of room for negotiation, but a lot of things are going to be kind of baked into the contract, you know, it's important to ask about, like, the doctor turnover rate, what the support staff is, RVU thresholds, all of those things are still important with a standard contract, and just find out from the other people, like, what might be negotiable, you know, salary is probably not going to be negotiable, but, like, little support things might be negotiable. In a standard contract, you can consider asking for this letter of understanding, which is basically, you know, not binding legal document, but just shows good intent, and so this is important if, like, somehow your manager changes, or your chief changes, or something, and, like, you have this letter of understanding that says, like, oh, you know, I was going to have this office, and, you know, this MA, or something, and now, you know, your chief is trying to say that you don't have those things. Well, you can bring this up and say, well, 15 years ago, when I signed my standard contract, you know, this was here, you know, and it may or may not work, but it's something in writing, and they may, you could, you could ask for that, but the bottom line is, is that if the contract is not the right fit, you're willing to do what? Walk away. Just walk away. Restrictive covenants. This is the second to last slide, so these are contractual clauses that restrict your ability to work in a certain geographical area for a certain period of time after leaving the employer. It could be something, like, you can't work for 100 miles is really far. It's usually more something like 25 miles or 50 miles, something like that, for, usually, it's a year, and this is a big deal because, again, we're preparing for the worst, even though we're hoping for the best, and so if there's employment termination, you know, you don't want to breach anything in your contract without legal counsel because that can be a big deal, and so you don't want to breach your restrictive covenant, either, if you have one, so this could mean that you're having to work somewhere else really far away for a year or take a year off or do locums for a year, so it can really impact your life if you have a restrictive covenant like this, but the enforceability varies by state. There's usually a buyout option that should be in your contract, too, so I have this restrictive covenant, but there's a $100,000 buyout option or something like that, so if you went to an employer down the road, which is within your restrictive covenant area, you could ask that new employer to buy out your restrictive covenant, so that hospital gives the other hospital $100,000 to buy you out, basically. Stuff like that exists. All that needs to be in your contract, though, and then there's ongoing public debate about the enforceability of restrictive covenants, also known as non-compete clauses, because they potentially, I mean, they do impact access to care, especially in underserved areas, so there's legislation looking into maybe that these are kind of not, they're not going to continue on, but right now, a lot of contracts still have them. Okay, get professional help. Choose a reputable company. I really like White Coat Investors, just sort of in general, and on their website, they have a recommended list of vetted contract negotiation companies, so you might want to consider that. This is a good podcast, all about contract negotiation, podcast 133 on White Coat Investors, and last thing is that, just remember, you're in a powerful position of negotiation. There's 14,000 practicing GI docs in the U.S. right now, and currently, the demand for GI docs exceeds the supply by 2,000 full-time GI doctors, and that number is only projected to rise, so these employers need you. They want you, but they're going to try and pay you as little as possible to come, unless you know your worth, and that's it. Thank you so much for having me.

job contract negotiation

GI fellowship

capital investment

contract review company

salary increase

geographic arbitrage

malpractice insurance