At a cost of around $100k to onboard a physician into a corporate medical group, you have a lot more negotiating power than you think. It’s important to handle negotiation tactics tactfully and understand all the options you have. Physician employees are about to get a leg up in the negotiations as medical groups are having to battle the burnout epidemic we’re facing.

This post is just as relevant to a physician employee as any other kind of clinician, whether MD/DO/NP/PA, you fall into one of 3 categories:

good provider
underperforming/poor clinician
stellar

Depending on which category you are in you’ll have a certain bargaining power. The extent you are willing to go in order to push the negotiations has a big impact on your potential success.

The areas of negotiation are:

employee benefits
salary
job advancement
work schedule
bonuses

Your Physician Employee Status

If you are a stellar physician employee then you’re wasting your time at a large medical group. Find a private smaller medical group and squeeze in there. It’s hard to stand out as a stellar physician and you’ll create more waves than you’re worth.

If you’re a good physician employee, as in, you go with the flow, you don’t rock the boat and you get along with most everyone else then you are the ideal candidate for mastering your negotiation tactics.

If you’re a shitty physician employee then it’s important to figure out why you’re considered shitty. Either you are an abrasive person and lack competence or you have a very strict practice style but just rub people the wrong way. You can tell the difference because if your personal life is as terrible as your career life then you’re just a shitty employee (sorry) – stop reading here. But if you have plenty of friends and get along with your family and have a balanced life otherwise then you’re just in the wrong medical group and might just have really poor negotiation tactics – read on.

Job Satisfaction

I loved the shit out of my job from 2009-2012 as an Urgent Care physician at Kaiser Permanente. The work was enjoyable, I loved the fast pace, and I befriended some great clinicians.

I didn’t know it at the time but my management team was toxic and so was the workplace. Ignorance was bliss and I had plenty of that.

I was satisfied with my job and was always picking up extra hours. There was no reason for me to need to negotiate for anything more. But unfortunately if you wait to master your negotiation tactics then it’ll be too late. As physician employees we are too valuable to be stagnant – always negotiate and always be reasonable in your negotiation tactics.

Capitalize on Being a Good Physician Employee

Be flexible if the schedulers need you to work more, don’t call in sick, and don’t argue with your medical director. This will ensure the highest bargaining power down the road which you’ll need – few clinicians will remain in the honeymoon phase of medicine past 5 years.

Satisfied But…

Perhaps you are in a position where you love the hours, love the coworkers, happy with the patients, but really wish you could have a higher income.

I will discuss the desire for a higher income in another section because going from $100 to $120 per hour doesn’t mean shit if that 20% bump is corroded by work inefficiencies.

Characteristics of a Good Job

1. Good management. It’s not easy to build a strong management team because an employer cannot prevent good managers from climbing the corporate ladder. If your medical director and charge nurse and HR director are all competent and caring individuals then you should weigh that against an extra $1-2k/month of income.

2. Friendly colleagues. There is nothing more I miss than working with a good colleague. My buddy Dr. S. was one of the main reasons I could keep showing up to work even though I was burnt out.

I’ve worked with amazing nurses at KP in SoCal and disasters at KP in Oregon – it makes a world of a difference.

3. No nurse union. Unions suck in medicine. Never came across a union which improved work conditions for providers. In fact, unions create as much headaches for those who are members.

A few medical groups handle their unions well but unless you have identified these it’s best to consider the downside of being a clinician in an environment where your nurses cannot be held accountable.

4. Low acuity/low patient volume. A competent practice can efficiently move a lot of patients through which can help make clinicians and staff feel more productive despite the higher volumes – this is very rare.

More often, it’s better to have a lower patient census and lower acuity. Patient-mills such as Kaiser Permanente are great places to learn how to be a fast provider but the higher volumes and higher acuities can wear you out regardless of how many dollars are waived in front of you.

5. Flexible scheduling. You might be the kind of clinician for whom medicine just comes easy. Naturally, you’d be more focused on the income and the quality of life the job affords you.

Having the flexibility to change your schedule is high on the list for younger clinicians who have kids or start a new relationship.

Dissatisfied With Work

You might find yourself dissatisfied with your work at your large medical group and this is when you need to get fancy in order to maximize on your employment negotiation tactics.

Reason for Dissatisfaction

Are you generally unhappy with life or medicine? Or is it the workplace or the nature of the work that is generating misery?

1. Poor management. If you have problem with management then the good news is that management in large medical groups turns over every 1-3 years. You can either milk the system by calling in sick a lot, seeing fewer patients, using FMLA, or filing for a short stint of disability.

2. Incompetent medical group. It’s rare for a large medical group to be incompetent. Sometimes a particular medical department is out of touch with reality but most larger medical groups have 3rd party consultants which help them keep up with the competition.

If it is an incompetent medical group you are dealing with then you need to bounce – ASAP. We’ll talk about how to tactically change jobs in a moment.

A great example is the shitshow that is the correctional medical institutions. Doctors leave for these stupidly high paying jobs in groves just to burn out from them due to mind-numbing management incompetence.

3. The salary. If you’re earning $100/hr and eyeing another medical group which is paying $120/hr then we’re talking peanuts. If you are getting paid $85/hr and are dissatisfied with your job because others are making $150/hr then it might be worth the switch. But why not negotiate with your current employer first?

Higher Salary

Is it worth it to jump shit for a $20/hour salary raise? Rarely.

Let’s say that your commute time increases or even worse, you have to move for this job, then $20/hour will not be worthwhile unless you are miserable then of course even a salary cut might be worthwhile.

Taxes

This is a strong argument. Understand that as a highly compensated employee, the extra money you make takes place in a higher income-tax bracket.

If you are making $250k and are going for a $40k/year salary bump then you’re only going to be seeing 50% of that money – so it’s not a $40k salary bump for you, it’s only an extra $20k a year.

Employee Benefits

One of the few things Kaiser Permanente had going for them was that they paid their physicians far higher than their competitors and they offered them the best employee benefits imaginable.

It’s quite possible to go from one medical group to another just to end up with a shitty 401k option, lose your 457 option, get less vacation time, or lose the ability to cash out your vacations.

Some medical groups will allow you to pick up extra shifts. Others will tell you that you can pick up extra until you get hired and realize that all the per diems have that market cornered.

Your Budgeting

During my wealth accumulation days I was one frugal little mouse. I hustled for every single dollar which is not an exaggeration.

If you are bleeding money from 18 different line-items on your budget then why bother negotiating for a 20% gross salary bump, of which you’ll see only half?

This isn’t meant to be derogatory (okay, yea, it is) but if you don’t take care of the leak in your bucket then why turn up the faucet? All things being equal it’s much better to stay put and cut your expenses by 20%. Changing jobs can be a headache – not always but usually.

Negotiation Tactics

Everyone will tell you that you cannot negotiate with this or that medical group. They will tell you that xyz has never been done before. Your colleagues, HR, and your chiefs will have no clue – you have to push your tactics up the chain.

People love their hard and fast rules because it gives them a feeling of security and sets boundaries. Few will achieve worthwhile accomplishments following rules.

I have worked for one of the largest medical groups in the US and I have successfully used different negotiation tactics to increase my salary, get less clinical time, do more meaningful work, and get a better schedule. Not because I’m stellar but because I’m willing to buck the trend.

Not Needing the Income

Not needing the income from your job is going to be your biggest bargaining tool. However, this must be backed by a solid resume. The resume doesn’t have to be anything spectacular but should demonstrate that you can handle different jobs, different positions, and have the potential to move up in an organization.

I recommend being tactful but upfront. “I am interested in this position because I am in the fortunate position of no longer needing the income but I am passionate about my work and want to make sure that it’s the right work environment so that I can excel.”

This can also play out in reverse. You might apply for a job position which doesn’t pay much now but has the potential for very high income in the future.

I applied to a large medical group in town and the recruiter told me that with my resume I could qualify for a better position – a position which hadn’t yet been created. I talked to the chief of the Urgent Care department who told me that if I was interested he would create this position for me.

He understood that I didn’t need the income and I wanted to do something that I would enjoy and hopefully excel at in order to make himself and the medical group look good. Because I wasn’t in a rush it worked out beautifully. I’ll write about the details of this position in a future post.

Move Horizontally Within Your Own Group

You might be a surgeon in your medical group who can’t stand scrubbing into another case but you’re happy to do more clinics. Even if that’s not an option understand that your negotiation tactics could create such a position.

If you’re a Primary Care doctor then it might make more sense to use your negotiation tactics to move into the Urgent Care, the Fast Track in the ER, Occupational Medicine, or Employee Health.

The most important thing is knowing about these options – maybe having the creativity to think them up. These aren’t going to be advertised to you. In fact, when you approach such options traditionally you’ll get the cock-block answer of “Sorry, we don’t have such a position available” or “Sorry, you must have completed an Occ Med residency” or “We only hire ER doctors for that position”.

Request a Leadership Role

Even if you don’t intend to ever take on a leadership role, it’s worth interviewing for it. By doing so you learn the ins-and-outs of your medical group. No matter how much you think you already know, there is always one more piece of information that you can use in your negotiation tactics arsenal.

Back in California at Kaiser Permanente I interviewed for a leadership position that came up not because I was interested but because I wanted to get to know the players. From that interview I learned that the Pediatrics department was desperate for clinicians during the cold and flu season. That’s how I was able to pick up shifts in the peds department – as you may know, pediatric medicine is like sorting mail, except, it pays more.

Suggest a Position

I realize that you might need some hair on your gonads to pull this off but if you can display even a little charm then you can have some legitimate options to suggest a new position for yourself.

Often all you need is local approval from your medical director or chief. Bonus points if you are willing to do this role for free at first gambling on it being remunerated in the future.

Flexible Schedule

I was assured by everyone I spoke to that it was impossible for me to not have a set schedule at Kaiser Permanente and that I must submit my availabilities 3 months in advance like every other tool.

Yet I managed to secure a float position where I was only responsible to make sure that I would pick up enough last-minute shifts to fill my full-time schedule. I knew that between Family Medicine, Urgent Care, and Internal Medicine there would be more than enough shifts for me to meet my full-time hours.

Pad Your Resume

May god forgive you for reading this section but… you have my blessing to lie on your resume. Not just lie but really get creative. Make up names, dates, medical groups that don’t even exist.

But… but… why Dr. Mo? It’s so wrong.

If your employer has ever lied to you then you are allowed to lie on your resume – with a caveat. If your employer has been the Buddha of employers then don’t you dare lie.

The caveat is that you are the sort of employee who actually has the skills that you’re about to lie about. Don’t say you led a team to improve patient throughput if you have no idea what that entails or how to achieve it.

Don’t claim you supervised PA’s and NP’s if you’ve never worked with them or ever had them run a case by you. But if you are the go-to person in your practice for NP’s and PA’s but your medical group has decided to add that extra responsibility without compensating you for it then guess what, it’s going on your resume like this:

Lead physician for management and supervision of Physician Extenders. 10-15 hours per week. 2010-2016.

Bonuses

Many medical groups are advancing their bonus models because of the way that medical groups are being compensated these days.

Even non-profits, government, or educational institutes have a profit-sharing or bonus model built into their compensation model somewhere.

The problem is that your HR and your medical director, nor your chief, will have a fucking clue about this.

The good news is that you don’t have to do all the leg-work for this. Simply suggest it, let the managers push it up the chain, and see what comes back. If you need a little bump then you can always say “That’s how we did it at my old medical group.”

Less Clinical Work

Medical groups are reluctant to offer or advertise administrative time. But just because something isn’t offered does not mean that it’s not available.

scheduling providers
negotiating with unions
onboarding new employees
interviewing new-hires
sitting on committees
handling QA cases
capturing chronic disease diagnoses

You might be offered a couple of hours a week of paid admin time or you might be able to shave off some clinical time from your shift. There are ways to milk this to best suit you.

More importantly, once you enter the world of admin time in a large medical group then you’ll see how much more opportunities are available for such non-clinical work. You can have your fill of useless meetings with providers who know nothing about medicine – but… that’ll be one less butthole you have to finger (referring to patient care).

Debt Forgivess

I think there is a time and place for debt restructuring but when I see it in practice it’s done ineffectively. If you go through all the headache and paperwork to go from 8% to 6% to save $3k/year but you are spending $6k/year on excess comprehensive auto insurance then what’s the point?

What about a debt forgiveness hook? A competing medical group offers you a $100k or $150k debt payoff if you sign up with them. Is it worth it?

I could write pages about this but the things that stand out to me the most are:

you’ll be locked into that job for 5-7 years
you likely will owe taxes on the forgiven debt
you won’t get a lump sum payoff

If you have $300k in student loan debt and are making $300k/year and are offered a $100k student loan forgiveness then I just don’t see it being worthwhile.

In fact, if it was worthwhile then your job wouldn’t offer it – sad to say it – but most of the benefits that our employers offer us are bloated and unnecessary and you can recreate for yourself at a fraction of the cost.

Threatening to Resign

Yes, this works but it has to be done tactfully. Understand that your HR and leadership team have dealt with a lot of clinicians who have threatened to resign over the years and if that’s the gist of your negotiation tactics then they will call your bluff.

Instead start shopping around for another job and interview and get some quotes. Don’t make this obvious and don’t rub it in anyone’s face.

In a professionally worded document or in a meeting bring up something along the lines of “A friend of mine at XYZ Medical Group reached out to me for a position which is offering a few attractive options. I’m committed to this company and have no intention of switching but I wanted to discuss a few options to possibly close the gap between what our competitors offer and what we offer. I’m curious how we can make it a win-win for both me as an employee and the medical group.”

Be patient, don’t be a child about this. If you do decide to take this approach then understand that you are placing your medical group in an awkward position.

proceed with tact
be patient
keep the negotiations going
be ready for a lot of no’s

What’s delightful about this strategy is that you can use it every 6-12 months. It’s called competition and every medical group understands this. If you’re not doing it then you’re going to be taken advantage of.