I am currently professor and chair of neurosurgery at Northwell Health in Hofstra. In that capacity, I oversee neurosurgery for the residency that we have and the fellowships that we have, but also for multiple hospitals, including North Shore University Hospital, Lenox Hill Hospital, and Long Island Jewish Hospital, amongst others. I feel like in this capacity beyond neurosurgery, I've had a chance to really look at how we build programs and how we recruit. When people are wondering if there are non-negotiable items, I think the first thing to think about as a graduating or a new and young surgeon is understanding the job that's being offered. So for example, if there is a job that's cut and dried about what is expected, there may be some non-negotiable issues such as call coverage, which everyone must take, or titles which may or may not be given early on, and those things are not things that the chair or system lead might be willing to give to a new graduating provider. That being said, in certain centers, for example my center where it's a very large system, there is some flexibility. So I could imagine, for example, that if someone were to come in as a major researcher, plan on getting grants, maybe being in the lab for a significant amount of time, that their call coverage may be different than someone who is mainly clinical. If everyone is really considered the same in that job opportunity, or the job is very, very clearly delineated as what is expected, pushing against those recruiters may be not smart or not prudent for the person applying. With regards to titles, same thing applies. If this is a title that's being earmarked as something that's given because the applicants have some special skill or competency, then the title may be something that's easily given. On the other hand, if there is no title, pushing for that as a new graduate, again, may not be prudent and may change the working relationship from a very beginning stage to being one that's not a great working relationship if one really pushes on such things. So I can imagine someone who is a dedicated researcher, maybe a lot of lab time, maybe their call coverage is not as much as someone who's being brought in to mainly do a lot of clinical work. So in those situations where there are many different types of jobs, this may be something negotiable. Similarly, if someone has a very nuanced or specific title, one can potentially ask for that title given that they're being brought in for something very specific, and getting that title may add some recognition not only to them but to the institution for having such a title. And so in those cases, they are negotiable. The take-home message is understanding what the job has been delineated as before one goes into the interview or at least gets some idea of that. If this is going to be a very clear job description, negotiating such things as call coverage and titles may not be prudent. On the other hand, if there is some fluidity, then bringing it up early might be very beneficial to the applicant. Now with regard to other non-negotiable items, I would just add that for me, I think everything is negotiable except working in some capacity. With regards to other non-negotiable items, the only thing that I would add for someone coming out of training is that value must always be given for a title or for some type of benefit. And so if someone is asking for something, they actually have to show that they're providing that value or at least convince your future employer that you're providing it. For example, if you're asking for something and not providing the work, the research, the patient access, or the academic benefits, then it's not negotiable because the value is not being prepared. For example, a ludicrous example would be if a surgeon says, I want to be a neurosurgeon, be paid like a neurosurgeon, but I'm not operating, I'm not seeing patients, I'm not doing research, I'm not teaching, then in reality, there is no value being provided and that negotiation is kind of dead in the water. So always think about providing your value and being creative with that, but also be understanding that you have to be held accountable to that. In that setting, I think everything can be negotiable, but it has to be a value add. There are some non-standard contract components you can consider talking about. When it comes to a number of these non-standard aspects of a contract, a sign-on bonus is often something that is considered a lot in such contracts. Relocation packages or moving expenses are often also considered. I would say third in that setting would be something like a CME or professional development support, and then sometimes even people talk about loan forgiveness. So I'll go through those individually. A sign-on bonus is something that is often seen as an extra step to getting someone to come with you. Systems are willing to do it because it's a one-off, it doesn't become part of the normal contract and therefore once that's done, they can budget that away. And sometimes it's the thing that quote-unquote gets the applicant over the finish line. And if that's the case, it can be something to use like that. Once again, I wouldn't ask for a sign-on bonus if you're happy otherwise, but if you're deciding this between two places or this bonus would really make a difference and arguing why that would be the case, then it seems very reasonable. A relocation package is something that I think is very helpful for people who are coming from far distances. So someone from California coming to New York, that could be a very valuable benefit to the person applying because that relocation would be very expensive. If on the other hand, the person say is in New York already and they're not moving from their house or they're in the program already and they're staying on the program and asking for a relocation package, that doesn't make any sense to me and I don't see that. So for example, you say, well, I want to get a bigger house than the one I lived in with my residency, that's not really a relocation package. So that one wouldn't be used in that setting, but I do think it's something that could make a place competitive. In other words, if one place in New York is willing to give relocation packages from California, that may be the difference to get them over. I would be very careful, however, as asking necessarily for both. Sometimes people will negotiate for a sign-on bonus and then they'll say, now I need a relocation package and sometimes what they'll hear is use the money from the sign-on bonus to pay for your relocation. You've already negotiated that. So be thoughtful about how you're going to sequence that. In terms of CME professional development, I think this is something that could be an investment in the person. So for example, if that CME or that professional development adds to the department or to the patients or to the group in general, then it's an investment and it can be very attractive for the employer to give that to the employee. On the other hand, if the CME professional development is something very nuanced and very niched and very maybe even a hobby for that person, they want to learn another language or they want to do something that may not be completely transferable or designated for their new job, it may not be something that's supported. So be understanding that you have to make the case for why this support would help the department. And then finally, loan forgiveness. I think that loan forgiveness is not something that I've seen much at all, but it's something that could be brought up. I think really it would be in terms of if without that loan forgiveness, would it change the way the person does their job or accepts their job? So for example, maybe if they are significantly in debt, would they have to take care of their children by using family members? And if their family members can't travel because they're far away, you could imagine making a case for saying, I need this loan forgiveness just to cover my cost of daily living. And without that, I might not take the job because I'm needing to rely on so many others. So that's a very compelling argument versus, hey, I have some debt and I'd like to just do you pay for that. That would be something that everyone can argue for and is not something that's usually given. So be thoughtful on that. And those are really the main things that people think about when they think about non-standard contract issues. There are a lot of details to think about in a contract, but I would think the overarching key takeaway that I would want to share with people out there is that this is a working relationship. And with that, one always has to think about how to provide value, not just for yourself and your family, but for the future employers and the future partners that you have. And therefore, always think about this is going to be a relationship, and when pushing for situations that would help your contract be more attractive, be careful not to over push. Or if one is really going to push, the understanding that you're going to have to then deliver and be accountable for that. In this way, I would say it's what's often described as an integrative negotiation. Integrative negotiation means it's good for both sides. And so if one is thinking about which way to go on something, think first, is this going to help my future employer and me? If you're going to help your future employer, they're going to want to do it just as much as you are. If this is something that seems to come off a little bit selfish or this needs to be done or else I'll be unhappy, and that's portrayed to that future employer, that may be a turn off. And so always thinking about how to be integrative. And what I always like to think about is a Venn diagram where there's some things that I want in my life. There's some things my employer wants in their lives. And there's things that we both want. Identifying that overlap is key to understanding how to get things that are good for you and good for your employer. Those are the things that are often given freely. And if you can identify those even before you begin conversations with that future employer, you're going to be in very good standing.

job opportunities

expectations

non-negotiable items

call coverage

titles