I am Dr. Aviva Abash. I've been practicing for 21 years, am a fellowship-trained epilepsy and stereotactic and functional neurosurgeon, and I have worked in four different U.S. academic medical centers and their affiliate hospital systems since completing my training. I've reviewed double that number of employment opportunities over the years. There is a significant amount of variation in employment contracts between different institutions and different practices, and I will try to speak in general terms. An employment contract is a legally binding document between you as the physician and the clinical institution or practice at which you are seeking employment. The components of a physician employment contract will differ depending on your practice type. An academic medical center employment contract will differ from a private or employed contract, and a government institution will be different from either of these two other types. I will describe the key components you should look for to help you review your first employment contract after residency. A typical employment contract will state your compensation structure, which will include your total annual base salary and usually a dollars-per-month amount. Your base salary is derived from clinical effort, estimated productivity, and national benchmarks for similarly trained physicians. You'll hear more about national benchmarks later in this video. For our purpose here, know that base salary is part of the compensation structure. In addition to your base salary, your compensation structure will include a bonus or clinical incentive opportunities, which are based on clinical performance metrics, such as the work RVUs you generate in excess of the agreed-to baseline work RVU expectation, or your academic contributions such as research grants obtained or journal editorial board positions, or quality metrics such as improvements in patient length of stay for your subspecialty, or observed over expected complication rates for your patient population. The duration of the contract, which can span a single year or multiple years, will be noted in the contract, as well as the required annual working hours to be considered a full-time employee. Note that full-time status is required for retirement contribution eligibility. Paid time off will also be described here in your employment contract. Your scope of work will include clinical duties such as call frequency, clinic time, or clinic template, which refers to the number of clinic blocks you will run, and how many patients you will evaluate in clinic, operative time, and whether you will have block time or open scheduling for the operating room. Research expectations, if you are considering employment at an academic medical center, will be funded typically through grants or extramural awards after the period of your startup package. It is crucial to negotiate for the total research startup package, including the cost of equipment, lab space, staff salaries, and buy-down for your own salary, that you will need to be successful in launching this aspect of your career. Work hours, call schedule, duties, and responsibilities do not generally appear in employment contracts for neurosurgeons. You are joining a team, and the expectation is usually that all parties will share equally in the workload. Now, there are a couple of caveats here. First, it is worth sorting out prior to signing a contract whether there are separate call schedules, for instance, for spine, vascular, pediatric neurosurgery, if it is important for you to be included or not included in one or another of these call schedules. Secondly, if the practice that you are joining allows people to opt out of the call schedule, say at 60 years of age, and a significant number of your prospective colleagues are in their late 50s, you will need to understand the burden this will create for you and what strategies you might negotiate for to mitigate this, for example, the implementation of call pay or the hiring of additional physicians. Exclusivity refers to the stipulation that a physician can only practice for the employer unless written consent is provided to the employee by the employer. Licenses, privileges, certifications, credentialing will all be included in the contract, as the employer will stipulate that the physician employee must maintain eligibility to practice in his or her specialty area, must maintain privileges to practice at the institution, and must be fully credentialed as terms of employment. Professional fees include society memberships, costs associated with maintenance of certification, costs associated with attendance at CME-granting events, items required for your practice such as surgical loops and headlight. These items can be listed in an employment contract but should be discussed with your employer. You may also have unfunded time, such as buy-down negotiated time for research, weekends, or self-protected hours. Finally, in academic medical centers, your teaching expectations will include medical student and resident education and possibly graduate students and postdoctoral fellows. The teaching expectation typically includes formal lectures, journal clubs, grand rounds, cadaver labs, and the more informal teaching that happens as we train the next generation of neurosurgeons and clinician investigators. This component of your job is typically covered in the letter of offer and not in the employment contract. Benefits include health, dental, and disability insurance, retirement saving options, malpractice insurance, and non-professional revenue opportunities, such as industry consulting and investment options. Benefits are an investment in your retirement and in the financial future of yourself and your family. There are multiple resources available on this topic, including benefits and long-term financial planning advisors, and you should invest the necessary time to inform yourself thoroughly about these various options. Employment-based medical benefits include health plans such as a PPO, HMO, or consumer-driven plan, and an option for a Flexible Savings Account, or FSA, or a Health Savings Account, known as an HSA. Your options will depend on the specific benefit mechanisms that your institution has in place. Other benefits included in your contract should be dental and vision coverage and disability and life insurance. A note on disability insurance. Make certain that the plan is geared towards physicians, as disability insurance is a form of income protection for you. Life insurance coverage might be term or whole life and is a means of protecting your family's future. Term life insurance is limited to a specific duration and then can be renewed if desired, but typically at a higher premium, whereas whole life is not term limited. Again, invest the time and effort to understand which type and amount of life insurance is appropriate for your situation and your financial goals, and seek advice from benefit experts. Retirement options, depending on the institution, can include defined contribution plans such as a 401A, 401K, or 403B, deferred compensation in a 457B plan, or a traditional IRA. Your contributions to each of these retirement plans is derived from your pre-tax income, which lowers your adjusted gross income, serving to decrease your taxable income. Another area covered under benefits is professional development. Institutional continuing medical education, or CME, budgets for academic research or clinical activities could include financial resources for CME granting activities, professional society memberships, other professional expenses such as journal subscription costs, operating loops and headlight, attendance at special courses or additional training, for example, and coverage of costs associated with Gamma Knife certification. Other examples include affiliation with universities and tuition reimbursement opportunities for you and or your dependents. Malpractice coverage is often part of an employment agreement or employment contract. You'll learn more about malpractice coverage in a later section of this video, but pay attention to who carries the premium. Is it the employer or the individual? Malpractice coverage terms are determined by employment organization and by the state in which you will be working. If the malpractice provided is a claims-based policy, you may choose to add TAIL coverage that extends beyond the malpractice coverage provided by the employer. TAIL malpractice coverage provides insurance coverage for claims brought after a claims-made insurance policy terminates, which typically happens when you leave one employer and go to the next. Other important areas to note in your contract are restrictive covenants, termination clauses and indemnification. Restrictive covenants include non-compete and non-solicitation covenants and are typically clauses in an employment contract which prohibit you from competing with your former employer for a certain period of time after termination of your employment or which prevent you from soliciting or dealing with patients of your prior employment. A termination clause or severance clause delineates the grounds for termination of employment and what will happen if you are terminated with respect to how much notice and what sort of payment you might receive depending upon the type of termination. An indemnification clause describes the responsibility of one party for losses incurred by another party. In this case, the organization employing you. Indemnification clauses should be reciprocal for both you and your employer. Note that your employer will not want to be responsible for losses caused by your negligence and you should not assume the risk for your employer's negligence. In addition to monetary items such as compensation, bonus or benefits, your letter of offer might also indicate whether, what kind and what percentage of staff support will be available to you. Depending on your institution, you may have a full-time surgical scheduler, an advanced practice provider to help run your clinic and outpatient practice and perhaps to help evaluate patients during uncompensated postoperative visits and a medical billing coder. Staff support could also include a department or practice administrator. It is not uncommon for people to focus on total compensation as the most critical attribute of an employment contract. Without diminishing the importance of being paid commensurate with your years of training and expertise, I do urge you to prioritize this aspect of the employment contract because without adequate support in the form of clinic, scheduling and administrative staff, it is difficult to impossible to meet your professional and career aspirations. The physical space you occupy might also be detailed in the letter of offer. Even if not explicitly stated on paper, you should discuss and understand your clinic details, how many clinic locations and exam rooms are there and what is the staffing ratio for you. Similarly, discuss with your employer and understand about the operating rooms you will have access to. Note whether these are in different facilities and if applicable, what block time arrangements will be made for you. Capital equipment needs and would-be useful items should be discussed and agreed to prior to signing your letter of offer and employment contract, but will likely not appear in either document. Dedicated or shared research space should be noted and will vary given the type and nature of the institution. Factors such as your access to the operating room, clinic space and shared operative or research equipment can affect your productivity in clinical and research arenas. It is also incredibly important to understand the proximity of the various professional spaces you inhabit. How much time will you need to spend commuting between clinic space, OR, departmental office, lab? Will there be secondary clinic and OR sites included? This commuting time is time spent not producing the things by which employers judge performance. Regarding negotiating for non-standard components of an employment package, it is worth noting ahead of time what you can live with and what are must-haves. All physicians are expected to recruit continuing medical education or CME credit to maintain certification. CME credit can be accrued through attendance at professional society annual meetings, which typically incurs meeting registration, travel, hotel and food costs. Although some amount is generally provided by employers to cover these costs, you might be able to negotiate for a greater amount. It is important to identify with your clinical mentor those items crucial for your success in clinical practice and verify that you will have access to these tools at your new place of employment. Sort out prior to signing your contract what equipment and or infrastructure that is necessary for your success is already in place at your new institution or needs to be purchased or updated. Included here is often a clinical directorship for a small salary stipend and a marketing budget if, for instance, you are planning to establish or expand a new clinical program for your employer. Research startup packages are negotiable and elements to negotiate include how much time per week you will need to be successful as a physician investigator. Note, however, that the greater the amount of time negotiated for research, typically the lower your annual compensation will be. Also negotiable can be the research staff you require to help you with your research mission, including a research administrator, grants accountant, research nurse coordinator and biostatistician. Finally, it is important to take inventory of what laboratory space, equipment and core facilities exist for you in the research environment and again consider what are the must-haves and the ideally-haves so that you are well positioned to launch your research career. In conclusion, I urge you to get professional advice on employment contracts. Speak to your residency chair who has a vested interest in your success after training. If possible, speak to neurosurgeons who were hired by your prospective employer within the last couple of years to learn from their experience. Find good legal counsel with expertise specifically in reviewing physician employment contracts and be prepared to pay for this counsel. State medical boards might be able to provide names of such individuals to you. Ultimately, though, it is your responsibility to fully understand your employment contract. Remember that professional support and benefits are crucial components of your overall employment package, not simply your total annual compensation. Get any negotiated non-standard must-haves in writing. For example, what research time buy-down or clinical program directorship has your employer agreed to? Realize that memories are imperfect and the leadership with whom you negotiated your position might leave the organization without delivering on these agreements. Above all, the most important component of your contract is trust in the organizational leadership of your department, your institution, and your practice. This is an important part of the process.

physician employment contracts

neurosurgeons

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