Nahush A. Mokadam, MD
7 min read
Key Points
  • A contract should include a thorough description of your position, your expectations, your key result indicators, your protected time (if any), your startup funds (if any), and of course, a salary. 
  • While salary is important, focus on clinical expectations, educational responsibilities, and benefits of the position, and determine if these are acceptable. 
  • Your points of negotiation should be reasonable, reasoned, and flexible; if you approach these as demands, rather than discussions, you will not be successful.

The Job Offer

Nahush A. Mokadam, MD (cardiothoracic surgeon)
Nahush A. Mokadam, MD

It is very likely that you will be presented with a potential contract or term sheet either during or immediately after the second visit. It should include a thorough description of your position, your expectations, your key result indicators, your protected time (if any), your startup funds (if any), and of course, a salary. 

Now take a seat. It is very likely that the salary is a large multiple of your current remuneration. Put a sticky note over the amount. Focus on the rest of the contract and term sheet first. You can come back to the salary later. Why is that important? Your success in this position does not lie in the money, but rather the structure and environment. Understand your rank, title, and track. So let’s break that down (and look, it is a lot like a portfolio of value):

  • Clinical expectations. This most likely will be the bulk of your responsibilities. What do they expect of you? Do you have case volume targets? Clinical revenue generation? Work RVUs? (What are wRVUs? That’s a whole other topic). How much of your effort is expected to be focused on clinical activity? Do you have performance and quality metrics? Are you expected to start or grow a new program? You really need to understand this part. How does your clinical productivity get recognized both monetarily and non-monetarily? Are you expected to cover more than one institution? How many and how often?
  • Research activities. This is focused on academic positions, but also may be present in non-academic settings. How is your research productivity measured?  What are the expectations? Manuscripts per year? Grants per year or grant amount per year? Are you provided with “protected time” to pursue research?  Do you have or need a lab? Lab personnel? Startup funds for the lab? Is your research productivity tied to your opportunity for advancement? Are there non-lab resources you need such as access to a statistician?
  • Educational responsibilities. Clinical residencies are present in a wide swath of settings, and you may well find yourself in charge of a resident even in rural settings. Does your employer have expectations of you in this regard? What does that look like? In an academic setting with a cardiothoracic residency, what is your responsibility to train, especially in the first year when you have your own steep learning curve?  
  • Administrative positions. It is unlikely that you will be given an administrative position in your first job, but keep in mind that titles are relatively cheap and may be used to entice you. Make sure you understand the responsibilities of any assigned roles. There may be performance metrics attached to these as well.  
  • Benefits. Hopefully, by now you’ve had a chance to meet with HR and hear about the benefits package. I’m surprised at how difficult I found it to understand benefits when presented with what looks like a wealth of options. Unfortunately, HR often is coached to not coach you but only to provide options for you to pick. You will need to decide about health care, retirement, voluntary investments, tax strategies, insurance options, and more. If you are unfamiliar with these, it may be helpful to ask a parent or older sibling, or hire a financial advisor. Also understand that benefits are determined at an institutional level and are often not amenable to negotiation. It may be worth asking and negotiating on other items that fall under benefits such as student loan forgiveness, leave for global health initiatives, administrative support, relocation expenses, and others.
  • Salary. This is the one everyone wants to talk about. You’ve been underpaid and overworked for a decade and are ready to enter full adulthood right? Partially. Your initial salary offer may seem overwhelming and hard to believe. Take a deep breath. Your salary is directly attached to very real expectations, some of which are outlined above. It is important for you to understand how that salary offer was derived. In some centers, it is based on national tables that are based on experience or rank. In others, it is directly tied to your clinical productivity. Before you respond positively or negatively to this information, you must understand the derivation. Read the fine print on the salary. Does it vary? Can you expect raises? Based on what and how often? Is there a ramp-up period during which a floor salary is guaranteed, but then sunsets after a year or two? Are you eligible for bonuses? How are they calculated? Is any of your salary subject to quality review? Which metrics? Do you divide your bonus with others in the group? You want to know all of this now, so that you are not surprised 9 months from now.

Pro Tip

Your program director and/or division director will happily review your contract. It is one of our responsibilities to ensure that no one takes advantage of you. They have experience and insight into favorable clauses and disastrous loopholes. They also can offer you advice on how to approach a negotiation. Ask for their time and attention, and you will get it.


I often am asked, “Am I allowed to negotiate?” Of course, you are allowed to negotiate. That means that after you have thoroughly reviewed your offer, you bring suggestions to the table as alterations. (These are not demands, and if you approach them that way, you will not be successful.) 

Your points of discussion should be reasonable, reasoned, and flexible. There are elements of a contract that will be non-negotiable (i.e., faculty code at a University, retirement plan contributions), and others that are certainly on the table (i.e., startup funding, protected time, salary). Your opportunity and responsibility is to determine why you believe your contract should be changed. Provide clear and concise rationale for it, and prepare to compromise.  

Remember, your future employer has probably done this before and may even have more than one candidate at this stage of recruitment. That being said, a cogent and respectful request for change can be a fruitful undertaking; and for a reasonable employer, can be met with a favorable response.

Pro Tip

Now is your best chance to get what you want, so don’t feel ashamed to ask.  

Licensing and Credentialing

Signed, sealed and delivered. You did it! You have a job, a contract, and a new life ahead. Be prepared for the avalanche of paperwork headed your way. If you don’t have a license in the state you are moving to, get going on this right away. 

Pro Tip

It is very helpful to have all your diplomas scanned so you can send PDFs/JPGs as supporting documentation. Online license applications and renewals have improved significantly, but some states are still onerous. Hospital credentialling is a slog of a process, and if you are going to be at more than one hospital, their systems are not likely to talk to one another, so you may be asked to fill out similar forms (pages long) with the same information.  Remember, in order to start work, you have to get privileges. Do this early.

Caution—downer ahead: If you have had the unfortunate experience of being named in a lawsuit, contact the legal firm that represented you to help craft a concise explanation of the event. You also will likely need all the legal numbers associated with it (i.e., docket number, court, date of filing, etc.). Your legal firm should have that information. All licensing and credentialing forms will require this information, and your applications cannot be processed until this is included.

Parting Thoughts

Every major transition in our lives is met with stress—applying to college, medical school, residency, and yes, your first job. I can tell you that this advice also may serve you well when looking at a new job beyond your first one. The key to successfully navigating these waters is to ‘know thyself.’ Represent yourself well internally and externally. Be honest with your own expectations. Understand what you are being offered—really understand it. Negotiate with grace.

Congratulations on the next phase of your career!  We all will watch it with great interest.


Read Part I: Preparation

Read Part II: Interviews