Attending Physician Contract: What You Need to Know

Your first attending contract is one of the most financially consequential documents you'll ever sign. A $20,000 salary bump compounded over a career adds up to over $600,000. A loan repayment signing bonus of $50,000 covers two years of residency interest. A poorly negotiated non-compete can restrict your options for years if the relationship doesn't work out. Most physicians leave money on the table — not because they're bad negotiators, but because they don't know what's negotiable. Here's what you need to ask for and how. The Fundamental Mindset Shift In residency, you took what you were given — salary is standardized, there's no negotiation. Attending employment is completely different. You have leverage, especially in: Shortage specialties (psychiatry, primary care, general surgery, OB/GYN in rural areas) Geographic markets with few specialists Hospital systems recruiting from outside their local network Any position that's been open for more than 6 months Even in competitive markets with many applicants, most employers expect negotiation. Not negotiating signals inexperience or desperation. Understand Your Compensation Structure Before Negotiating Pure salary: A fixed annual salary regardless of how many patients you see or procedures you perform. Common in academic medicine, VA, Kaiser-like models. Predictable income, lower upside. RVU-based compensation: You're paid per Relative Value Unit (RVU), a Medicare-derived measure of physician work. More patients and procedures = more RVUs = more income. Most common in private practice and many employed group models. Base + RVU productivity bonus: A guaranteed base salary (floor) plus a bonus for producing above a target threshold. Most common structure for employed physicians. The critical questions: What's the base? What's the RVU threshold where bonus kicks in? What's the RVU conversion factor (dollars per RVU)? MGMA benchmarks: The Medical Group Management Association publishes salary data by specialty and percentile. Always know your specialty's 50th and 75th percentile before entering negotiations. This is your objective anchor. A salary offer $40,000 below MGMA median in your specialty and region is factual information, not opinion. What to Negotiate: The Full List 1. Base Salary The obvious one. Do your homework: Pull MGMA or Medscape salary data for your specialty and region Factor in geographic cost of living (an offer in rural Mississippi vs. San Francisco requires different calibration) Know whether the offer is below, at, or above market before the conversation Starting negotiating point: the MGMA 50th percentile as the floor, asking for the 75th. Most employers can meet somewhere in between. 2. Signing Bonus Signing bonuses for physicians routinely range from $10,000 to $100,000+ depending on specialty and demand. Common structures: Paid upfront on start date Paid in installments (50% at start, 50% at 12 months) Subject to clawback if you leave within 1–3 years (very common — read the fine print) For student loan purposes: A $50,000 signing bonus that's taxable income is worth approximately $30,000–$35,000 after tax. Still meaningful — it's equivalent to 1–2 years of aggressive loan payments. But some employers will offer student loan repayment as a benefit (paid directly to your servicer) which may have different tax treatment than a cash bonus. 3. Student Loan Repayment Benefits Many health systems now offer student loan repayment as a recruitment benefit, separate from salary. This can include: $10,000–$50,000 paid directly to your loan servicer per year Annual contributions over 2–5 years as retention incentive May be tax-advantaged if structured under IRS Section 127 educational assistance programs (up to $5,250/year tax-free as of 2026) If an employer offers $20,000/year in loan repayment on top of salary, that's $20,000 that doesn't go through your paycheck — no FICA, no federal income tax on the first $5,250. Always ask whether the employer offers student loan repayment as a benefit, even if it's not in the initial offer. 4. Relocation Assistance Moving across the country for your first job is expensive. Physician relocation assistance ranges from $5,000 to $30,000, often paid as a taxable benefit. Always ask. Small practice groups may not have a formal program but may be willing to contribute toward moving costs in lieu of other negotiating items. 5. CME Allowance and Professional Expenses Standard CME allowances are $3,000–$5,000/year plus 3–5 days of paid time. Some specialties require board recertification, conference attendance, and specialty society membership — those costs add up quickly. Ask for a CME budget itemized from the position's offer, not bundled into the base. Professional expenses to negotiate: Medical license fees (often 2–3 states for locum coverage) DEA registration ($888 as of 2026) Board certification fees Malpractice tail coverage (more on this below) 6. Malpractice Insurance and Tail Coverage Occurrence vs. claims-made policies: Occurrence policies cover incidents that happen during the coverage period, regardless of when the claim is filed. Claims-made policies only cover incidents reported while the policy is active — if you leave, claims filed after your departure aren't covered without "tail" coverage. Most employers carry claims-made policies because they're cheaper. When you leave, you're responsible for purchasing tail coverage — typically 1–3x the annual premium, or $15,000��$50,000 for surgeons. This is the hidden financial risk in every physician employment contract. Negotiate who pays for tail coverage — this is one of the most underappreciated negotiating points. Getting the employer to cover tail if they terminate you (without cause) vs. if you resign is standard. Getting them to cover tail in any scenario is harder but worth asking. 7. Non-Compete Clauses Non-competes restrict where you can practice if you leave. Typical physician non-competes: 1–3 year duration 5–25 mile radius from your primary practice site Sometimes limited to specific specialties or patient populations The enforceability of non-competes varies dramatically by state. California bans physician non-competes outright. Other states heavily restrict them. Some states (many in the South and Midwest) enforce them aggressively. Always have a healthcare attorney review the non-compete before signing. If you leave the employer and the non-compete forces you to move your family 30 miles to comply, that's a serious quality-of-life issue. Negotiating for: Shorter duration (1 year instead of 3) Smaller geographic radius (10 miles instead of 25) Patient-following clause (your established patients can follow you) Buyout provision (you can pay a fee to exit the non-compete early) The non-compete negotiation is where attorney review pays for itself multiple times over. 8. Call Schedule On-call responsibility directly affects quality of life and, if you're paid by RVU, income. Clarify: How many nights/weekends per month are you on call? Is in-hospital call vs. backup call? Is call paid separately or included in compensation? How does call coverage change when colleagues leave (if the group is understaffed)? A call schedule that sounds manageable can become brutal if the practice loses a physician and you're covering for two people. Ask about current call schedule AND what happens if the group is short-staffed. 9. Partnership Track (for Private Practice) If you're joining a private practice group, ask about the partnership track: How long is the partnership track (typically 1–3 years)? What are the buy-in requirements (often $50,000–$300,000)? How is partnership income distributed? What do partners earn vs. employed physicians? Partnership in a well-run group can significantly boost income (20–50% higher than employed physician salary) but requires understanding the buy-in cost and how the group values its assets. 10. PTO, Parental Leave, and Benefits Often treated as fixed when they're sometimes negotiable: Extra vacation days Protected time for research or academic work (academic positions) Parental leave beyond the minimum Health insurance premium share 401(k) match and profit-sharing percentage These individually may seem small, but 5 extra vacation days × $1,500/day physician production value = $7,500/year in economic value. The Negotiation Process Step 1: Get the written offer first. Don't negotiate verbally against an informal conversation. Request everything in writing. Step 2: Review thoroughly (ideally with an attorney). Healthcare employment attorneys charge $300–$600/hour for contract review. A 2-hour review at $500/hour = $1,000 that can save you $20,000–$100,000+ in salary, tail coverage, or loan repayment. Step 3: Identify your priorities. You probably can't win on everything. Decide what matters most: base salary? signing bonus? non-compete terms? Call schedule? Know your top 3 before the conversation. Step 4: Make a single counteroffer. Don't cherry-pick 8 items and nickel-dime every line. Come back with a consolidated counter: "I'm excited about this opportunity. I'd like to request: (1) base salary at $XX, (2) $XX in student loan repayment benefit, and (3) reduced non-compete radius to 10 miles. On those three items, I'm ready to sign." Step 5: Give them a reasonable timeline. Employers will sometimes use urgency as leverage ("we have other candidates"). It's fine to say you need 2 weeks to review and consult with an attorney — that's standard practice for physician contracts. Common First Attending Contract Mistakes Accepting the first number. Employers routinely have salary bands that start below the midpoint. The first offer is rarely the best offer. Ignoring tail coverage. "It's included" is not the same as "it's included even if you resign." Read the tail coverage provisions carefully. Budget for potential tail costs if it's not covered. Not getting the RVU model in writing. If you're on a productivity compensation model, get the exact RVU conversion factor, threshold, and bonus structure in writing. "You'll do great here" means nothing if the RVU model changes after you start. Signing without a non-compete review. A few hundred dollars in attorney fees prevents years of geographic restriction. Not asking about student loan repayment. Many employers offer this benefit but don't mention it in the initial offer. Simply asking "does the organization offer any student loan repayment assistance?" is worth asking every time. Underestimating the long-term math. A $15,000 salary increase in year 1, compounded with merit increases over a 30-year career, adds up to $600,000+ in cumulative compensation. The conversation is worth having. FAQ Is it okay to negotiate your first physician contract? Absolutely — and it's expected. Physicians who don't negotiate are leaving real money on the table. Employers are not going to rescind an offer because you professionally counteroffered. The worst they say is no. How much more can I negotiate from the first offer? Depends heavily on specialty, location, and market demand. Primary care physicians in rural shortage areas can often negotiate $30,000–$50,000 more. Urban academic physicians in competitive markets may have less room on salary but more flexibility on signing bonuses, loan repayment, or call schedule. Should I hire an attorney to review my first physician contract? Yes, for any employed position with a non-compete clause or complex RVU compensation structure. A healthcare employment attorney who specializes in physician contracts will spot issues you miss. Expect to pay $500–$1,500 for a thorough review. Well worth it. What is a physician signing bonus, and is it taxable? A signing bonus is a one-time lump sum paid at hire as an incentive to accept the position. It is taxable ordinary income, withheld at supplemental wage rates (22–37%). Many have clawback provisions — if you leave within 1–3 years, you repay a prorated amount. Can I negotiate student loan repayment as part of my offer? Yes. Many health systems offer student loan repayment as a benefit — some up to $20,000–$50,000/year. Ask explicitly in every negotiation. The first $5,250/year may be tax-free under Section 127 of the IRS code. Model Your Financial Future Your attending salary directly affects your loan repayment strategy. Use the MedDebt Calculator to see how different salary scenarios change your PSLF timeline, aggressive payoff costs, and net worth projections. Enter the salary from your best offer and your loan balance — it takes 2 minutes and shows you exactly what your financial picture looks like in each repayment scenario.

This article is for informational purposes only and does not constitute financial, legal, or tax advice. Every borrower's situation is unique — consult a certified student loan advisor or fee-only financial planner before making repayment decisions.

Once you've finalized your contract terms, check out managing your first-year attending budget to establish a solid financial foundation for this critical career transition.

Once you've finalized your contract terms, it's equally important to have a plan for managing your newfound income, which is why maximizing your first attending paycheck deserves careful consideration.

Disclosure: This article is for informational purposes only and does not constitute financial, legal, or tax advice. Loan program details change — always verify current rules on studentaid.gov. MedDebt may earn a referral commission if you refinance through links on this site.