Looking For Your First Job in Psychiatry: A Guide for PGY-4s

Those of you who have been reading the blog might know that I’m currently in my last year of training, which means that in ~3 months I will finally be somewhere that I chose to live and work. It only took *checks notes* 24 years of education to get here (20 if you don’t count residency). Nice!

I wrote this essay as a collection of things that I wish someone would’ve taught me before I started looking for jobs in my final year of residency. It should give you a decent place to start without being too overwhelming. Keep in mind that most of my efforts went to finding a job in academia. A thank-you to my co-resident Suchakree Sanguansataya (a.k.a. Po) who had much more experience on the non-academic side of the job hunt and helped me fill in the gaps.

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Harness the Cynicism of the Internet

My research naturally started with the most reliable source of information I could think of. I am, of course, talking about internet forums. Places where everyone is anonymous, no credentials are required, and posters can say almost anything they want without real-world repercussions.

I spent a significant amount of time looking through the SDN Psychiatry subforum (specifically this post and this one) and the White Coat Investor subforum for employment and contract questions.¹

These forums are a great place to get critical takes on jobs and will help you to see through the façade² of most postings. There’s some real schadenfreude instruction in seeing someone post excitedly about how a recruiter has just contacted them about this amazing job that pays $400k a year and then watching their enthusiasm dwindle as questions from the grizzled veterans slowly show them just how hard they will be working for that money.

Figure Out What You’re Looking For

When I started residency, I would’ve told you that I was private-practice bound and it would be a cold day in Hell when I would ever consider staying in academic medicine. Unfortunately, I had not yet read Dante’s Inferno;³ it turns out that the Third Circle of Hell contains frozen slush that the gluttonous are forced to lie in. Academia it was.

Me and my wife’s geographic preferences were very narrow, basically just states on the East coast from NC to NY. That also narrowed things down considerably. I also decided that I would look exclusively for inpatient jobs. I find C/L totally uninteresting at best and exasperating at worst, and while I like acuity, ED psychiatry prevents you from seeing any of the fruits of your labor.

The point is: before you start looking, you need to at least outline what you think you want as a starting point. At a minimum this should include (in no particular order of importance):

• Locums vs. Permanent

• Part-time vs. Full-time

• Academic vs. Non-academic vs. Public/State-Run

• Geographic location

• Type of practice (inpatient, outpatient, C/L, ED, PHP, IOP, etc.)

You should also try and get a sense of what salaries are like for a given geographic region and for academic vs. non-academic. Generally:

• Academic jobs pay substantially less than comparable positions outside of academia.

• The rules of supply and demand apply: more remote the location, the better the pay and the more power you have to negotiate a job of your liking

There are not many free resources to give you precise numbers on this, though Doximity’s Physician Compensation Report is an OK place to start. There’s this anonymous survey collecting physician compensation that’s making the rounds. If you fill it out (which you can do even if you’re a resident), you’ll get access to their data for free, and there’s a pretty good amount of it! Since I wrote this piece the anonymous survey has evolved into Marit Health, which now has an actual website that is better organized.

For academic data, the AAMC will sell you its compensation survey for $100 if you’re a member, but the geographical areas are very large and I found it to be pretty worthless. MGMA will charge you $400 for a 1 year membership (split it with friends) that gives you access to all of their data — I have not personally used them because a recruiter gave me the data for psychiatry for free. If you’re looking to work outside of academics, my sense is that having something like the MGMA data could be worth it from a negotiating point of view.

There are other things that will absolutely matter, but I think this is a good place to start without getting too obsessive.

When Do I Start Looking/Applying?

Prior to PGY-4, I think it would benefit most residents to take a peek at job listings every once in a while, if only so things don’t feel so overwhelming.

I started my job search early, around August. Some might say that’s too early. I might say that a little extra neuroticism conscientiousness around major life decisions never hurt anyone. Frankly, 18-year-old me could’ve used a little more of it when he made the decision to only apply to 5 colleges out of high school, three of them being Cornell, Stanford, and Columbia.⁴

Realistically, 3 months into your final year of residency is a good time to start applying. That will give you enough time to do enough research, not have to panic about squeezing in site visits, and get credentialing/license applications done on time.

Applying

At first, I started looking on physician job boards like Practice Link and system/hospital specific job boards. This is a fine place to start, but when looking at job postings, be cynical.

Whenever you see phrases describing salary as “world class” or “competitive,” you should assume that they mean “bog-standard” or “competitive relative to what the NHS is paying those poor suckers in the UK.” Most of what you’re reading is copy written by recruiters designed to make the job seem maximally appealing without actually telling you any details that might scare you away. Take, for example, this job posting. It basically tells us that this is an academic inpatient job in Philadelphia. If you’re lucky, you might get a salary or salary range for the position, but assume that you will be towards the low-end of that scale; if even the high-end looks to be under market-rate, move on.

I think it’s a good exercise to look through about a couple dozen listings that match your basic criteria, apply to a few that look good, and speak to their in-house recruiters. This will give you a feel for the process and help you start to understand the differential between job postings and what the job actually is.

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Should I Use A Recruiter?

Just to be clear, there are outside recruitment firms (aka headhunters) and inhouse recruiters that usually work for the HR department of the hospital/company you’re applying to. I’m talking about the former here.

Honestly, I don’t know. I didn’t use one and wasn’t interested. I saw comments/speculation that the way these recruiters make their money is by getting some percentage based off of whatever the position’s salary is, which means that you would ultimately get paid less. Is this the exact model? I dunno,⁵ but the funds have to come from somewhere and it seems reasonable to assume that the money a recruiter earns comes out of whatever the system was going to pay to compensate you.

Maybe this is worth it if you find a recruiter that you really like and that seems to do a good job. My opinion is that this is a super important decision that you shouldn’t be filtering through a third party with opaque financial incentives.

Dr. Sanguansataya suggested that external recruiters can be helpful since they may be aware of positions that are not publicly posted. He also recommended that you check if a job presented to is also posted publicly; sometimes the public listing has better terms (and is probably a good indication that the recruiter is costing you money).

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Although I found it to be a good exercise in learning about the process, going through job boards didn’t work very well for me. There weren’t a lot of jobs that fit what I was looking for and I couldn’t be confident that I was seeing what was actually available. Some of the boards for hospital systems and universities looked like they were straight from the 90s (probably were) and had byzantine search menus that left me wondering if there really were no job openings or if I needed to be searching for “psychiatry” instead of “psychiatrist” or maybe “open rank faculty psychiatrist”???

I also kept hearing the same phrase over and over again whenever I would read forum posts asking about the best places to look for jobs:

The best jobs are ones that are never posted

For whatever reason I couldn’t get this idea out of my head, and so I decided to just start emailing department chairs.

I sent a short email (CV attached) telling them that I was looking for inpatient work, was passionate about teaching, and that I would love to speak to them about potential openings in their department. Here’s an example of one email I sent:

Hi <Department Chair>

My name is Nils, I’m a PGY-4 in the general adult psychiatry residency at Tufts in Boston. I’m reaching out to see if your department is looking to fill any positions for a start date in the second half of 2025.

Clinical education is a major professional passion of mine, and I'm looking to start my career off in academia. Specifically, I’m looking for inpatient work in an academic setting that will involve the teaching and supervision of residents and medical students, with emphasis on the former. I am not currently interested in purely C/L, ED, or outpatient positions.

If you think that I may be a good fit for any open positions you have (or may have soon!), I’ve attached my CV for you to review yourself or pass along to the relevant people. I’m happy to provide any more details that you think might be useful, but I figured I should keep this first email brief. Thanks for your time!

This has worked surprisingly well. About 20% never responded to me. The remaining 80% either put me in touch with the VP of the service line for their system or set up a meeting to speak with me directly.

I don’t see why this couldn’t apply to other systems and settings as well, except replace “Chair” with “Medical Director” or whatever. People are surprisingly nice and generally like when you show enough interest in their organization to go through non-standard channels.

I would say that if you talk to people this way, and they tell you that they don’t have anything available now but they will have a job posting in a few months that they’ll notify you about… assume that they will totally forget about you and that you will need to be the one to reach back out for updates. In my experience this was not just a polite way of telling me to fuck off; I did get somewhere when I followed up later on.

Actually, I think you can take that entire suggestion and just apply it to the whole process. Sometimes you need to be a little annoying persistent and remind people that you exist and are still interested.

The Process

I’ve found the general structure of the process to be relatively consistent, so I’ll just walk through it.

At the outset, I would highly encourage you to take lots of notes as you go. This will help you keep track of details that you would otherwise forget, allow you to start comparing programs, and to pick up on details that you will inevitably forget to ask about early on in your interviewing process. Once I was done with interviews, I would put together a list of pros and cons to help consolidate what I had learned and make it easier to compare between programs. Here’s an example of my pros/cons summary from Zucker Hillside (somewhere I really liked!)

A Screening Interview

This first interview can be done by many different people. Sometimes it’s the Chair, sometimes the VP of the service line, and sometimes by someone in recruitment. The purpose of this interview is:

1. For the employer to make sure you are a serious person who is actually interested in the position.

2. For you to get a general outline of the position to decide if you want to learn more.

Usually these run about 30 minutes. Your primary concern should be getting the bare minimum you need to decide if this job sounds like it’s worth spending more of your time on. If you don’t manage to do this the first few times, that’s OK!

Here are some of the things I asked about:

• Clarify what the job is (yes, seriously! One recruiter misunderstood the difference between inpatient and C/L, which ended up in a rather awkward conversation between myself and a medical director down the line)

• Compensation

• Retirement benefits

• Workload (patient load, # consults, appointments per day)

• Call schedule

• Vacation days

• Are there requirements for midlevel supervision?

• Internal/external moonlighting

This is the time to ask about any special non-negotiables. For me, this was ensuring that I would have substantial time working with residents.

Outside of vacation days and retirement, I would recommend against asking about benefits in detail unless there is some make-or-break benefit that you absolutely need to have (e.g. fertility services included in health insurance). It’s a waste of time when you can just request the benefits packet they send to their new hires.

The person you’re talking to will rarely know the answer to all of your questions. Make sure you ask to speak with someone who can answer them. Also keep in mind that the people you are talking to at this stage are usually relatively removed from the position you are applying for and may inadvertently give you incorrect information (this is part of why you keep notes!).

Virtual Interviews

After the screening interview you will generally have between 1-4 virtual interviews with people who work in the department. Sometimes — this only happened to me twice — you will be invited directly for a site visit.

Usually, the people you’re speaking to will be directly related to the position you’re applying for. For me, this usually meant speaking to: the chair (if I hadn’t already), the residency program director, the chief for the unit I would be working on, an inpatient attending, and someone from HR to review benefits.

Don’t be afraid to request to speak with particular people if they’re not already lined up for you. I would regularly ask to speak to a couple of the chief residents, which was always arranged without any fuss.⁶ You should also ask to speak to someone who has recently joined the unit/department/practice to get a sense of what their experience has been like. Dr. Sanguansataya highly recommends you ask to speak to someone other than the people the employer has selected for you, to ensure that you’re not just meeting with cheerleaders for the organization.

Your questions at this point should be tailored to the position of the person you’re talking to and should be aimed at getting into the details of the job. It’s also good to re-ask some of the “basic” questions from the screening interview to make sure that the answers you get are consistent.

Be ready to be the person driving the interview! Coming straight out of residency, these interviews were quite different than what I’m used to. Instead of being peppered with dozens of questions like “Why psychiatry?” and “Tell us what you think your biggest weakness is,” it’s more likely you’ll get a couple of questions before they turn things over to you. There was more than one occasion where my “interviewer” sat down, introduced themselves, and asked me what I wanted to know.

Here are some examples of questions I would ask:

• Compensation:

  • If on a base + production model, how much did people in a similar position exceed their wRVU targets by, on average?

  • If there are bonuses (esp. for quality metrics), what percentage of people in the department qualified?

  • How do I get compensated for covering when others are on vacation?

  • When do I get raises and how are these calculated?

• Workload/Unit Details:

  • How big is the unit and how many docs cover?

    • Smaller unit/Few attendings means that vacations are harder to schedule

  • What’s the average length of stay?

    • If this number is very short you need to figure out why.

  • Avg. # of admits/discharges per day

  • What support staff are available on the unit?

  • How much pressure do you get from Utilization Review about discharges?

  • Is staffing ever an issue?

  • What is the patient mix like in terms of diagnoses?

• Call

  • How busy is call?

  • Where are you in the call chain? (e.g. are there midlevels who are first line?)

  • How much is “required” vs. “volunteer” (and is it really “volunteer” or is that just what they say until they don’t have anyone to cover?)

• Midlevel supervision

  • Will I be required to work with/supervise midlevels?

  • How involved will I be in their hiring?

  • Do I collect billing for the midlevels I supervise?

• Morale/Work Environment:

  • What kind of person would do well here/struggle here?

  • Are people friends outside of work?

  • Why did the last person leave this position?

  • How long have you been here? What has kept you here? What brought you here?

Site Visits

If the virtual interviews go well, the next step is a site visit. I have never turned one of these down at a place that I was interested in working at. I don’t know why anyone would. There are places that have seemed great on paper and in virtual interviews, but gave me an awful impression after a site visit.

Institutional Myopia Is One Of My “Icks”

When you’re arranging for a site visit it’s reasonable to expect that they will fly you (and your partner if you have one) to them, pay for lodging (sometimes food), and transportation. This is not a guarantee; one place in New Jersey didn’t pay for anything,⁷ but I was willing to eat the cost because the place sounded good on paper, flights from Boston weren’t particularly expensive, I could do the whole thing in a day, and my wife didn’t feel the need to see the area.

Personally, I would be very wary of anywhere that was not willing to pay for you and your partner to visit. This isn’t because I think we’re entitled to such treatment, but because I think it reflects poorly on how their system thinks about hiring its physicians.

Think about it.

Psychiatrists are in demand. Even after you accept an offer it takes somewhere between 4-6 months to do credentialing and onboarding before you can even start. On top of that, you’re going to cost them at least $300k/yr in salary + benefits.⁸ If they’re not willing to spend a couple thousand dollars more to help ensure that you know what you’re getting into — making it more likely that you will stay at the job — I don’t think it speaks well of their organizational decision making. I’d bet that organizations that don’t cover site visits have increased turnover and longer vacancies, neither of which are things that I would like to deal with as an employee.

That said, this short-sited behavior seems to be the exception, not the rule. In fact, you shouldn’t be afraid to ask for a little more during your site visit if you think it will help you make a decision. For example, there were two times where my site visit was scheduled for Thursday and Friday, so I asked if we extend the reservation on the rental car and the hotel to Sunday so my wife and I could see the area on our own; I even offered to pay for the extra days.⁹ In both cases the employer was happy to extend the trip and told me not to worry about the extra cost.

We Are A Vibes Based Specialty, After All

Unless you’ve skipped virtual interviews, site visits are primarily about vibes.

An invitation to visit is 75% about giving you the chance to make sure you’d be comfortable with working/living there and 25% them making sure that you’re not some secret weirdo that can only hold it together on Zoom. If you didn’t do virtual interviews I’d say it’s more like 50/50.

Some suggestions:

• It is OK to say no to something on the schedule they prepare for you, or to ask for changes

• Try and do a visit that is at least 2 days long, especially if you have never been to the area. A single day is just not nearly enough time to get a good sense of a place, and I found my impressions were more likely to be heavily influenced by superficial details since I didn’t get to see the nuts-and-bolts of care.

• Make sure that at least half of one of those days is free for you to explore the area. Visit some neighborhoods, eat at some local restaurants, maybe schedule a tour with a realtor.

• Do your best to see some aspect of the clinical team in action. Interviews are no replacement for seeing the interpersonal dynamics of a team first-hand.

  • Sitting in on some part of rounds is a great way to do this.

Understanding Compensation

Do not fixate on how big the salary number is. I know all those those 0’s look very attractive (there’s a Freudian joke somewhere in here), but until you know the details of the job they’re just a distraction.

The question you should be trying to answer is “am I getting paid commensurate with the amount of work I’m doing?” An inpatient job paying $220k where you carry a small patient load and are out the door by 1pm can be a sweet gig. Another position might pay $400K, but that probably won’t feel nearly enough when your caseload is 20 patients, you’re doing 5+ admits/discharges a day, supervise 2 midlevels,¹⁰ and have mandatory weekend call every month.

For high-level comparisons, it can be helpful to distill your total compensation into a single number consisting of:

1. Your base salary +/- production

2. Any yearly bonuses

3. Any substantial student-loan payment programs or other large financial incentives that are functionally income.

4. Employer contributions to your retirement accounts

It’s also a good idea to try and simplify things down to an estimate of hourly pay. I think that $200/hr is the absolute minimum most of us should be considering.

Salary/Production Models

There are three major ones you should be aware of:

Flat Salary

Not much to explain here. They say they’re going to pay you $XXX/year and that’s it.

However, there are some models that may allow you to increase the amount of time you work to earn more. For example, at one job 1.0 FTE was paid at ~$240,000/yr. but only worked 36 weeks a year. I was told that if I wanted to work, say, 40 weeks, I would be paid as a 1.1 FTE and make ~$265,000/yr.

Salary + Production

In this model, you are typically given a guaranteed/base salary with the option to earn more money based on your productivity. Productivity in this case means the amount of billing you do, which is usually tracked in wRVUs. Every billing code you use has a wRVU value attached to it, which are set by CMS (you can look up wRVU values here). The idea is simple: do more work, earn more money.

In this model, there is (?almost) always an “RVU threshold” that you need to hit before you get paid for additional productivity.¹¹ Some employers will pay you your base salary regardless of how many RVUs you produce, others will require you hit your threshold to get your full base salary.

Some things to pay attention to here:

1. This pay model is more beneficial for those who are able to scale up/down the amount of work that they do.

   1. If you’re a C/L or ED psychiatrist, you’re mostly at the mercy of the consulting teams when it comes to production, so make sure you get a sense of how slow/busy the service you’re walking onto is.¹²

   2. Outpatient psychiatrists are able to maximize these models the best. Want more RVUs? See more patients.

      1. Important to note: wRVUs don’t scale linearly with time spent (i.e. a 60 minute appointment does not give 2x the wRVUs of a 30 minute appointment)

   3. Inpatient psychiatrists are somewhere in the middle depending on demand, efficiency, and how loose their ethical standards are.

2. Some places will start you on a base + production model for the first 1-3 years of employment, but then switch to a production only model afterwards.

Flat Production (a.k.a. Eat What You Kill)

I haven’t come across this in academia. I’m guessing that it’s more common in group private-practice models? Make sure that if you’re going to work somewhere that does this, you have a good sense of:

1. How long it will take to build up a full-time patient panel (weeks, months, years?)

2. What the insurance mix of the patient population is like (different insurances reimburse different amounts per wRVU)

3. Are you reimbursed based on billing or collections?

   1. If collections, what’s the collections rate?

4. Will there be midlevels working under you? If yes, how are you compensated for supervising them?

Ask To See The Books

If you’re looking at anywhere with production metrics, you should be asking for hard data to see how other physicians are billing and earning. Ideally this information should cover the breadth of their employed physicians so you can be confident they are not just cherry-picking people with high production numbers. When you look at those numbers, ask yourself if these billing practices seem reasonable. Dr. Sanguansataya told me about at least one job he was looking at which seemed excellent on the surface, but when he looked at the billing codes for individual appointments things looked somewhat… overbilled.

Bonuses

The concept of a bonus is generally pretty uncomplicated; your employer is giving you a chunk of cash for some reason. I’m not going to talk about them much except to highlight that bonuses can be structured so that they are a pair of golden handcuffs in disguise.

There are some signing/retention bonuses (and “loan repayment programs”) that are not treated as lump sum no-strings-attached payments, but instead are structured as 0% interest loans that your employer will “forgive” a portion of each year.¹³ If you end up staying at a company for the term of the loan, this is a great deal, but it can be a problem if you decide to leave early. Some places will require you to repay the entirety of the loan with interest. Others will let you keep what has been forgiven, but will require you to repay the remaining unforgiven balance, again with interest.

I have seen so, so many posts from people who have not realized this and spent all the money, and then tried to leave the job only to find out they were on the hook for tens of thousands of dollars. Don’t let this be you.

The wisest advice I have seen regarding these types of bonuses is to stick them in some sort of interest-bearing account and leave them alone until the loan has been completely forgiven. That way if you decide to jump ship, you’re not suddenly on the hook for tens-of-thousands that you may not have at a moments notice.

Retirement/Employer Match

Employer matches/contributions are basically free money.¹⁴ I think you should consider this as part of your overall compensation, since it can be so variable from place to place.

Employer matching is exactly what it sounds like; you need to contribute some percentage of pay which they will match, up to some percentage of your total salary. Matching is usually, but not always in a 1:1 ratio. I’ve seen some places that matches 0.5% for every 1%.

Employer contributions are simply some amount of money they will put into a retirement account regardless of what you save. This number is usually based on a percentage of your salary and is usually capped at some base salary number. e.g. A 10% contribution, up to a salary of $300,000, means that the max yearly contribution would be $30,000 even if your salary for that year was, say, $350,000.

I’ve seen total matching + contribution percentages range from 10.5% (8.5% contribution + 2% match) on the high end, to an abysmal 1% (0.5% contribution + 0.5% match) on the low end. The average seems to be around 5-6%.

For salaried jobs, matches and contributions do not usually consider any bonuses or production to be part of your salary for purposes of calculation. I am not sure how this works for pure production based jobs — please let me know if you do.

The last thing to be aware of is vesting - which is a fancy way for your employer to say “you don’t get to keep any of the money we are so generously giving you until you’ve been here long enough.”

Most vesting schedules are 3-year cliffs; i.e. After 3 years of employment the contributions are now yours, but if you leave before 3 years you get nothing.

Getting An Offer

Assuming you didn’t weird anyone out at your site visit, they will probably extend you an offer. Sometimes this comes in the form of an offer letter, which is basically a summary of the full contract without the formal legal language. Other places will skip right to sending you a full contract.

Getting a contract to you can take a while! It took me a full month from the time that I said I would like to be provided with an offer before I was provided with a contract to review; my understanding is that this lag time is pretty typical, especially in big university systems. That said, if it’s taking multiple months to get you something signable without solid communication from the employer, I would probably be looking elsewhere. You can often speed up the turnaround time by telling them that you have another offer you need to respond to.

Do I Need My Contract Reviewed By A Lawyer?

The advice that I consistently see online is that you absolutely should pretty much no matter what. I’m not convinced by this as a blanket rule and I did not have my contract reviewed before signing.

Why not? Well, I read the contract and felt I understood it well enough that I didn’t see a whole lot of value in having it reviewed. It contained the specifics on everything that was critically important (my role and responsibilities, non-compete terms, call requirements, etc.) to a sufficient enough degree for me.

The biggest thing, though, is that there just wasn’t much that I was going to do with the information from a review. In my case — as is the case with many large academic centers — the contract I was given is pretty boilerplate for my academic rank, and individual negotiation on things like salary, bonuses, or non-compete clauses is something that the institution just wouldn’t do. That’s not to say that there aren’t things that can be negotiated on (more on this later), but there wasn’t anything left that I needed to negotiate further or have clarified for myself. The only possible thing that a review could’ve highlighted for me would’ve been a deal-breaker clause that I totally missed. I read through the contract enough times that there was nothing I could’ve been that confused about.

I think it is good to think about what you might get out of a better understanding of your contract when you decide whether or not to have it reviewed. I think the value of a review goes up when:

• There is a lot of room for modification of the contract itself

• You are applying to a job where you will take on a very complicated or very important role

• Reading legalese feels like trying to decipher the Voynich Manuscript

And goes down when:

• There is little/no room for adjustment of the base terms or even the language of the contract

• The contract is short and uncomplicated

Negotiation

Everything is negotiable… except when it isn’t.

I think that the right attitude is to think that everything might be negotiable, and your job is to figure out what actually is negotiable. Try and have a sense of what your non-negotiables are and where you’re willing to give-and-take. Remember, it never hurts to ask… unless you ask for something so outlandish that you come across as unserious. This is pretty hard to do when everyone knows this is your first job.

If you negotiate something make sure it is put into your contract, in writing. Do not accept handshake deals over email. If you do, don’t be surprised if it gets taken away a few years down the line.

This is not a section on how to negotiate. If that’s what you’re looking for, I found Getting to Yes to be an accessible introduction to some of the basic ideas of negotiation. The bottom line is that you need to be willing to walk away.

For Profit/Private Practice/Non-Academic/Etc.

This is where the “everything is negotiable” mindset is primarily applicable. I’ll briefly touch on a few broad categories of things.

Anything compensation related

I’m talking base salary, $/RVU, signing bonus amount/structure, relocation bonus, CME allowance, compensation for midlevel supervision. You name it. The more undesirable the task and the more liability it carries, the more money you should be asking for.

PTO

Unless working part-time, you should not accept anything less than 20 days of PTO (not including hospital holidays). If you’re salaried, asking for significantly more PTO than originally offered might require you to accept a drop in salary, though I’ve seen people negotiate 1-2 extra weeks without this tradeoff. If you’re on a production model, keep in mind that more PTO means less RVUs.

Work Hours/Location

There is so much more available to you than a standard M-F work week with 20-25 days of PTO. To give you an example of how nontraditional things can get, here’s what my situation at Duke will be: I’ll work M-F for 3 weeks and cover one full weekend somewhere in there, then I’m off for a full week. If I want 2 weeks off in a row, I could do 6 weeks instead.

There is room to be creative.

How many days a week are you interested in working? Are you willing to do longer days if it means you get a 3-day weekend? How many days would you like to work from home? How does a 7-on/7-off schedule sound to you? One inpatient position I interviewed for was doing a 7-on/7-off schedule, but was willing to allow me to do a traditional 5-day work week.

For outpatient settings in particular, you’ll want to make sure that you have enough time to write your notes and do other tasks. Make sure you negotiate enough admin time (default is around a half-day a week). You should also discuss how long patient appointments will be and how many patients you will see a day.

Midlevel Supervision

Midlevel supervision entails a significant amount of liability, especially given the poor quality of many NP training programs. If a midlevel working under you is sued, you are very likely to be named as a co-defendant on the lawsuit. Make sure your compensation for supervision reflects this liability. Ask to be involved in the hiring process.

Side-Gigs

If you’re planning on doing medical work on the side (e.g. consulting, expert witness work, private practice) make sure that this is negotiated ahead of time. It seems pretty common for contracts to have a clause that stipulates that you will not do any outside medical work, either at all, or without express approval of some higher-up.

Academia

Compensation

Many large academic centers have adopted physician employment models that offer very little flexibility for individual physicians in terms of pay, vacation time, etc.. In my experience, this isn’t just a case where they say that they don’t negotiate. In every instance — except one — where I attempted to negotiate pay for an academic job, I was told “Sorry, we don’t negotiate individual agreements.” When I would tell them that would be a total deal-breaker, they would say “OK, let us know if you change your mind!” It’s not a negotiation tactic, it’s an institutional policy.

The one exception was willing to adjust my base salary by “a few thousand dollars.” So, again, ask, but don’t be surprised if the answer is no.

Time and FTEs

My impression of negotiation in academia is that it is more about figuring out what you will be doing and how much of it, as opposed to how much you will be paid for it. The common parlance around this are fractions of FTE (full time equivalent), where 0.1 FTE is (roughly) a half-day a week. The default for “pure” clinical work is 0.9 FTE clinical and 0.1 FTE administrative, which covers things like teaching, note writing, etc.

You might be able to negotiate how much time you’re spending on different clinical services. Maybe you like a bit of variety and want to spend 50% of your clinical time doing inpatient work, 30% doing C/L, and 20% doing ED. Perhaps there is a clinical niche you’re interested in and you want time to start up a specialty outpatient clinic or consult service, but you’re going to need 0.2 FTEs of admin time instead of just 0.1. If you’re very interested in teaching, you might be able to arrange to have 0.2 FTE as protected time to lecture, facilitate small groups, work on curriculum, etc. If you want more vacation time and are willing to get paid less, see if you can negotiate a 0.8 FTE position.

Keep in mind that not all work is equal in its contribution to FTEs. The department might consider a full day of outpatient work to be worth the same amount as a half day of ECT work. If your role has flexibility in the services it spans, you should try and learn how FTEs are calculated across different services.

Finally, keep in mind that the job you take might get labeled as 1.0 FTE, but it may have considerable flexibility in how long your day actually is depending on the efficiency of you and your team. There were more than a few inpatient jobs I interviewed for that, officially, were “9am-5pm five days a week,” but in reality were “get in any time you want before 10am, go home whenever you’re done with your clinical work which is usually around 2-3pm.”

Side-Gigs/Moonlighting/Private Practice

Academic institutions are both jealous and arrogant. They like to insist that they give you so much support and career development that you couldn’t possibly do any work on the side, because that would just be so unfair to them and all of the resources they are just pouring into you, and what would the other institutions say if they saw you working somewhere else that would just be so embarrassing for everyone so better that you just don’t, OK?

That said, most places I interviewed did allow you to have an outpatient practice as an inpatient doc, as long as it was run through the university. They always took a percentage of billing, but let you set rates and see your patients as you pleased… as long as it was outside of your official work hours.

Turning Down Offers

Let’s wrap this up. It’s ok to turn down offers. You are not obligated to accept a job just because they flew you out, took you out to dinner, and seemed to really like you.

Just because you turn down a job doesn’t mean you’ve burned a bridge. Psychiatry is a small world and nobody wants to make enemies. If they liked you enough to interview you, do a site visit, and extend you an offer, they would probably like to hire you in the future.

Send a polite email saying thanks, but no thanks, and all will be well.

1. WCI isn’t psych specific, but there’s a lot of information that works across specialties

2. The diacritic under the ‘c’ is called a cedilla, by the way

3. Still haven’t

4. I am not taking questions about the size of my ego — nor my novel methods of compression — at this time.

5. If you are a physician recruiter and do know, please let me know.

6. As an aside, I think residents — particularly those in their last year of training — are some of the best people to talk to about what a program is like. Unless they’re planning to stay there, they have very little incentive to sugarcoat. Residents also tend to be reflective of the program itself (to a degree, of course) and can be a good bellwether for the nature of the program as a whole.

7. Rutgers. It was Rutgers. Sorry to call you out Rutgers, but c’mon. Maybe this is because it’s technically a state school, in which case c’mon New Jersey.

8. If you’re not, costing them that much, look elsewhere.

9. In retrospect I should’ve only made that offer if they said they would not pay for it.

10. I will not call them APPs, sorry. “Midlevel” is not a derogatory term and you will not convince me that it is.

11. Theoretically I could imagine having a pretty low base salary and productivity starting from your very first RVU, but I’ve never seen this in practice.

12. You should also consider how this might alter how you have to run your service. If you’re someone who wants to be able to reject bad consults out of a sense of professional ethics, be aware that the temptation to cave for the sake of your salary will be ever-present.

13. Which is taxable income!

14. If you think it’s not free money you are not saving nearly enough for retirement. You are going to be making 6-figures a year, please learn some financial skills.