Joseph V. Sakran, MD, MPH, MPA

Those of you who are either poker players or have watched those that play will understand the importance of having a poker face in some circumstances. Although poker typically results in a zero-sum game, the strategy and tactics in achieving an optimal outcome are quite similar to contract negotiations. Coming into the “game” prepared with a strategic approach and the ability to be observant, and having the aptitude to maintain a high level of emotional intelligence are fundamental to success. This is the third and final article on this special series titled “The Art of Negotiation.” In the first article, we looked at big picture concepts related to the negotiation of contracts in medicine (ACS Surgery News, October 2015, p. 13), and subsequently we delved the task of gathering information (November 2015, p. 9). We will end this series by looking at how we can put everything together in order to best position ourselves in reaching a win-win solution.

Understanding your emotional approach

One of the first things discussed early on within this series of articles is the fact that contract negotiations in medicine are far from a simple transactional deal. The relationship building in the negotiation context extends far beyond this one deal. For those new to the job market, the right job can be the culmination of dreams and ambitions years in the making. Job negotiations should not be taken lightly nor sabotaged by out-of-control emotions. You may experience a variety of emotions during a negotiation such as anxiety, anger, sadness, and excitement.

These feelings can directly affect the process, and therefore understanding how to internally deal with them can make for a smoother and potentially more beneficial end result.

Anxiety management

Anxiety is a feeling often experienced during the early stages of the negotiation process. One response to anxiety is avoidance – cut negotiations short and make a quick agreement. But avoidance can undermine some of the basic tenants of negotiation where the ability to be patient and persevere is critical. Anxious negotiators can end up making weaker offers, spending less time negotiating, and getting a less-than-optimal agreement. The ability to minimize feelings of anxiety is related to preparation and practice.

Have you ever walked into an exam feeling unprepared and wishing you had studied more or done a few more review questions? There is a clear difference in how you approach an exam you are unprepared for versus one for which you have mastered the material.

Do your homework and your anxiety will be less.

Imagine the following scenario. A colleague of mine was back for a second interview at a medical center that overall had what she was looking for, and therefore she had begun the negotiation process with the committee including the chief of the service. They began by telling her how wonderful their offer was, and even mentioned that a few other candidates were interested in taking this position if she hesitated. This technique to exert pressure on candidates is not uncommon, yet it made her anxious. As the conversation went on, her anxiety continue to build.

She was able to excuse herself for a moment and she texted me from her sanctuary, which at that time happened to be a restroom stall. “Joe, what if I don’t agree to the terms? Am I going to lose this potentially great opportunity? I should just sign the contract?” she said. I was able to remind her of a few things. First, I told her, you are at the table for a reason, which primarily has to do with the fact that you may provide value to the organization. Second, I asked her if she knew what were they looking for. It is critical to understand what the institution considers important since it will allow you to leverage your skill set. If the answer is not clear, then ask questions to help illustrate what they value to help advance their objectives.

Once you have determined what they value most, you can negotiate with greater confidence.

Finally, you should never sign a contract without taking time to really review it. If a potential employer is not willing to give you that time then it should be a red flag that something is not right!

Anger management

Anger is another emotion that, unlike anxiety, can result in an increase in intensity of the negotiation. While certain aspects of this might seem appealing and even at times beneficial, in general, anger impairs the overall process, results in a higher likelihood of an impasse, and potentially damages the long-term relationship. In fact, even if a deal is ultimately agreed upon, trust among the parties is reduced, making for a potentially difficult working relationship in the future. It is wise to make every effort to minimize aggression during the discussion and ensure the other team understands your goal of reaching a win-win solution. Remember that even in the best circumstances, these complex negotiations usually result in a combination of elements gained and lost. The most skilled negotiators will leave the table confident that they achieved a great deal, while making sure that the other party also feels good about the agreement.

The value of MESOs

The term Multiple Equivalent Simultaneous Offers (MESO) negotiation is a strategy that is used when multiple interests are involved. MESO fits perfectly with the type of compensation packages physicians aiming to negotiate where base salary is not the only aspect under discussion. The idea is to make multiple offers that, in your mind, are essentially equivalent.

The three steps required are as follows:

1. Identify and prioritize important issues, and assign them a relative weight

2. Identify different likely outcomes for each issue

3. Develop three or more equivalent offers

This strategy gives you the opportunity to gather information about the other side in order to better understand where their priorities lie, and provides you the opportunity to be assertive at the negotiating table but also flexible and cooperative. MESO does require an investment of time in putting together these plans, and will ultimately require you to reveal some of your own interests. At the end of the day, people feel good about being given multiple choices rather than a single option. This typically results in greater value, and will often enhance the probability of reaching an agreement.

Parting thoughts

The process of negotiating a contract can be unsettling. This series has aimed to provide you with some of the basic principles that might help facilitate these discussions that at some point in time you will inevitably be required to have.

The following are 10 summary points that you might find helpful:

1. Preparation is the key. (Do your research, talk to people.)

2. Maintain a high level of emotional intelligence.

3. Listen and be observant during discussions.

4. Be creative in your approach. (Remember, its not all about the base salary!)

5. Maintain discipline when responding to questions (especially when unsure).

6. The only way to guarantee an agreement is to get it in writing.

7. The goal is to reach a win-win solution.

8. Maintain honesty and integrity throughout the process.

9. Understand that you are building long-term relationships.

10. Gut instinct is not a strategy.

Napoleon Hill said, “The starting point of all achievement is desire.” Whatever that desire may be, remember to think of all the variables critical to turning that desire into achievement. My hope is that some of the techniques I have described will be useful as you prepare to take that next step into the surgical workforce.

Feel free to tweet me for questions, comments, or ideas @Josephsakran.

Dr. Sakran is an ACS Fellow, and assistant professor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is the immediate past chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

Those of you who are either poker players or have watched those that play will understand the importance of having a poker face in some circumstances. Although poker typically results in a zero-sum game, the strategy and tactics in achieving an optimal outcome are quite similar to contract negotiations. Coming into the “game” prepared with a strategic approach and the ability to be observant, and having the aptitude to maintain a high level of emotional intelligence are fundamental to success. This is the third and final article on this special series titled “The Art of Negotiation.” In the first article, we looked at big picture concepts related to the negotiation of contracts in medicine (ACS Surgery News, October 2015, p. 13), and subsequently we delved the task of gathering information (November 2015, p. 9). We will end this series by looking at how we can put everything together in order to best position ourselves in reaching a win-win solution.

Understanding your emotional approach

One of the first things discussed early on within this series of articles is the fact that contract negotiations in medicine are far from a simple transactional deal. The relationship building in the negotiation context extends far beyond this one deal. For those new to the job market, the right job can be the culmination of dreams and ambitions years in the making. Job negotiations should not be taken lightly nor sabotaged by out-of-control emotions. You may experience a variety of emotions during a negotiation such as anxiety, anger, sadness, and excitement.

These feelings can directly affect the process, and therefore understanding how to internally deal with them can make for a smoother and potentially more beneficial end result.

Anxiety management

Anxiety is a feeling often experienced during the early stages of the negotiation process. One response to anxiety is avoidance – cut negotiations short and make a quick agreement. But avoidance can undermine some of the basic tenants of negotiation where the ability to be patient and persevere is critical. Anxious negotiators can end up making weaker offers, spending less time negotiating, and getting a less-than-optimal agreement. The ability to minimize feelings of anxiety is related to preparation and practice.

Have you ever walked into an exam feeling unprepared and wishing you had studied more or done a few more review questions? There is a clear difference in how you approach an exam you are unprepared for versus one for which you have mastered the material.

Do your homework and your anxiety will be less.

Imagine the following scenario. A colleague of mine was back for a second interview at a medical center that overall had what she was looking for, and therefore she had begun the negotiation process with the committee including the chief of the service. They began by telling her how wonderful their offer was, and even mentioned that a few other candidates were interested in taking this position if she hesitated. This technique to exert pressure on candidates is not uncommon, yet it made her anxious. As the conversation went on, her anxiety continue to build.

She was able to excuse herself for a moment and she texted me from her sanctuary, which at that time happened to be a restroom stall. “Joe, what if I don’t agree to the terms? Am I going to lose this potentially great opportunity? I should just sign the contract?” she said. I was able to remind her of a few things. First, I told her, you are at the table for a reason, which primarily has to do with the fact that you may provide value to the organization. Second, I asked her if she knew what were they looking for. It is critical to understand what the institution considers important since it will allow you to leverage your skill set. If the answer is not clear, then ask questions to help illustrate what they value to help advance their objectives.

Once you have determined what they value most, you can negotiate with greater confidence.

Finally, you should never sign a contract without taking time to really review it. If a potential employer is not willing to give you that time then it should be a red flag that something is not right!

Anger management

Anger is another emotion that, unlike anxiety, can result in an increase in intensity of the negotiation. While certain aspects of this might seem appealing and even at times beneficial, in general, anger impairs the overall process, results in a higher likelihood of an impasse, and potentially damages the long-term relationship. In fact, even if a deal is ultimately agreed upon, trust among the parties is reduced, making for a potentially difficult working relationship in the future. It is wise to make every effort to minimize aggression during the discussion and ensure the other team understands your goal of reaching a win-win solution. Remember that even in the best circumstances, these complex negotiations usually result in a combination of elements gained and lost. The most skilled negotiators will leave the table confident that they achieved a great deal, while making sure that the other party also feels good about the agreement.

The value of MESOs

The term Multiple Equivalent Simultaneous Offers (MESO) negotiation is a strategy that is used when multiple interests are involved. MESO fits perfectly with the type of compensation packages physicians aiming to negotiate where base salary is not the only aspect under discussion. The idea is to make multiple offers that, in your mind, are essentially equivalent.

The three steps required are as follows:

1. Identify and prioritize important issues, and assign them a relative weight

2. Identify different likely outcomes for each issue

3. Develop three or more equivalent offers

This strategy gives you the opportunity to gather information about the other side in order to better understand where their priorities lie, and provides you the opportunity to be assertive at the negotiating table but also flexible and cooperative. MESO does require an investment of time in putting together these plans, and will ultimately require you to reveal some of your own interests. At the end of the day, people feel good about being given multiple choices rather than a single option. This typically results in greater value, and will often enhance the probability of reaching an agreement.

Parting thoughts

The process of negotiating a contract can be unsettling. This series has aimed to provide you with some of the basic principles that might help facilitate these discussions that at some point in time you will inevitably be required to have.

The following are 10 summary points that you might find helpful:

1. Preparation is the key. (Do your research, talk to people.)

2. Maintain a high level of emotional intelligence.

3. Listen and be observant during discussions.

4. Be creative in your approach. (Remember, its not all about the base salary!)

5. Maintain discipline when responding to questions (especially when unsure).

6. The only way to guarantee an agreement is to get it in writing.

7. The goal is to reach a win-win solution.

8. Maintain honesty and integrity throughout the process.

9. Understand that you are building long-term relationships.

10. Gut instinct is not a strategy.

Napoleon Hill said, “The starting point of all achievement is desire.” Whatever that desire may be, remember to think of all the variables critical to turning that desire into achievement. My hope is that some of the techniques I have described will be useful as you prepare to take that next step into the surgical workforce.

Feel free to tweet me for questions, comments, or ideas @Josephsakran.

Dr. Sakran is an ACS Fellow, and assistant professor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is the immediate past chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

Those of you who are either poker players or have watched those that play will understand the importance of having a poker face in some circumstances. Although poker typically results in a zero-sum game, the strategy and tactics in achieving an optimal outcome are quite similar to contract negotiations. Coming into the “game” prepared with a strategic approach and the ability to be observant, and having the aptitude to maintain a high level of emotional intelligence are fundamental to success. This is the third and final article on this special series titled “The Art of Negotiation.” In the first article, we looked at big picture concepts related to the negotiation of contracts in medicine (ACS Surgery News, October 2015, p. 13), and subsequently we delved the task of gathering information (November 2015, p. 9). We will end this series by looking at how we can put everything together in order to best position ourselves in reaching a win-win solution.

Understanding your emotional approach

One of the first things discussed early on within this series of articles is the fact that contract negotiations in medicine are far from a simple transactional deal. The relationship building in the negotiation context extends far beyond this one deal. For those new to the job market, the right job can be the culmination of dreams and ambitions years in the making. Job negotiations should not be taken lightly nor sabotaged by out-of-control emotions. You may experience a variety of emotions during a negotiation such as anxiety, anger, sadness, and excitement.

These feelings can directly affect the process, and therefore understanding how to internally deal with them can make for a smoother and potentially more beneficial end result.

Anxiety management

Anxiety is a feeling often experienced during the early stages of the negotiation process. One response to anxiety is avoidance – cut negotiations short and make a quick agreement. But avoidance can undermine some of the basic tenants of negotiation where the ability to be patient and persevere is critical. Anxious negotiators can end up making weaker offers, spending less time negotiating, and getting a less-than-optimal agreement. The ability to minimize feelings of anxiety is related to preparation and practice.

Have you ever walked into an exam feeling unprepared and wishing you had studied more or done a few more review questions? There is a clear difference in how you approach an exam you are unprepared for versus one for which you have mastered the material.

Do your homework and your anxiety will be less.

Imagine the following scenario. A colleague of mine was back for a second interview at a medical center that overall had what she was looking for, and therefore she had begun the negotiation process with the committee including the chief of the service. They began by telling her how wonderful their offer was, and even mentioned that a few other candidates were interested in taking this position if she hesitated. This technique to exert pressure on candidates is not uncommon, yet it made her anxious. As the conversation went on, her anxiety continue to build.

She was able to excuse herself for a moment and she texted me from her sanctuary, which at that time happened to be a restroom stall. “Joe, what if I don’t agree to the terms? Am I going to lose this potentially great opportunity? I should just sign the contract?” she said. I was able to remind her of a few things. First, I told her, you are at the table for a reason, which primarily has to do with the fact that you may provide value to the organization. Second, I asked her if she knew what were they looking for. It is critical to understand what the institution considers important since it will allow you to leverage your skill set. If the answer is not clear, then ask questions to help illustrate what they value to help advance their objectives.

Once you have determined what they value most, you can negotiate with greater confidence.

Finally, you should never sign a contract without taking time to really review it. If a potential employer is not willing to give you that time then it should be a red flag that something is not right!

Anger management

Anger is another emotion that, unlike anxiety, can result in an increase in intensity of the negotiation. While certain aspects of this might seem appealing and even at times beneficial, in general, anger impairs the overall process, results in a higher likelihood of an impasse, and potentially damages the long-term relationship. In fact, even if a deal is ultimately agreed upon, trust among the parties is reduced, making for a potentially difficult working relationship in the future. It is wise to make every effort to minimize aggression during the discussion and ensure the other team understands your goal of reaching a win-win solution. Remember that even in the best circumstances, these complex negotiations usually result in a combination of elements gained and lost. The most skilled negotiators will leave the table confident that they achieved a great deal, while making sure that the other party also feels good about the agreement.

The value of MESOs

The term Multiple Equivalent Simultaneous Offers (MESO) negotiation is a strategy that is used when multiple interests are involved. MESO fits perfectly with the type of compensation packages physicians aiming to negotiate where base salary is not the only aspect under discussion. The idea is to make multiple offers that, in your mind, are essentially equivalent.

The three steps required are as follows:

1. Identify and prioritize important issues, and assign them a relative weight

2. Identify different likely outcomes for each issue

3. Develop three or more equivalent offers

This strategy gives you the opportunity to gather information about the other side in order to better understand where their priorities lie, and provides you the opportunity to be assertive at the negotiating table but also flexible and cooperative. MESO does require an investment of time in putting together these plans, and will ultimately require you to reveal some of your own interests. At the end of the day, people feel good about being given multiple choices rather than a single option. This typically results in greater value, and will often enhance the probability of reaching an agreement.

Parting thoughts

The process of negotiating a contract can be unsettling. This series has aimed to provide you with some of the basic principles that might help facilitate these discussions that at some point in time you will inevitably be required to have.

The following are 10 summary points that you might find helpful:

1. Preparation is the key. (Do your research, talk to people.)

2. Maintain a high level of emotional intelligence.

3. Listen and be observant during discussions.

4. Be creative in your approach. (Remember, its not all about the base salary!)

5. Maintain discipline when responding to questions (especially when unsure).

6. The only way to guarantee an agreement is to get it in writing.

7. The goal is to reach a win-win solution.

8. Maintain honesty and integrity throughout the process.

9. Understand that you are building long-term relationships.

10. Gut instinct is not a strategy.

Napoleon Hill said, “The starting point of all achievement is desire.” Whatever that desire may be, remember to think of all the variables critical to turning that desire into achievement. My hope is that some of the techniques I have described will be useful as you prepare to take that next step into the surgical workforce.

Feel free to tweet me for questions, comments, or ideas @Josephsakran.

Dr. Sakran is an ACS Fellow, and assistant professor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is the immediate past chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

All surgical trainees eventually have to take on the challenge of finding the right fit for themselves within the workforce. Our training typically lacks a step-by-step guidance for entering the workforce. The first article of this three-part series on the Art of Negotiation (ACS Surgery News, 2015, p. 13) gave us a 30,000-foot view. Now let’s take a more granular look at the necessary components needed to get a competitive compensation package.

The process can be overwhelming, and so it is vital that you have a graduated approach to accomplishing the necessary tasks. You should begin by gathering the relevant information so that you can be prepared to negotiate and eventually make the most informed decision.

Understanding the base salary

The majority of us will focus on how much direct compensation or base salary we should ask for. While I don’t want to minimize the importance of this one number, it is far from the only thing that needs to be considered, as many variables play a role when deciding whether or not to accept a position.

There are two resources that should be used to give you a frame of reference. The first is the Association of American Medical Colleges (AAMC) report of medical school faculty salaries, which provides us with academic salary information. The second is data regarding private practice salaries that is from the MGMA physician compensation survey. These resources can be expensive to purchase on your own; however, nearly every institute will have a copy that you should be able to use.

When determining the competitiveness of base salary, one must take the following into consideration: Specialty, Practice Setting, Professional Level, and Geography.

Specialty – A wide range of salary support exists between surgeons based on specialty with neurosurgery at the top of the spectrum and other surgical specialties somewhere below. You will need to look closely at the AAMC and MGMA data to get a good idea of what salary range to expect in your specialty.

Practice Setting/Professional Level – This category is divided into two sections, academic and private practice. These can be further broken down into professional levels: assistant professor and associate/full professor in the academic setting, and starting salaries, 1-2 years in a specialty, and all physicians in the private practice setting.

The differences between salaries for these groups can vary depending upon level of experience and geography. For those that are fresh out of training it is important to notice that salaries early on in one’s career can be similar between the academic and private practice setting yet become widely disparate as surgeons become more seasoned. An example of this can be seen in neurosurgery where if you look at the physician compensation in 2011, the median starting salary for private practice is $400,000. The equivalent academic median salary is $408,000. You might look at this and think it is more beneficial from a purely monetary standpoint to be in an academic job; however, when you look at what happens after 1-2 years in private practice, that median salary jumps significantly to $634,884. Even as an associate professor, which is five or more years out, the median salary is $487,000.

Geography – Location can be important, considering the significant differences in compensation across the country. Imagine the following two opportunities: One is employment in the DMV (D.C., Maryland, Virginia), at an academically affiliated medical center just outside our nation’s capital. The other is in the rural Midwest at a comparable medical center. Taking into consideration the same professional level, which base salary is going to be higher? In the majority of circumstances it will be the rural Midwest, as they attempt to recruit candidates that might not otherwise have an attachment to the area. This can be important during the negotiation process, as it provides you with a bit of insight when it comes to how far you might be able to push the envelope. It also is important to note that in areas that are highly saturated with surgeons, or “attractive” cities that people want to live in, this will ultimately diminish your negotiating ability.

Retirement packages

One other aspect that is not typically included in these resources has to do with retirement packages. These can vary widely and should be looked at carefully. For example, there are some institutes that will put $20,000 toward your retirement while others will contribute $55,000 annually. Everything else being equal, even if the base salary is higher by $25,000 at the institute contributing $20,000 toward retirement, the other offer is still advantageous. While almost everything in a contract is negotiable, the one exception is typically the retirement package. The majority of centers have a standard that is across the board for all faculty. Therefore, focus your time and energy in other areas that can be negotiated.

Division of Time

How your contract structures your time matters a lot. Assume that you are taking a position at an academic medical center. You are interested in maintaining a “triple threat” model of clinician, teacher, and researcher. How do you ensure that you will be successful? The terminology that you should be familiar with is the clinical full-time equivalent (FTE). If your contract has you at a 100% clinical FTE, you are likely not to get any protected time for research. For those highly motivated individuals, you would end up burning the midnight oil, an using your free nights and weekends to pursue your research interests. However, most physicians would not consider this a sustainable model, not to mention the negative impact it would have on your personal life. If your focus is research heavy, the perhaps you’re looking for a position that is 50% clinical FTE. A good rule of thumb is that every 20% of an FTE equates to one day of protected time during the week. Therefore an FTE that is 80% clinical, and 20% research should average to one day a week of protected time. It is reasonable to ask the department to support you for the first 3-5 years as you build your research portfolio. Some institutions might then require you to bring in funding through grants at the end of that time period.

Get it in writing

During the negotiation process, it is highly likely that you will be negotiating with someone that has trained you – perhaps a mentor, or a prominent surgeon. You must learn to remove the emotion from the business aspect of this process. Promises are not sufficient, and your contract needs to clearly articulate the reached agreement. An example of a situation I saw where the agreement was not formalized happened to a colleague of mine, who after he was hired ended up having his division chief move to another institute. The new division chief that took over had different plans for how he would function within the team. The bottom line is that everything you believe is important to your success must be in writing.

The next article will finish highlighting other important aspects that will set you up for success when negotiating your compensation package, and provide some final tricks of the trade that will help make this somewhat intimidating yet exciting process easier!

Dr. Sakran is an assistant professor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is currently chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

All surgical trainees eventually have to take on the challenge of finding the right fit for themselves within the workforce. Our training typically lacks a step-by-step guidance for entering the workforce. The first article of this three-part series on the Art of Negotiation (ACS Surgery News, 2015, p. 13) gave us a 30,000-foot view. Now let’s take a more granular look at the necessary components needed to get a competitive compensation package.

The process can be overwhelming, and so it is vital that you have a graduated approach to accomplishing the necessary tasks. You should begin by gathering the relevant information so that you can be prepared to negotiate and eventually make the most informed decision.

Understanding the base salary

The majority of us will focus on how much direct compensation or base salary we should ask for. While I don’t want to minimize the importance of this one number, it is far from the only thing that needs to be considered, as many variables play a role when deciding whether or not to accept a position.

There are two resources that should be used to give you a frame of reference. The first is the Association of American Medical Colleges (AAMC) report of medical school faculty salaries, which provides us with academic salary information. The second is data regarding private practice salaries that is from the MGMA physician compensation survey. These resources can be expensive to purchase on your own; however, nearly every institute will have a copy that you should be able to use.

When determining the competitiveness of base salary, one must take the following into consideration: Specialty, Practice Setting, Professional Level, and Geography.

Specialty – A wide range of salary support exists between surgeons based on specialty with neurosurgery at the top of the spectrum and other surgical specialties somewhere below. You will need to look closely at the AAMC and MGMA data to get a good idea of what salary range to expect in your specialty.

Practice Setting/Professional Level – This category is divided into two sections, academic and private practice. These can be further broken down into professional levels: assistant professor and associate/full professor in the academic setting, and starting salaries, 1-2 years in a specialty, and all physicians in the private practice setting.

The differences between salaries for these groups can vary depending upon level of experience and geography. For those that are fresh out of training it is important to notice that salaries early on in one’s career can be similar between the academic and private practice setting yet become widely disparate as surgeons become more seasoned. An example of this can be seen in neurosurgery where if you look at the physician compensation in 2011, the median starting salary for private practice is $400,000. The equivalent academic median salary is $408,000. You might look at this and think it is more beneficial from a purely monetary standpoint to be in an academic job; however, when you look at what happens after 1-2 years in private practice, that median salary jumps significantly to $634,884. Even as an associate professor, which is five or more years out, the median salary is $487,000.

Geography – Location can be important, considering the significant differences in compensation across the country. Imagine the following two opportunities: One is employment in the DMV (D.C., Maryland, Virginia), at an academically affiliated medical center just outside our nation’s capital. The other is in the rural Midwest at a comparable medical center. Taking into consideration the same professional level, which base salary is going to be higher? In the majority of circumstances it will be the rural Midwest, as they attempt to recruit candidates that might not otherwise have an attachment to the area. This can be important during the negotiation process, as it provides you with a bit of insight when it comes to how far you might be able to push the envelope. It also is important to note that in areas that are highly saturated with surgeons, or “attractive” cities that people want to live in, this will ultimately diminish your negotiating ability.

Retirement packages

One other aspect that is not typically included in these resources has to do with retirement packages. These can vary widely and should be looked at carefully. For example, there are some institutes that will put $20,000 toward your retirement while others will contribute $55,000 annually. Everything else being equal, even if the base salary is higher by $25,000 at the institute contributing $20,000 toward retirement, the other offer is still advantageous. While almost everything in a contract is negotiable, the one exception is typically the retirement package. The majority of centers have a standard that is across the board for all faculty. Therefore, focus your time and energy in other areas that can be negotiated.

Division of Time

How your contract structures your time matters a lot. Assume that you are taking a position at an academic medical center. You are interested in maintaining a “triple threat” model of clinician, teacher, and researcher. How do you ensure that you will be successful? The terminology that you should be familiar with is the clinical full-time equivalent (FTE). If your contract has you at a 100% clinical FTE, you are likely not to get any protected time for research. For those highly motivated individuals, you would end up burning the midnight oil, an using your free nights and weekends to pursue your research interests. However, most physicians would not consider this a sustainable model, not to mention the negative impact it would have on your personal life. If your focus is research heavy, the perhaps you’re looking for a position that is 50% clinical FTE. A good rule of thumb is that every 20% of an FTE equates to one day of protected time during the week. Therefore an FTE that is 80% clinical, and 20% research should average to one day a week of protected time. It is reasonable to ask the department to support you for the first 3-5 years as you build your research portfolio. Some institutions might then require you to bring in funding through grants at the end of that time period.

Get it in writing

During the negotiation process, it is highly likely that you will be negotiating with someone that has trained you – perhaps a mentor, or a prominent surgeon. You must learn to remove the emotion from the business aspect of this process. Promises are not sufficient, and your contract needs to clearly articulate the reached agreement. An example of a situation I saw where the agreement was not formalized happened to a colleague of mine, who after he was hired ended up having his division chief move to another institute. The new division chief that took over had different plans for how he would function within the team. The bottom line is that everything you believe is important to your success must be in writing.

The next article will finish highlighting other important aspects that will set you up for success when negotiating your compensation package, and provide some final tricks of the trade that will help make this somewhat intimidating yet exciting process easier!

Dr. Sakran is an assistant professor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is currently chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

All surgical trainees eventually have to take on the challenge of finding the right fit for themselves within the workforce. Our training typically lacks a step-by-step guidance for entering the workforce. The first article of this three-part series on the Art of Negotiation (ACS Surgery News, 2015, p. 13) gave us a 30,000-foot view. Now let’s take a more granular look at the necessary components needed to get a competitive compensation package.

The process can be overwhelming, and so it is vital that you have a graduated approach to accomplishing the necessary tasks. You should begin by gathering the relevant information so that you can be prepared to negotiate and eventually make the most informed decision.

Understanding the base salary

The majority of us will focus on how much direct compensation or base salary we should ask for. While I don’t want to minimize the importance of this one number, it is far from the only thing that needs to be considered, as many variables play a role when deciding whether or not to accept a position.

There are two resources that should be used to give you a frame of reference. The first is the Association of American Medical Colleges (AAMC) report of medical school faculty salaries, which provides us with academic salary information. The second is data regarding private practice salaries that is from the MGMA physician compensation survey. These resources can be expensive to purchase on your own; however, nearly every institute will have a copy that you should be able to use.

When determining the competitiveness of base salary, one must take the following into consideration: Specialty, Practice Setting, Professional Level, and Geography.

Specialty – A wide range of salary support exists between surgeons based on specialty with neurosurgery at the top of the spectrum and other surgical specialties somewhere below. You will need to look closely at the AAMC and MGMA data to get a good idea of what salary range to expect in your specialty.

Practice Setting/Professional Level – This category is divided into two sections, academic and private practice. These can be further broken down into professional levels: assistant professor and associate/full professor in the academic setting, and starting salaries, 1-2 years in a specialty, and all physicians in the private practice setting.

The differences between salaries for these groups can vary depending upon level of experience and geography. For those that are fresh out of training it is important to notice that salaries early on in one’s career can be similar between the academic and private practice setting yet become widely disparate as surgeons become more seasoned. An example of this can be seen in neurosurgery where if you look at the physician compensation in 2011, the median starting salary for private practice is $400,000. The equivalent academic median salary is $408,000. You might look at this and think it is more beneficial from a purely monetary standpoint to be in an academic job; however, when you look at what happens after 1-2 years in private practice, that median salary jumps significantly to $634,884. Even as an associate professor, which is five or more years out, the median salary is $487,000.

Geography – Location can be important, considering the significant differences in compensation across the country. Imagine the following two opportunities: One is employment in the DMV (D.C., Maryland, Virginia), at an academically affiliated medical center just outside our nation’s capital. The other is in the rural Midwest at a comparable medical center. Taking into consideration the same professional level, which base salary is going to be higher? In the majority of circumstances it will be the rural Midwest, as they attempt to recruit candidates that might not otherwise have an attachment to the area. This can be important during the negotiation process, as it provides you with a bit of insight when it comes to how far you might be able to push the envelope. It also is important to note that in areas that are highly saturated with surgeons, or “attractive” cities that people want to live in, this will ultimately diminish your negotiating ability.

Retirement packages

One other aspect that is not typically included in these resources has to do with retirement packages. These can vary widely and should be looked at carefully. For example, there are some institutes that will put $20,000 toward your retirement while others will contribute $55,000 annually. Everything else being equal, even if the base salary is higher by $25,000 at the institute contributing $20,000 toward retirement, the other offer is still advantageous. While almost everything in a contract is negotiable, the one exception is typically the retirement package. The majority of centers have a standard that is across the board for all faculty. Therefore, focus your time and energy in other areas that can be negotiated.

Division of Time

How your contract structures your time matters a lot. Assume that you are taking a position at an academic medical center. You are interested in maintaining a “triple threat” model of clinician, teacher, and researcher. How do you ensure that you will be successful? The terminology that you should be familiar with is the clinical full-time equivalent (FTE). If your contract has you at a 100% clinical FTE, you are likely not to get any protected time for research. For those highly motivated individuals, you would end up burning the midnight oil, an using your free nights and weekends to pursue your research interests. However, most physicians would not consider this a sustainable model, not to mention the negative impact it would have on your personal life. If your focus is research heavy, the perhaps you’re looking for a position that is 50% clinical FTE. A good rule of thumb is that every 20% of an FTE equates to one day of protected time during the week. Therefore an FTE that is 80% clinical, and 20% research should average to one day a week of protected time. It is reasonable to ask the department to support you for the first 3-5 years as you build your research portfolio. Some institutions might then require you to bring in funding through grants at the end of that time period.

Get it in writing

During the negotiation process, it is highly likely that you will be negotiating with someone that has trained you – perhaps a mentor, or a prominent surgeon. You must learn to remove the emotion from the business aspect of this process. Promises are not sufficient, and your contract needs to clearly articulate the reached agreement. An example of a situation I saw where the agreement was not formalized happened to a colleague of mine, who after he was hired ended up having his division chief move to another institute. The new division chief that took over had different plans for how he would function within the team. The bottom line is that everything you believe is important to your success must be in writing.

The next article will finish highlighting other important aspects that will set you up for success when negotiating your compensation package, and provide some final tricks of the trade that will help make this somewhat intimidating yet exciting process easier!

Dr. Sakran is an assistant professor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is currently chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

As I maneuvered through the winding cobblestone roads of the Old City in Jerusalem, the smell of fresh bread intertwined with spices filled the air. Sensory overload blended with the multicultural flavor of the Holy City is a scene difficult to paint with words. In the hustle and bustle of the market, I can still vividly see the image of a lady negotiating over a bag of zaatar (thyme). As her kids pulled on her garb trying to move their mom along, I watched as the buyer and seller went back and forth on the final price of the herbs. This was negotiation as an art form! With both parties satisfied with the deal and parting with a smile, it was clearly a win-win outcome. But bargaining in a fashion so common in the souk (open air market) is not the norm in the United States.

In my household, I was taught to never accept the first offer, and therefore, negotiating in second nature to me. As I neared the end of my fellowship and began my job search, I began to really enjoy the negotiation process with potential employers. I was surprised to learn, however, that not only was this not common practice among my colleagues, but also at times discouraged. I heard remarks like, “Don’t worry about your first contract, it doesn’t really matter,” and “These contracts are all pretty standard,” or “You better not ask for too much or they will find someone else,” or “Negotiating will upset them.” While I was baffled by this attitude, it dawned on me that, despite our trainees spending more than a decade in surgical training, many clinicians are currently entering surgical practice unprepared to negotiate the best contract to meet their needs. Let me be clear, I do not claim to be an expert in negotiations. However, I offer my experiences as a hope that it might provide some insight and guidance to those entering the medical workforce.

This introductory article is one of three meant to provide insight when it comes to basic negotiating principles for those doctors heading out into the work world. In no way is it meant to be a comprehensive guide, yet I hope that it offers an idea of what to look for and how best to approach these formal discussions.

Often individuals can find the negotiation process uncomfortable and stressful. However, the ability to negotiate well is something that can be learned, and is not predicated on some innate ability. The key to reaching optimal outcomes really comes down to two things: 1) walking into the negotiation prepared; and 2) maintaining a high level of emotional intelligence that allows you to be disciplined at the table. With the medical community being relatively small, the process should be geared toward building a relationship, in hopes of meeting the interests of all stakeholders. The resulting relationship, whether good or bad, will have future ramifications. This applies to both the employer and employee. Your goal is not to “one-up” the other party, but to ensure you walk away with a solution that meets your needs based on your interest.

Walking in prepared

One of the first steps in making sure you are well prepared is taking the time to determine what your interests are and how you would prioritize them. Do your homework! Often we get caught up in the salary number while losing sight of a wide range of potential benefits that might be discussed (for example, research support, time protection, employment for spouse, moving costs, signing bonus, mentorship, support for advanced degrees) and included in your overall compensation package.

The ability to be creative and move past focusing on one number will enhance your ability to attain better outcomes. That creativity requires that you take time to research the position, speak to colleagues and mentors, evaluate national salaries based on your specialty and expertise, and attempt to understand the other parties’ interest. This preparation will allow you to leverage the acquired knowledge in order to reach an outcome that would be considered a win-win. Part of your preparation also requires you to determine your best alternative to a negotiated agreement is (BATNA), a term coined in 1981 by Roger Fisher and William L. Ury in their book “Getting to Yes.” The BATNA essentially means if one does not accept the agreement, what is the best walk-away. Not only should you evaluate your own BATNA, but also that of the other parties.

Maintaining discipline

The ability to sustain a high level of emotional intelligence, be an active listener, and maintain discipline in your response can be critical to a negotiation. This tends to be more problematic when you are negotiating in a team because you are not in control of all that is being communicated by your team members. When you are the sole negotiator, as is the case in many of these faculty contracts, one has the ability to minimize the risk of serious gaffe at the table.

Additionally, developing and understanding your goals prior to the negotiation and where they rank from a priority and preference standpoint can reduce errors. This discipline also allows you to develop a strategic approach to the negotiation process that will ensure a systematic and thoughtful process in reaching the desired outcome. Every so often you run into a situation in which you are not prepared to answer a question or may need more time to think about it. One might respond by saying “That is an interesting option; let me take some time to think about it.” It is important not to commit yourself in the midst of a negotiation if you are not 100% sure the option is right for you. Having to come back and retract something you agree to can break down trust between the parties, which is detrimental to the relationship.

Parting thoughts

Negotiating your first contract can be nerve-wracking. The importance of taking the emotion out of the business aspect should not be overlooked. As well-trained, competent surgeons, you deserve to reach an agreement that you not only deem fair, but one that also will set you up for future success. Making sure that you are prepared, and having a systematic strategy is critical in this process. Gut instinct is not a strategy.

Dr. Sakran is an assistant profesor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is currently chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

As I maneuvered through the winding cobblestone roads of the Old City in Jerusalem, the smell of fresh bread intertwined with spices filled the air. Sensory overload blended with the multicultural flavor of the Holy City is a scene difficult to paint with words. In the hustle and bustle of the market, I can still vividly see the image of a lady negotiating over a bag of zaatar (thyme). As her kids pulled on her garb trying to move their mom along, I watched as the buyer and seller went back and forth on the final price of the herbs. This was negotiation as an art form! With both parties satisfied with the deal and parting with a smile, it was clearly a win-win outcome. But bargaining in a fashion so common in the souk (open air market) is not the norm in the United States.

In my household, I was taught to never accept the first offer, and therefore, negotiating in second nature to me. As I neared the end of my fellowship and began my job search, I began to really enjoy the negotiation process with potential employers. I was surprised to learn, however, that not only was this not common practice among my colleagues, but also at times discouraged. I heard remarks like, “Don’t worry about your first contract, it doesn’t really matter,” and “These contracts are all pretty standard,” or “You better not ask for too much or they will find someone else,” or “Negotiating will upset them.” While I was baffled by this attitude, it dawned on me that, despite our trainees spending more than a decade in surgical training, many clinicians are currently entering surgical practice unprepared to negotiate the best contract to meet their needs. Let me be clear, I do not claim to be an expert in negotiations. However, I offer my experiences as a hope that it might provide some insight and guidance to those entering the medical workforce.

This introductory article is one of three meant to provide insight when it comes to basic negotiating principles for those doctors heading out into the work world. In no way is it meant to be a comprehensive guide, yet I hope that it offers an idea of what to look for and how best to approach these formal discussions.

Often individuals can find the negotiation process uncomfortable and stressful. However, the ability to negotiate well is something that can be learned, and is not predicated on some innate ability. The key to reaching optimal outcomes really comes down to two things: 1) walking into the negotiation prepared; and 2) maintaining a high level of emotional intelligence that allows you to be disciplined at the table. With the medical community being relatively small, the process should be geared toward building a relationship, in hopes of meeting the interests of all stakeholders. The resulting relationship, whether good or bad, will have future ramifications. This applies to both the employer and employee. Your goal is not to “one-up” the other party, but to ensure you walk away with a solution that meets your needs based on your interest.

Walking in prepared

One of the first steps in making sure you are well prepared is taking the time to determine what your interests are and how you would prioritize them. Do your homework! Often we get caught up in the salary number while losing sight of a wide range of potential benefits that might be discussed (for example, research support, time protection, employment for spouse, moving costs, signing bonus, mentorship, support for advanced degrees) and included in your overall compensation package.

The ability to be creative and move past focusing on one number will enhance your ability to attain better outcomes. That creativity requires that you take time to research the position, speak to colleagues and mentors, evaluate national salaries based on your specialty and expertise, and attempt to understand the other parties’ interest. This preparation will allow you to leverage the acquired knowledge in order to reach an outcome that would be considered a win-win. Part of your preparation also requires you to determine your best alternative to a negotiated agreement is (BATNA), a term coined in 1981 by Roger Fisher and William L. Ury in their book “Getting to Yes.” The BATNA essentially means if one does not accept the agreement, what is the best walk-away. Not only should you evaluate your own BATNA, but also that of the other parties.

Maintaining discipline

The ability to sustain a high level of emotional intelligence, be an active listener, and maintain discipline in your response can be critical to a negotiation. This tends to be more problematic when you are negotiating in a team because you are not in control of all that is being communicated by your team members. When you are the sole negotiator, as is the case in many of these faculty contracts, one has the ability to minimize the risk of serious gaffe at the table.

Additionally, developing and understanding your goals prior to the negotiation and where they rank from a priority and preference standpoint can reduce errors. This discipline also allows you to develop a strategic approach to the negotiation process that will ensure a systematic and thoughtful process in reaching the desired outcome. Every so often you run into a situation in which you are not prepared to answer a question or may need more time to think about it. One might respond by saying “That is an interesting option; let me take some time to think about it.” It is important not to commit yourself in the midst of a negotiation if you are not 100% sure the option is right for you. Having to come back and retract something you agree to can break down trust between the parties, which is detrimental to the relationship.

Parting thoughts

Negotiating your first contract can be nerve-wracking. The importance of taking the emotion out of the business aspect should not be overlooked. As well-trained, competent surgeons, you deserve to reach an agreement that you not only deem fair, but one that also will set you up for future success. Making sure that you are prepared, and having a systematic strategy is critical in this process. Gut instinct is not a strategy.

Dr. Sakran is an assistant profesor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is currently chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.

As I maneuvered through the winding cobblestone roads of the Old City in Jerusalem, the smell of fresh bread intertwined with spices filled the air. Sensory overload blended with the multicultural flavor of the Holy City is a scene difficult to paint with words. In the hustle and bustle of the market, I can still vividly see the image of a lady negotiating over a bag of zaatar (thyme). As her kids pulled on her garb trying to move their mom along, I watched as the buyer and seller went back and forth on the final price of the herbs. This was negotiation as an art form! With both parties satisfied with the deal and parting with a smile, it was clearly a win-win outcome. But bargaining in a fashion so common in the souk (open air market) is not the norm in the United States.

In my household, I was taught to never accept the first offer, and therefore, negotiating in second nature to me. As I neared the end of my fellowship and began my job search, I began to really enjoy the negotiation process with potential employers. I was surprised to learn, however, that not only was this not common practice among my colleagues, but also at times discouraged. I heard remarks like, “Don’t worry about your first contract, it doesn’t really matter,” and “These contracts are all pretty standard,” or “You better not ask for too much or they will find someone else,” or “Negotiating will upset them.” While I was baffled by this attitude, it dawned on me that, despite our trainees spending more than a decade in surgical training, many clinicians are currently entering surgical practice unprepared to negotiate the best contract to meet their needs. Let me be clear, I do not claim to be an expert in negotiations. However, I offer my experiences as a hope that it might provide some insight and guidance to those entering the medical workforce.

This introductory article is one of three meant to provide insight when it comes to basic negotiating principles for those doctors heading out into the work world. In no way is it meant to be a comprehensive guide, yet I hope that it offers an idea of what to look for and how best to approach these formal discussions.

Often individuals can find the negotiation process uncomfortable and stressful. However, the ability to negotiate well is something that can be learned, and is not predicated on some innate ability. The key to reaching optimal outcomes really comes down to two things: 1) walking into the negotiation prepared; and 2) maintaining a high level of emotional intelligence that allows you to be disciplined at the table. With the medical community being relatively small, the process should be geared toward building a relationship, in hopes of meeting the interests of all stakeholders. The resulting relationship, whether good or bad, will have future ramifications. This applies to both the employer and employee. Your goal is not to “one-up” the other party, but to ensure you walk away with a solution that meets your needs based on your interest.

Walking in prepared

One of the first steps in making sure you are well prepared is taking the time to determine what your interests are and how you would prioritize them. Do your homework! Often we get caught up in the salary number while losing sight of a wide range of potential benefits that might be discussed (for example, research support, time protection, employment for spouse, moving costs, signing bonus, mentorship, support for advanced degrees) and included in your overall compensation package.

The ability to be creative and move past focusing on one number will enhance your ability to attain better outcomes. That creativity requires that you take time to research the position, speak to colleagues and mentors, evaluate national salaries based on your specialty and expertise, and attempt to understand the other parties’ interest. This preparation will allow you to leverage the acquired knowledge in order to reach an outcome that would be considered a win-win. Part of your preparation also requires you to determine your best alternative to a negotiated agreement is (BATNA), a term coined in 1981 by Roger Fisher and William L. Ury in their book “Getting to Yes.” The BATNA essentially means if one does not accept the agreement, what is the best walk-away. Not only should you evaluate your own BATNA, but also that of the other parties.

Maintaining discipline

The ability to sustain a high level of emotional intelligence, be an active listener, and maintain discipline in your response can be critical to a negotiation. This tends to be more problematic when you are negotiating in a team because you are not in control of all that is being communicated by your team members. When you are the sole negotiator, as is the case in many of these faculty contracts, one has the ability to minimize the risk of serious gaffe at the table.

Additionally, developing and understanding your goals prior to the negotiation and where they rank from a priority and preference standpoint can reduce errors. This discipline also allows you to develop a strategic approach to the negotiation process that will ensure a systematic and thoughtful process in reaching the desired outcome. Every so often you run into a situation in which you are not prepared to answer a question or may need more time to think about it. One might respond by saying “That is an interesting option; let me take some time to think about it.” It is important not to commit yourself in the midst of a negotiation if you are not 100% sure the option is right for you. Having to come back and retract something you agree to can break down trust between the parties, which is detrimental to the relationship.

Parting thoughts

Negotiating your first contract can be nerve-wracking. The importance of taking the emotion out of the business aspect should not be overlooked. As well-trained, competent surgeons, you deserve to reach an agreement that you not only deem fair, but one that also will set you up for future success. Making sure that you are prepared, and having a systematic strategy is critical in this process. Gut instinct is not a strategy.

Dr. Sakran is an assistant profesor of surgery and Director of Global Health & Disaster Preparedness for the department of surgery at the Medical University of South Carolina. He is currently chair of the ACS Resident and Associate Society and recently finished a year at the Harvard Kennedy School of Government studying public policy, economics, and leadership development. He has no relevant disclosures.