81. Physician Contracts 101 | Jon Appino, MBA

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Our guest today is John Appino. John is the founder of Contract Diagnostics, which, as the name suggests, is a Physician Contract Review Company. They operate nationwide and their team of specialists reviews contracts in all 50 states. They've also been doing this gig for about 12 years, so suffice it to say that they have tons of experience. What I love about Contract Diagnostics is that they do provide an exceptional service but are passionate about Physician Contract Education. As buddy physicians, we spend countless hours training and learning about health and the human body so we can look out for our patients. Unfortunately, we aren't taught much about how to look out for ourselves. The reality is, as we've spoken about on this podcast, that there are parts of medicine that are a business and we need to approach it as such. Well, the lack of education on that front leaves an opportunity for mishaps for many physicians, and that's where John and his company come in. They help physicians get their fear shake, so to speak, when it comes to physician contracts. So in this episode, we introduced the topic of Physician Contracts. We talk about why John started reviewing contracts in the first place. We touch on timelines for starting the job acquisition process. One is it too early, and if there's even such a thing, we branch off into the nuances of how to structure a contract when agreeing to terms far in advance. We talk about communication and the approach with potential employers. We address all things compensation, compensation structures, essentially the what, when, and how for addressing this topic, which quite honestly gets unbalanced attention and is clearly the most popular when it comes to a job evaluation. I also asked John to share his three most valuable tips for first time attendings when reviewing their first attending contract or approaching these conversations. So be sure to stick around till the end for that. Now without further delay, please enjoy this episode with John Appino. All right, John, welcome to the show, man. Excited to be here. I love doing these guesting on podcasts. They're always super fun. And of course, like I always say, any question is a good question. Absolutely, man. And I agree with that, you know, just on my research. I've been listening to you a lot and full disclosure, again, you know, we work with you. I personally worked with your company, and so I remember before I officially hired you, I had listened to every episode that essentially like on your website, you have listed. And so I went in well and foreign, but then I had some specific questions. And I was like, okay, I just got to pull the trigger in. And obviously, as you've talked about multiple other places, like those couple hundred bucks are so well worth and which we're going to touch on. But you know, you've been doing physician contract review for a little over a decade, if I'm not mistaken, is that right? 12 years. And it's crazy when you say that because it seems like it was, yeah, I would, it seems like it's been four or five. I'll talk to people now and they'll say, John, we work together back in, you know, whenever. And I'm going, you know, did you have a kid like, yeah, the kids now, you know, eight or something, you know, and it's crazy to realize how far and how long it's been. But yeah, we've had a fun, fun road over the past 12 years or so. I love it, man. And you know, what I'll say is when I was doing my review and trying to find different companies, and you know, I came across a lot of physicians who had these contract review companies. And to me, that was intuitive, right? They made sense physicians who are like mine and people, they're trying to stand up for your colleagues. And we know that there's a lot of language and a lot of different things that you could make mistakes, a lot of opportunity to lose money. We spent the last couple of weeks, last couple of months really talking about student loans. And it's at the forefront of everybody's mind. And we know we've given it, it's fair, sure as we were talking offline is because there's opportunity to really screw things up and lose thousands and a hundred thousand dollars, right? And this isn't dissimilar to that. And so before we talk a little bit more about the specifics, I got to know is, how did you get into physician contracts? Like, what was the inspiration to start this 12 years ago? Oh, story over a beer with a buddy, you know? Yeah. I long story short, I've been into, you know, creating companies, if you will, to help people provide value. One, when I was 17, another one I was 20. And then I was having a, so I've always kind of looked for market opportunities, right? Not necessarily, how can I become a billionaire and make it ton of money, but how can I find a niche where people need help in? And I was, I had a friend who was an oncologist, finishes training, went to a good job. And I was saying, tell me about the process. And so we talked about the recruiters, we talked about, you know, the site visits, we talked about everything that you guys go through when you find physicians. And you know, I thought I'm going to reinvent recruiting at first was the idea. And then I'm like, no, I'm going to create a company that does everything from real estate to recruiting, to contracts, to, you know, disability insurance and leasing BMWs and, you know, everything. It was a huge banner. It was going to be the best thing ever. You know, and the more I kind of looked into it, there was no good brand for a contract with you. People could call it attorney in a state or if they're in Kansas and they're going to Texas, do you work with somebody there in Kansas? Do you work with somebody in Texas where your job is? There was no like national brand, if you will, for this process. And my friend, the oncologist, went and hired a lawyer who was actually in Kansas. He was going to Texas. And he said the lawyer charged him 400 bucks or something like that and basically spent 12 minutes saying, contract's fine. Here's three things you should know. And my friend said, well, how about the pay? What is it the good pay for an oncologist in Texas? And the lawyer's like, I don't know, I'm a lawyer. I don't know what people get paid in Texas. And my friend said, well, there's these RBUs in there. One of these RBUs things. And the lawyer says, I don't know what RBUs are, I'm a lawyer, not an expert in RBUs. And we were talking about this over beers. I just thought there was a better process to educate and to help and provide this service. So we created a company that spans all 50 states. I would think more importantly, we understand the differences, not just between Delaware, Texas and California, but also between dermatology, PM and R, cardiology, interventional, and EP and imager as far as cardiology goes. And we understand the nuances between not just the physicians themselves or personalities, but also the contracts, the compensation structures, the risk with private equity, your hospital buyouts and certain specialties, this is all we do. So we see trends coming, which is really kind of cool. We saw the psychiatry trend coming well before it was published. We saw the rheumatology trend. We've seen private equity trends for a long time. And so we basically created this company to help people around this particular niche of contract reviews. We don't do anything else. I figured instead of doing everything sort of okay, we could be really, really good at one thing. When specialization, of course, is something that physicians can appreciate. So that's kind of how we came to that was 13 years ago, it took us a year to set everything up to the focus groups with residents and fellows and create the company that they wanted. And it's worked out okay. Yeah, I love that. Always comes back to seeing a need and jumping on that opportunity, right? And I like that you talk about, you know, just going a mile deep, but only staying an inch wide, right? Specializing. Initially, you were like, I'm going to do a little bit of everything. And then you said, you know, this is what we need to be in. It's so complex. But I think what people don't understand, when they think doctor, they're like, all doctors are critical. But primary care pediatrics, compared to plastic surgery, like those are different jobs. I mean, just because you have a doctor in the title, like, there's nothing in the further you get out from your training after medical school, a plastic surgeon knows nothing about primary care pediatrics and vice versa, right? And so, absolutely. And the composition plans are completely different. And the risk is completely different. And, you know, talking about equipment, the needs and staffing is completely different. And, you know, biopervations is completely different. Partnership is different in different specialties. So there's, yeah, it's, if somebody says, well, I'm a lawyer, I can look at a contract. They might be very well capable of looking at a contract, but the position contract is much different than a real estate contract is much different than, you know, something else. And so that's what we specialize here, which is, which is, which we enjoy doing. I love that, man. So now fast forward, like the next 12 years, you guys have done several thousands, if not hundreds of thousands of contracts at this point. And, you know, the one of the questions that comes at time and time again, and people ask me now, because I recently went through it is, when is it too early to begin a job search? And I'm going to say to one of my best friends who's graduating residency this year. And he asked me, when should I start looking? And I said, well, you know, I started August of my fellowship year, which was about 11 months before graduation. And so we're in October now. So yeah, now, and he's like, really, isn't that too early? And I was like, I don't know. I can just tell you what my experience has been and earlier won't hurt you. So you expert, when is it too early? So I don't think it's ever too early, depending on what you're looking for. It's funny. We used to get busy every year around December, January, with like any quarries, you know, people would call us in December, hey, how much you charge and then we'd get busy with reviews January through May or June. And then it went to November, then October, then it went to September. Now we don't really, we used to have a really slow summer, which was nice. And now this last summer, we were the busiest we've ever been. And so people are looking forward to. What do you think that is? I think the pandemic had something to do with it initially, as far as people wanting, like, okay, no matter what happens, I've got my contract, I know where I'm going, right? I think that people, I think as people assume others are looking earlier, they want to, you know, even earlier so they can get access to the great jobs. So if there's going to be whatever, 100 jobs in excess year, and if you wait too long, there's 20 left. And now, you know, maybe the 80 good ones are taken. So how do we make sure that we jump in and get earlier? I will tell you, it's okay if we timestamp this. It's October 10th of 2022. We did, this is probably a month and a half ago. We did a contract that starts in 2026. Starts. They start their employment in 2020. Four years. Wow. Yeah. Now there's stipends in place or student loans in place. This decision knew I want to go to this particular market, I think, I think he had family there. He's like, look, I might as well, you know, take some loan repayments starting now. I might as well take a stipend starting now. I know I'm going to go there. I know they're going to need me. So let's just get it done. And so that's the record so far as four years in advance. But most of the time people tend to start looking about a year in, about a year away from the job. They'll kind of start looking. I encourage everyone to kick a lot of tires. I encourage people to go on a lot of site visits and interviews. Everything is a skill that not everybody has, especially a scientist position. And so I recommend everyone go on a couple of site visits, even if their practice runs, figure out what you're not doing right and then tweak it for the job that you really want and give yourself plenty of time. But if you do that and you're going to get multiple offers, the last thing we want is for somebody to give you an offer and say, look, here's your contract. You need to let us know within 10 days. And you have another site visit set up in 11 days, right? Yeah. So if you're doing that, which I encourage, I make sure you let everybody know, look, I'm intending that I could decision by this particular date. So if you want to make a letter of intent or a contract, please let me have it by this particular date. Just to kind of set the timing so we don't have any hoops as far as time goes. So I want to follow up on this concept of getting a stipend earlier. So the way I'm familiar with it is somebody will go to residency. And they know that by the end the time they finish, it could be a subspecialty, it could be a specialty, that that institution has a job, right? It sounds like kind of what you're presenting to me, the case was somewhat similar. And so for those who don't know, the stipend will be like the, you might get an extra $1,000 a month on your, on your salary, is that, is that kind of what it is? Something like that. Some variation of that. Yeah. It can be, yeah, about 1,000 to 1,500, 2,000. Right. What I've seen the most, but it's in the, it's, it's, it's just a payment, every single month that needs to be paid back if you don't show up. Right. And then so is the idea, usually for whatever however many years they're paying you that stipend, you are in that contract for that many years, or is it just that until you pay that certain amount back? It typically. So typically how it's set up is you sign today and you're going to start, let's say, in a year. So every month, for the next 12 months, they'll give you a stipend, the 1,000 to 2,000 bucks. And it shows up now. Now depending on how the facility structures it, you may get the full amount now. They may tax you on it and give you a pro, the tax amount. If they give you the full amount, I'm sorry, if they give you the tax amount, usually, if you don't show up to work, then you have to repay it, of course. If you do show up, they make you work an extra two years, three years, one year depending on the stipend amount, or you need to repay all of it or a portion of it, sometimes with interest, sometimes without. If they don't give you, if they don't take out any taxes, so it's a thousand bucks, this into a thousand bucks, a thousand dollar check every month, typically when you show up, they'll amortize that and forgive it over the course of the same time for 12 months or 36 months. And what they'll do is you don't have to repay the money if you stay working. You're kind of working it off as debt, if you will, but you need to pay taxes on the forgiven debt. So the contract might say something like, for every month you work, we will forgive one 12, one 24th, one 36th of the amount. So let's just say they give you, you know, they give you 2,000 bucks every single month for 12 months. So over the, and then they say, we'll forgive it over two years, okay? So they have, they have $12,000 to forgive over 24 months, it's 500 bucks a month. So if your paychecks are, let's say, 20 grand a month, your paychecks, they're going to pay you the 20 grand, but you'll be taxed on 20,500. They'll pay the taxes then as you're working it off. And of course, if you work for the dedicated time frame, you'll owe them no money. If you don't, you potentially will owe them a pro-rated amount depending on how the contract's up. Got to cut a check. Now, the one thing that strikes me that would be a little tricky about that part is if some, so let's take that case that you talked about a month and a half ago, or if somebody would send a contract four years from now. Now every single year, when you look at these databases, they get updated, you got inflation, the economies, crazy, the market rate or the appropriate average compensation for whatever specialty it is, that's going to change in four years. How does, you know, if you lock it in and you've signed on the dotted line in four years from now, now you're, let's just say the average compensation is significantly higher for that specialty, you know you're not going to pay your worth or the market value. How does somebody renegotiate that? What happens there? Yeah, so it's all dependent on the terms of the deal, of course. What we recommend is if somebody has, if you're signing out that far, if you put something in the contract, again, maybe they're hiring more behind you, I'd hate to have somebody else get a higher pay as well. So we would recommend that the position have language inserted that says you'll be paid at this rate or whichever benchmark is that they look at. So oftentimes, if an employer might say we paid compensation to say MGMA or a tri-blank or a third party analysis. So we would say that we want that analysis done, most employers do it every year, every other year. And if that analysis has changed to the higher, then you'll receive that amount on starting. If it's gone lower, you're guaranteed the amount that you signed for. We'll also recommend physicians have baked into the agreement if they're signing out far. If we paid this amount or higher based on other physician's signings or based on current market rates or based on the current compensation plan. When you sign out far, lots of things can change. We see all the time. You'll be compensated x dollars per year and have access to the compensation plan. It's now most of the time they change those for everybody in the department. So if they're changing the same plan for everybody, you'll be on the same plan as everybody. But maybe it's not a good plan. Maybe they've lowered rates. And so it's really good to make sure you understand the full texture of the contract on how it's warranted. But signing out really like that does have risk, some that you can mitigate against and sometimes you just can't. Yeah. I think people are starting to get a sense of how complex this can be, especially if you're trying to project several years in their future. And you know, the other thing actually that comes to mind is I actually had a really good friend who was on a similar plan like this. They actually did residency at this program. New ended up doing a fellowship. So three plus act on a fourth year. And they were getting this type in like this is their hometown institution, born or raised. And so that's where they're settling. Wife is there, everything like that. The issue became so they did family medicine, subspecializing sports medicine. And the idea was, hey, we're going to continue manning this outpatient family medicine clinic and be the sports medicine provider. Well, this individual realized that towards the end of the fellowship, this is not the patient population I want to be working. I want to work in the sports medicine orthopedic surgery department and do a lot of ultrasound and specific procedures that are not available to me in that department. And so this was a very stressful time you shared with me because it was four years of stipend. Now luckily, this, you know, this institution like the head of musculoskeletal medicine orthopedic call the family medicine department was like, come on, like we need the sky. Like let us go and they actually ended up, they worked out a deal. But most of the actually that money was forgiven. They didn't have to end up paying back because they were within the institution. And you know, they were just in need there. But again, as you alluded to, circumstances change. Life happens four years, three years, two years are down the road. And if you lock in, it might be difficult. What's an appropriate way for somebody to approach and say, hey, just kidding. I actually won't be able to do this. I know you paid me a lot of money. Is there a way? How do you suggest people approach that? You know, I don't know that I have a magic wand or a sea of sauce. You know, I always recommend transparency and honesty. I think as soon as you know something, you should tell them. I think phone calls in those situations are better than emails, but phone calls and a follow up email. If it's, I want to shift internally. I think it's good to have internal stakeholders that are on your side that can, you know, that you can call Leon and say, hey, I've already spoken to you. I have department and they're in favor of the transition and, you know, and you know, they're talking to finance on how they're going to transfer budgets because maybe the department has a budget for something and they have an allocated, you know, the dollars to one budget over the other. So I think having internal, you know, stakeholders that you can lean on, I think is an important thing if you're transferring inside of an institution. Like it sounds like like you're sheeted. If it's, I took a job and I no longer want to come to this job. Again, I think transparency is super important with kindness. So, you know, hey, here's the reason why maybe it's, you know, the stars aren't aligning. I've found what I feel is a better opportunity for my family and my career and maybe the future are stars of all-in. Now, do I think that they'd let you out of repaying this stipend? I doubt it. I wouldn't if I was an employer. I mean, if I'm giving you money, yeah, I mean, if I've been giving you money, counting on you being here, it likely means that they've said no to other candidates. It likely means, you know, again, if they have the, if they have a candidate pool at a certain given time of year of 30 people and they chose you and they gave you a stipend, they're going to call 29 people back and say no thanks and they're going to plan on you being there and all of a sudden you call and say, I can't make it. It really does screw the employer over. And so that's why we say people will ask us sometimes. John, if I sign this and I find something better, can I get out? Most of the time the answer is yes, but I'll just, I'll just tell that person, maybe, but know the downstream effects of that, right? I mean, it's not good for the facility. It does kind of screw them over. They're going to be upset. It's going to cost them money. They're going to have to call back other candidates. You have to go back and do all additional interviews. It's going to cost them extra money. So don't be surprised depending on how the terms are worded. If they come after you for damages or if they do ask for the money back, which I think they probably should. So if there's no like magic wand, I would just say be open, be honest, be transparent. As soon as you know something, let them know. Don't fear the conversation and not make that phone call today, but move it to tomorrow and the next day and the next day, and it was fire and email off at Friday at five o'clock saying, sorry, I can't show up for work. Yeah, so take a head on it. Yeah, I agree. So that's definitely the minority of cases. You know, I recently heard Eddie Doug on a podcast talking about, you know, during the hiring process, like hiring somebody is like going on a date or two or three dates and then saying, I'm going to marry this person, right? In real life, if we did that, our friends would say, that's preposterous, like you don't know anything about this person. And essentially that's what the job acquisition process is like. Like you alluded to, right? A couple of meetings, maybe a site visit. And now she was talking about employer specifically, but I imagine the same applies to job candidates, prospects. And so, you know, appreciating that concept, the key question becomes, are there specific questions, tactics, things that we should look out for? Two to three things that maybe you can think of that can help accelerate that curve of really getting to know that employer a little bit better, so you can make the well-informed, quote unquote, better decision. Yeah, I do, I do. But before we run out of that, think about this in 2020, you know, March, April, May, June, you know, lockdowns, people can't travel, physicians, I know I talked to a hand surgeon in Pennsylvania. He said, I can't leave the state job because I, then I got a quarantine for two weeks when I get back. And I just, I can't do that. Surgeons and asthesia, even clinicians were doing interviews through Zoom. And they were signing contracts without ever being in the city or let alone the facility or seeing how the nurses interact with each other. Or what's the vibe in the OR? You know, what type of equipment is there? I mean, they were, they were taking positions, and they never even had one site visit let alone three. You know, so I'm grateful that things are, how are we going to find back to normal? But that is we're able to go on site visits, and you know, you guys are able to have, you know, discussions, tour facilities, you know, meet potential colleagues and everything else live. To that end, I would look at it, again, I think it's something that everybody should practice. I don't think it's something that comes naturally to people. We have a job diagnostics flyer that I can send to you if you wanted to send it out to everybody. You're posted somewhere as far as things that we recommend for the items that you guys think about as you go through them. But I would go through the site visit, interviewing them just as much as they're interviewing you. I want to know why the position is open. If someone got fired or somebody quit, why they quit. If they're just expanding, that's fantastic. One of their plans for the future. You know, if somebody retired, great. Where do their patients go? Am I going to be busy from day one? How do you bucket my patients? So I don't jump into an established position schedule on day one. You know, so I think I think understanding a lot about the job itself is super important. If you have community needs, whether they're a family or school or religion or social, make sure that the community offers those things for you as well. So it's not just about the job, the facility and the money. It's about, you know, how happy you're going to be when you're not working. Does the city offer those kind of things? But the end of the day, I think I tell you guys to trust your gut at the same time, right? You guys, I mean, you guys, you know, you're intuitive people in general. And I think, you know, going in somewhere, if it doesn't feel right, it's probably for a reason. Even if the compensation is fantastic, it doesn't feel right. There's probably a reason behind that. If they've, I've had some people on the phone when we're doing reviews saying, you know, John, I don't know if I trust these guys, but here's their contract. And, you know, my first thought is, if you don't trust them, why are you considering going there? I mean, and I'll tell you this, I mean, we look at contracts every day, all day. But a perfect contract doesn't make up for a bad employer or a town that you or your spouse doesn't want to be in. And vice versa, a terrible contract doesn't make up for a wonderful group or a great set of colleagues or an amazing town with more fun than you could ever imagine. So, you know, that's why I think the discussion between you and the facility, you and your colleagues is super important. One thing I do recommend, if the job is open because of a departing physician, so somebody left the position, whether it's whatever story they get, they moved away for family, they had a child, they wanted to stay home, you know, they wanted to go part-time, they went somewhere else or, you know, fill in the blank. I always want to know, is it possible that I contact that person? And I want to know, I'm not that I really want to, if I'm the interviewer, I'm, it's not the interviewer, it's not that I really want to talk with them, I want to see how they're going to react. So, if I say, you know, well, oh, so the position's open because somebody moved away to be closer to family, okay, great, could I get their number so I can just reach out to them real quick? If they say, sure not a problem, here it is, I don't care if you call them or not. If they say, well, we prefer not, then I'm faking maybe something's up and I'd probably dig into it a little further. So, I think that there's some things like that that that we can do to kind of make sure it's the right position, but at the end of the day, I just say, trust your God, you know, make sure you do understand the contract, so we do understand out clauses. Some contracts, we looked at one today, there was a three-year period from your start date that you couldn't quit. So, if you didn't like the job, you can't go anywhere, right? And it's a small word, right? It says, after the initial term, either party can terminate in 90 days, right? Not during the initial term, it's after. So, it's one small word and it changes, you can't quit for three years. So, if that's the case and you don't know about the town or the people, maybe that a great job to take because if you don't like it, the schedule's off, something's not right, spouses don't like it. You might not be able to leave without paying a lot of money to get out of it. Yeah, I think that's why most of like at least some of these finance experts will talk about not purchasing right out of residency because I don't know what percentages, but as a minority, the physicians that stay within their first job in the first two years, am I correct? I mean, you might have the numbers on this. Last I looked, which was a few years ago, and I think it's a higher for a couple reasons. Last number I looked was 56% of people are not at their first job three years later. Two years later. Yeah, so the majority after two years, yeah. And it's gone up. I mean, I write article saying like, I think it was 68% of radiologists are changing jobs right now. I mean, anesthesia right now, people are all over the map as far as people losing contracts, gaining contracts, resigning, reaffiliating, purchasing private equity. I mean, there's been so many changes in so many specialties lately that I'm convinced it's much, much higher than 56% after two years right now. Yeah, I'll buy that. So you know what, hearing you talk about kind of that process, it seems, it doesn't, it seems very similar to me when we're continuing residency into continuing fellowship, right? That gut feel, look at the town, look at some of the ancillary things. And so I think most physicians will probably have some experience and can probably figure those things, the intuitive things out that you talk about. Obviously, the salary, the composition, which is four times five times six times, depending on those, you know, those are, and then some of those nuances that that we'll touch on now, right? And so one of the first questions, I'm sure that you get and people ask, Hey, what's the, what's the salary, right? That's what we want to know. We've delayed this gratification for a long time. We've got a lot of student debt that we've talked about. So I got to pay that. And so when is an appropriate time to bring up the conversation for salary? It's a great question. I don't want people wasting their time at site visits and everything else. If, you know, they're looking at making over 300 and the offers 250, you know, and I don't want to punt that decision. However, I also don't want to, I don't want to, I don't want to, I don't want anybody to make commitments or what might be, what might appear as acceptance without, I mean, if you were going to work with a company like ours without talking to us, right? Or without having, you know, clear, clear data on what the job should offer in terms of compensation. So if they ever ask, what are you looking for for pay? I just love replying with something that says, you know, I'm sure that you guys will be competitive with the other offers that I'm seeing. You know, or I'm sure you guys are off for a competitive salary with my skillset in this market. Leave it open, right? Let them make the first offer and then ask a lot of questions around how they got it and what, you know, and expectations and everything else once we have a number from them. But I'm guessing that multiple generally know like a range when they go in there. If they don't, I would ask them during the science and how do you typically set compensation and just kind of say, well, we usually set it around the median of MGMA. Okay. Now we can go pull MGMA. We give it to you at our company if you have a certain package. And then we can kind of see where they're going to be. But I never want the physician to accept or, you know, give any verbal like I'm expecting 300. They come back at 300 and then we say you should really be at 325. And now the employer is thinking, maybe exactly if you want, you kind of sound like a jerk now. Yeah, we can help reframe the argument, of course, and provide that context for the physician to use. But I do think that having salary conversations when we get formal documents or contracts is the important thing. Because I worked with somebody today and I said it was, they were using our compensation product and she was a radiation oncologist and she was shifting jobs and she wanted to know what they were offering with spare. And I said, well, here's where I would expect the range to be. But just because they offer you, if they were to offer you a million bucks, it doesn't mean that's a great deal. Because again, devils are in the details. So you could have a million dollar salary or $500,000 salary or $400,000 salary, whatever it is, twice your normal. But it might be a terrible job. It might be a terrible contract. It might be a really, really bad, risky situation. And if we're balancing benefit and risk, you know, the benefit of a huge salary might not be worth the tremendous amount of risk you're taking based on the terms. So I encourage salary and discussion to be either with a letter of intent. If you're going to negotiate it before you see the contract or once we get the contract, we can understand the full risk. Then I think it's a great time to start to begin compensation discussions. But there's also, again, when it comes to compensation, just good discussions. It matters. Has the job been open for two years or did it just open up last week? Maybe they've already interviewed 500 people. They can't find anybody because nobody wants it. Or maybe it's a great position. It's not going to be open long. We don't have a lot of time to wait. So I think there's other questions that matter in terms of how we're going to go about making sure that compensation is fair and then making sure, of course, we negotiate a fair model. Sorry. How can one figure out how many people they've interviewed? Can you just straight up ask that question? Are you interviewing a lot of people or how many people? I think you can ask a question like, what's interest been like for the job? Why is the position open? Did somebody leave, somebody retiring, somebody step away from medicine? They say, oh, well, the position's open because we're expanding. Have you guys had a lot of interest in the position? We have a ton of candidates, or no, we really haven't. It's been kind of slow. Recruiting super, super hard, they might say on the other side. So I think there's ways around that we can ask what the interest level has been like and kind of see around about how they have interviewed set up. I also think you can talk about timelines. So maybe you ask a question like, do you have a lot of interviews set up for the position? They say, oh, yeah, we're interviewing over the next two weeks. Or you can say, what's the timelines look like for the position? They may say, well, depending on how the visit goes then, you're probably going to contract out here. Probably not a lot of kids coming up after you. Or they may say, you know, we're probably going to discuss things and make an offer in two weeks. Okay, I'm guessing they're discussing things because one, they got a lot of people to discuss that who's the best set. So I think there's some questions that we can kind of lead in with. They kind of give us some hints as to how they're doing in terms of other candidates and those types of things regarding the position. I love them, interest the trade. And you know, just hearing you talk about the whole composition piece. And I want to emphasize, it's only a small piece of the puzzle. You know, I think about my job acquisition process. And I created a word document. And it had needs, wants, and nice to have. I don't think salary was in any of them, right? I mean, there was some criteria, location, family, like all other things are important. So it's very individual specific. And that's why I like you talked about, you know, the contract can be changed. But it's hard to change the town or the city or the region of the country you're living in. That's probably not going to happen. The employer same thing under normal circumstances is much harder to change. But contract can be can be molded, right? Depending on the situation and what not. Absolutely. And renegotiations and everything. Now, some of the places, and in fact, a lot of places are moving more to an RVU base model in addition to a base salary. Like, so they'll start off with a base salary and then depending on your RVU, your production, bonuses, et cetera, et cetera. Is there a good way? Because again, most folks graduate, they don't understand that RVUs are like, we don't get it. We're not taught that. So is there a way to ask, hey, put some concrete numbers on it. Like, what are most providers making based on RVUs like additional to their salary? How do you ask that question? Absolutely. So again, we have a whole list of questions that we recommend people ask around compensation. Not one of them is, can I have more? So I think when it comes to compensation, I mean, I want to know how they came up with whatever plan they have. If it's RVU-based, has it ever been different? Do they have any plans to change? If it's collection-based, the same thing. If there's a quality bonus, right? If there's a citizenship bonus or any other type of pay, I want to know kind of where they came up with it. Right? I love to seek to understand before we decide how we're going to ask and what we're going to ask for. The other thing, when it comes to RVUs, I want to know expectations. So maybe the contract says something like, you have a salary of 300,000 and RVUs at 50 bucks a piece over your salary, okay? So we can divide 300,000 by 50 and see you got to make 6,000 RVUs. So before you get a bonus, okay? Well, I'd want to know what's the average? Well, is the average 4,000? Is the average 10,000? What are your expectations of me? When do you think I'll hit that number? Do you think I'll bonus in the first year? If the salary is only guaranteed for one year, I'd want to know how many people make more in a year or two and how many make less on a percent basis. If you hire 10 doctors in this practice or 100 doctors depending on how big it is, how many of them need a second year to kind of ramp up or does everyone kick off in your one and get some bonus at the end of your one and then year two, they're off and running? I think I'd want again, what's the range? So for asking averages, so if the average is 7,000 RVUs a year, great, what's the range? Well, the range is 4,000 to 13,000. It's a big range. So I think we can kind of discuss what separates different people. I think again, getting even deeper, if there's multiple offices, does one office produce more than the other? Well, is the average RVU per patient in which office? I think there's lots of questions that we can ask to kind of set the frame for what is the next one, two, three years. Look like in terms of your number one, your expectations of me and the number two, my expectations on production and income moving forward. And I also love knowing expectations of you because obviously if we can exceed expectations and we're sitting down at the table in two years for renegotiation, I love being, we'll say, you said in year one, you'd be happy if I did 4,000 RVUs in year two if I did 5,000, you'd be thrilled. Well, as you know, I did 4,800 in year one and 6,000 in year two. So I'm exceeding your expectations. Therefore, on this next contract term, I'd like X, Y, and Z. So I love having, I love kind of prepping what happens down the road with conversations that we can have today as well. So I know that probably the best thing to do is have that in writing within the contract the first time, right? Hey, these are the expectations. If you do this in year one, then year two, year three, this is what it's going to be. But sometimes, particularly with large institutions or academic institutions, that you would have this standard contract and then you just have like additional documents, exhibit whatever or see the supplemental document that's kind of a kid or to an individual physician. Is that the appropriate place to have them document or if they're not willing to document, do you kind of just advise clients to document on their own? So when they were there renegotiation time, they were like, hey, look, this is what we talked about. I haven't writing in my own notes. So I wouldn't expect like expectations to be in a contractor documented. It's more like a verbal discussion. I wouldn't expect a compensation plan to be documented. So if it's here's your salary, here's your conversion factor, here's a threshold, I wouldn't expect all that of course to be documented in some kind of formalized plan, as well as the reconciliation process, the payment process, the timing for everything, termination, pay and everything else. But in terms of like what their expectations are, that's I think just a great verbal discussion. I think it shows that you're interested in the position. I would take a lot of notes on that just so we can have them when we go back in at the end of one year or two years or three years, whatever we're having that meeting. The other thing that we didn't talk about, I would love also to get a copy of any reports. So if you are on a production schedule, no matter what our views are collection or some other kind of hybrid, I would love to ask you know, how do I get information? Do I get a monthly report? Do I get a quarterly scorecard? How are the numbers reported back to me? And they might say something like you know, well, we give you a report every month, every quarter, you know, or we put it online. I would love to see an example of what that looks like. I think getting that does two things. One, it shows that they're able to do it because number one, I want them transparent with their numbers because far too many physicians who are attending that I speak with and I'll say, hey, what are your numbers? And I'll say, I don't know, I made this much last year. And I'll say, what do you mean? How many are views are you doing? They'll say the employer's not telling me. I just have an extra bonus show up every quarter, but I don't know what it's for. So I want to make sure number one that they can pull the reports. They are transparent with the numbers and the number two. I want to make sure that if we see that report, it's likely that we'll have additional questions. So maybe there's a sort of quality metric pay that's in there. Maybe there's pay for additional call. Maybe there's another stipend for something else. Maybe there's a maybe they're factoring our views for a certain reason and we don't know why. Maybe they are or are not giving credit for nurse practitioners or or multiple codes. So I think if we get a copy of those reports, we can kind of analyze it and then ask more questions on their compensation plan at appropriate. Love that. Now we're brought up academic institutions and just large institutions. Often when candidates will interview for that position, they'll say, hey, really, really isn't much salary negotiation. This is kind of what everybody gets and this is kind of what it is. Is that how true is that? You know, is that do you find that to be your experience if that's more likely the case? Most of the most of the time, yes. I think it does just because it's non-negotiable doesn't mean that all the terms should be really understood. But I would expect an academic institution to be less flexible than other positions as far as you know as far as how the money works. But again, it all depends. If you're the 26th hospitalist going into a program at an academic facility, your negotiating capital, I don't feel, is as good as a, you know, as a sub fellowship trained neurosurgeon who's going to start a program at a facility. You know, we worked with, worked with somebody who's going to start a heart transplant program at a facility. It was an academic facility and we negotiated, he had the negotiation package with us and we negotiated everything from, you know, administrative time to where his office was going to be, what kind of like you he wanted to salary, to signing, to stipend, to, you know, additional administration pay, to a medical director ship, to, you know, additional CME dollars. There's all kinds of things that we negotiated. But he'd already successfully started four heart programs from scratch and this is fifth one. So again, his frame is likely different than, you know, than somebody else joining a facility that, that's more of, you know, joining more of the group than somebody that has a unique ability like that to, to bring to the table, in which of course has much more negotiating capacity. So it all depends. But in general, I would say yes, academic contracts tend to have less wiggle room when it comes to, you know, most things, financial being one of them in terms of negotiating ability. Yeah, now I love that and it goes back to kind of what I, when I highlighted that, you know, there are a lot of other things like benefits you talk about CME. I mean, that's a big thing. It's expensive to travel. These conferences, membership fees, they're very, very expensive and it quickly adds up as I'm learning that I no longer have a resident or fellow discount. You know, you brought up the fact that, you know, with Zoom interviews, people were able to kind of, or interview, people were interviewing at places that they just had never even seen the light that, that city. But that also, it's a double, like, the flip side of that is it also opened up the network for folks, right? For fellowship and for residency interviews, they were playing the places that they had no intention of traveling, right? And so I imagine more people are looking at places that they typically wouldn't go to just because of circumstances that they didn't want to travel. And they're like, oh, no, I'm curious what Southern California, well Southern kind of is beautiful, but maybe like Arizona. And so I will interview with this employer and that kind of stuff. And so how, how does one compare salaries in completely different regions, right? I mean, coasts don't pay as well as middle of the country, right? And then like, I know, again, we're talking a lot about composition, but again, this is like the first thing that everybody's mind is, how do you do that? Are there regional databases? Do you have an internal database that kind of can compare different regions and say, hey, this is what you can expect if you're in New Jersey versus in Ohio? Yeah, so there's lots of databases out there. I mean, you know, MedScape takes the survey, Doc Symmetry has a survey. I think Mayor Hawkins, the recruiting company has a survey, and there's all all over the place. Those are as maybe scientific surveys, and they're not leaned on by employers as like MGMA, the medical group management association, kind of a gold standard, the MGMA data set. It costs well into five figures to have MGMA on an annual basis. We haven't here a contract diagnostics. There's Sullivan-Codder data, which is very good. There's AMGA. There's AMC data. That's pretty good for academic institutions. So there's lots of different data set. The problem is the data sets, although they do have state-specific numbers, the values, the comfort intervals are not very significant, and so they tend to buck them into regions. And so regions, they have East, South, Midwest, and West. And West includes California, which is southern and northern, which also includes Wyoming, also includes Washington State, Hawaii, Alaska, and Colorado. And so you've got this wide area that is different, right? Sacramento is different than San Diego is different than Nevada is different than Reno. I'm sorry, Las Vegas and Reno, but it's all in the same region if you look at it. So it makes it challenging using one of those larger databases. Again, that's what a lot of employers use. The other challenging thing about the large databases is they take a lot of time to generate. I mean, we're surveying tens of thousands of physicians taking all the data, cleaning it, aggregating it, putting it into the right form, reporting it, and publishing it. Well, it takes time. And so every year, it's about May or June, is when the new MGMA data comes out. So the fifth or six months of a year, so this May, we got 2022 data, which is based on 2021, because they capture for 2021, and it takes the five or six months after the year's close for rate wages to say, kind of, here's what we were. So it's always a big lag in the data. You can imagine how that was during a pandemic and how we're still trying to kind of flush away at it. But it also doesn't pick up on trends very quickly because it's slow to come to market. So that's some of the challenges about using some of the bigger data sets on the market. Our data and contract diagnostics is raw. So if we do 10 contracts today or 50 contracts today, we get 10 or 50 data points. So if you're a hospitalist going to Chicago, you know, maybe we did one today, one the other day, and two, four weeks ago. So we have four deals fresh within the last month, for an example, right? So we're not looking at what's in, again, and so that's that's a hospitalist Chicago. Okay. Now if we're going to compare that to the MGMA data, which again, gold standard, fantastic data set, we'd be looking at hospitalist data for the Midwest region, which includes Chicago, Urbana, includes Springfield, Illinois, Amazury, it includes Kansas City and St. Louis, it includes Columbia, it includes Iowa City, you know, and it includes Sioux Falls, South Dakota. Okay. So it's hard, you can see how it's challenging to say a hospitalist in Sioux Falls, South Dakota, or a smaller town of 20,000 people, South Dakota is the same as Chicago, but that's how the data is reported out. And so it can be very, very challenging to look at what your data says, but yeah, I mean, to answer your question, is there a way to, you know, find out what's normal and typical there is, you know, but again, a data set might not tell the whole story. So if there's a position, even if it's in San Diego, and they've had four people in and out over the past five years, they can't give anybody to stay there, and they're hiring you. Okay, that's a different story, than you're going to, you know, UC, you know, University of Southern California. Okay. And so there's a lot of things that happen with the story. I think that matter on compensation, even if you're looking at San Diego and San Diego or Chicago and Chicago, the story definitely matters. And I think that needs to be taken into account as well, which is why it's really good to have somebody who does contracts or compensation structures every single day on your team, which is not a plug for our company, of course. It just has people go about the process and do due diligence on a position. I encourage everyone to get help. Um, compensation is sometimes the same area or a different area than the full contract. And it's important to have somebody who really really understands position compensation and how it changes per region and then keeps up on on trends as well. Yeah, absolutely. I mean, there's just too much, too much opportunity to do kind of get tripped up, right? All the things that we talk about, you have to get very granular. And it's something we didn't touch on that you've mentioned, Pam and Pam again, is you guys start the conversation about learning the story of the person like, Hey, what's your story? Like what matters to you? Right? And then we can kind of advise to you, Hey, okay, look, this maybe isn't the average compensation or isn't that meeting for the data? Yeah. But you've got all these other factors, which matter more. And maybe that's why it's a better fit. And I think that's really when it comes down to, um, now you brought up the MGM. You mentioned that it's like five figures on an end will to maintain that. But can, can people access that and just pull it once for themselves? Is that like a reasonable thing or you have to be working with a company in order to get that? I don't think, I don't think that people can, I don't think we can do like a one-time pull. Okay. I'm not 100% sure, but I don't think that that's a service that MGM offers. They typically don't like to work with lots of individuals on, uh, you know, a $100 piece basis. They might run themselves in chunks. I think it's much easier for them in their business model. Uh, makes sense. So cool. Well, John, I know we're coming up on time and there's so much more that we can get to talk about. But we expected that. And for the listeners, there will be a part two, hopefully a part three, depending on what we get into. Um, I mean, we want to talk about non-compiece. We want to talk about asset protection. And then of course, negotiation. It's a scale in how to build that up. I want to get your thoughts on that. But before we sign off here, I do want to ask you one more question is, um, just a maybe the reductionist way is what are three mistakes that you see new physicians, particularly come out of training first job that they make when considering their first contract. There's something that we should be paying a little extra attention to. And it can be both academic, primate, whatever. Three, I would say, um, if it's just in the approach, I would say, um, some people don't have their contracts review it. And I think that's a big mistake. And it's not, again, not a sales pitch for us at all. Um, why I've openly said it many times. I don't care who everyone uses. I just want you to do somebody because there's just too much on the table to not pay a couple hundred bucks and have somebody check it out. Um, so I would say, like that's the biggest mistake that anybody could make is not even if they say it's an unnegotiable contract or not changing anything sign or don't. You gotta know what's in there. You gotta know how to get out. You gotta know what your risk is. So I think not understanding those things or thinking that because you read it as a physician who's untrained at this and it looks good, I think that's a big mistake. I think you should have professional help in the process. I think not taking it seriously. Um, the contract or the position, uh, is another thing. I, I talked to lots of people. They say, you know, you know, it's only my first job. So I'm just kind of checking the box here and then you know, once I find my dream job, then we'll have a review then we'll, um, I'll spend more time interviewing or spend more time negotiating. This is just kind of a filler between after training and between I get my real job, you know, those things matter, you know, so it's important to know what kind of experience you're going to get. The college you're going to work with, what kind of risk is on you with the, with the agreement, what it's going to mean for your second job if and when you do sign one. So again, taking the process seriously, the interview, the relocation if necessary, the, the, the signing, again, the contract, I think is another red flag. Um, if you don't take the process seriously. And if I thought of a third, I would say, I would say not doing due diligence, um, understanding the practice, understanding the community, understanding kind of what you're getting into in terms of, in terms of the opportunity. Aside from the contract, that's one thing. But again, if you have community needs, if your spouse has needs, if you've got social needs, you want to, your single, you want a good dating scene or, you know, you love your food eating, you want great restaurants or you travel overseas a lot, you need a good airport, you know, whatever those things are, I'd say, do a lot of due diligence on the community because even if you think it's going to be a long-term job, if it's not because the community isn't lying up, even if the job's everything you love, it can be super painful if you've got a great job with a great contract and a great employer and great pay, but your spouse is unhappy. Um, and so I'd say do a lot of due diligence on the community as well, spend as much time as you can there, do as much research as you can on it, and, um, and take that process, um, and have as much fun with it as you can, I guess. Yeah, I love that. And the second one is especially interesting to me because, you know, as we talked about, what if you start the job, or I would push back to that person, say, what if you start the job and you realize, hey, man, this is actually a pretty good job. And I like it. And I want to stay here longer. And now you're kind of locked into something that maybe you weren't the best terms and you could have done a better job if you took a seriously, as you say. Well, John, a lot to touch on a lot, we touched on today, but a lot to touch on the future. So we'll save a part, part two, man. Thank you so much. Absolutely. Thanks for having us. Thank you so much for tuning in. If you enjoyed this episode or found it to be valuable, please be sure to send it to someone whom it also gained value from it. And if you did find yourself enjoying it, please take a moment to leave a five-star rating. 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