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Join us for an insightful episode as we navigate the complexities of negotiating your first employment contract as a doctor. Our guest, attorney Ethan A. Nkana, shares invaluable advice on avoiding common mistakes, understanding salary ranges, and effectively advocating for your value. We’ll discuss the importance of having multiple job offers, critical contract clauses, balancing student loan debt repayment, and negotiating non-salary benefits like education loan debt assistance and work-life balance.

Ethan A. Nkana is an attorney.

He discusses the KevinMD article, “How rookie doctors crush their first contract.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Ethan Nkana. He’s a talent agent for doctors, and today’s KevinMD article is “How rookie doctors crush their first contract.” Ethan, welcome to the show.

Ethan Nkana: Kevin, thank you for having me. I’m delighted to be here with you.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Ethan Nkana: Yeah, I spent my entire career working as a hospital executive, so I actually worked with doctors from the other side of the table. And my mom is a doctor, she’s an anesthesiologist, and she really was my inspiration to get into medicine through the business side. And ultimately that led me down the path to getting my law degree, my MBA, again spending 15 years doing everything in hospitals that can be done. And now I get to use everything I learned on that side of the table to advocate for doctors in contracts and negotiations.

Kevin Pho: Now, for all the doctors that you interact with, before they meet you, in general what is their knowledge when it comes to business and contract negotiation and things outside of medicine like that?

Ethan Nkana: I often say that doctors have the same training in contracts as I have in medicine. So if that tells you anything, that’s about how much training they have. But it’s not their fault. Through residency, medical school, there’s no formal training or education in what to expect in the business side of medicine.

And so my mom pointed this out to me really early on in my practice, but I spend so much of my time with residents, fellows, physician associations. This weekend I’ll be in Nebraska with the Nebraska Academy of Family Physicians doing education. So I see that as part of my responsibility, is to help doctors get the answers to the test, remind them that you deserve to be paid fairly, and give them strategies on how to get that.

Kevin Pho: So I have to ask this question. As you were negotiating on behalf, as a hospital executive, and I’m sure that you’ve negotiated with a lot of physicians, did you ever take advantage of that lack of contract and business knowledge that a lot of doctors don’t have?

Ethan Nkana: I have found, in my 15 years working in health care, that the reasons that doctors get into medicine are very different from the reasons that MBAs get into medicine. Doctors, and you can tell me if I’m out of bounds here, Kevin, but the doctors I work with get into medicine because they want to make an impact on people’s lives, generally speaking.

Whereas when I was in health care, I was always worried about that next promotion, how to make my boss look good, how to make myself look good, how to keep the budget balanced. And there was this specific thing that CEOs used to say about doctors, which I think is comical now: I want my doctors to be as busy as possible, as quickly as possible, for as cheap as possible.

And so if doctors knew that that’s what we were thinking about them when I was on the business side, I think they would have been a little more thorough in their advocacy for the fact that they actually do deserve better, and they leave a ton of value on the table.

Kevin Pho: All right. So let’s talk about your KevinMD article, titled “How rookie doctors crush their first contract.” So for those who didn’t get a chance to read your article, tell us what it’s about.

Ethan Nkana: The thing that I experience most in my work is patients who don’t believe they need doctors. So in my world, that’s doctors who think, oh, it’s not a big deal, I don’t need to negotiate, it’s a standard contract. And you’ve probably seen in your practice patients who think, well, I can do it on my own, or I have this friend who gave me some advice. Doctors do the exact same thing when it comes to their contracts.

And again, I don’t think it’s their fault. I think it’s a function of the system where they come up. They’re told exactly what to do, where to go to residency, in the match. And then this switch flips, but they don’t know it, where now they actually do have power and influence to say, this is how I want to practice medicine, this is what I think is safe for my patients, and I deserve to be paid fairly for my contributions to the employer.

Kevin Pho: So what are the dangers of a physician just simply signing on the dotted line without any type of negotiation or contract review?

Ethan Nkana: The most common doctor I work with is the doctor who didn’t negotiate their first contract. If I were to put together a greatest hits album of the reasons that doctors call me in crisis, the worst case scenario is usually, I got fired or let go because of something that I didn’t see in the contract that I should have seen when I initially did my negotiation.

The other thing that I see really often is, my pay was cut or completely erased. I talked to a doctor earlier this week who, again, no fault of her own, but in February had her pay cut to zero. Cut to zero.

Kevin Pho: Wow.

Ethan Nkana: So of course my stomach drops when I hear this. And she said, well, my husband does well, so we can make things work. It’s like, no, you deserve better than that. That’s not OK, and you’re not crazy for thinking that that’s not right and that’s not fair.

So those are kind of the big things that doctors tend to come to me about when it comes to their first contract, or really what they should have done in their first contract. They just end up getting themselves in a really tough spot. So I often say, just finish the last 0.2 miles of the marathon, and it will pay off in dividends for you throughout the length of your practice.

Kevin Pho: And these doctors who come to you in crisis, are they primary care physicians, specialists, inpatient, outpatient, surgeons? Or does it run the gamut across the spectrum of physicians?

Ethan Nkana: I talk with every specialty under the sun. I could pick up the phone today and it could be an orthopedic surgeon, a pathologist, an IR doctor. There’s really no themes in terms of which doctors are feeling stressed. I’m sure you could look at some Medscape reports and they would show which doctors are suffering from burnout more than others, and there probably are more stressful specialties. But when it comes to the doctors that reach out to me, it really just runs the gamut of every specialty out there.

Kevin Pho: All right. So let’s say we have medical residents about to graduate and looking for their first job, and they get presented with a contract, and we have you on the show. What are some red flags? What are some first steps that they should do with that contract?

Ethan Nkana: The first thing that you should do to increase the value of that offer is double down and get a second one. If you get a second offer in the same area, in the general care setting of this other offer, now you have the opportunity to say, hey, I am so excited to join this practice and all the amazing things we can do together. The only thing I’m hoping you might be able to just make a couple updates on is closing the gap on the base salary offer from this other employer in town, and maybe increasing the signing bonus. The schedule would look a little bit better if it fit some of my practice goals so I can still do my side hustle.

So now, as a physician who’s coming out of training, who feels, well, I don’t have leverage because I haven’t done anything yet, now you actually have practical leverage by having that second offer. So anytime I do education for residents, fellows, I tell them, if you ignore everything else I say, the one thing you can do to increase the value of your offer, from a schedule perspective, support perspective, or being paid fairly, it’s by having a second offer.

Kevin Pho: Great. What else should we look out for?

Ethan Nkana: Those are the big three. So I often say, when I talk to doctors, generally speaking it has something to do with their schedule. I want to be able to see my family at some point during the week. I don’t want to work ungodly hours so that I’m not available and focused for my patients during the day.

Secondarily, support. I talked to a doctor last week who was the only person in her clinic. No MAs, no administrative staff, she was the only one. So I often hear doctors complaining about the lack of consistent support staff in their practice. So you must know, what support do you need, and what support is the employer providing to you?

And then lastly, fair pay. Now I know that that’s kind of a broad statement, but I typically think about that in three buckets: your base, your bonus, and your bennies. Your base is the money that doctors get just for showing up, doing a good job, doing no harm. That’s, in sports, you call that your guarantee.

Your bonus is the compensation that you get for achieving a goal or completing a task. It could be as simple as a signing bonus, put your John Hancock and you get 50k, or something a little bit more involved, like, hey, we improved our hospital’s readmission rate and in turn we got some additional compensation for that.

And then lastly the bennies, which you don’t deposit into a bank, but it can have a tremendous amount of value on a doctor’s life. And I even throw in education loan debt assistance as an uncovered gem that many doctors overlook, where you can get anywhere from $35,000 to $50,000 a year from your employer to pay down your student loan debt. So again, that’s money that you get to help achieve the lifestyle goals that you’ve set for yourself, just by showing up and asking for it.

Kevin Pho: So when looking for a second opportunity within the same area, on a practical level, how does a physician go about doing that?

Ethan Nkana: There’s a couple of ways that I go about it that I think are fairly efficient. So first and foremost, identify the employers in that geographic radius. And we interview every doctor very much like an initial patient visit, and we talk about, well, which care settings are off limits? Some doctors may have preferences for academic settings where they do a hybrid of teaching, administrative work, research, and clinical work. Other doctors may say, well, I want to go fully clinical and earn as much money as possible. And so we’re always thinking about, how can we prioritize the physician’s goals within their practice and their life?

So first, identify which employers kind of fit your criteria as employers that you would be interested in working with, not just from a care setting and reputation, but also from a support perspective. Do a site visit, see the facility, see the staff.

The second strategy that we use is, we identify all of the job postings within that geographic radius. So you can go to places like PracticeLink, that’s a really good example, where they aggregate job postings for a geographic area, specialty, and care setting. So I would, one, go to the employers and see which job postings fit your criteria for the employers you like, and then secondarily look at PracticeLink or other job posting aggregators where you can find opportunities, again, that fit your criteria.

Kevin Pho: So tell us a story. Give us an example where a physician did exactly that to their benefit and increased the value of the contract they eventually signed by doing that strategy.

Ethan Nkana: The overwhelming majority of my clients, and I think this is the primary difference between a talent agent, the work that I do, and maybe kind of a contract review factory that you might see if you Google physician contract review, I don’t get paid by the hour, and I don’t get paid if I don’t get results. So the overwhelming majority of my clients, 90 percent plus, stay with their current employer for a better schedule, more support, and more pay.

And the way we do that is, I think as an easy example, I worked with a group of six OB/GYN physicians, all women, and they were wanting to leave and go private practice from their large national health system employer. I said, well, going private practice is a major shift from being employed. Tell me more about where it hurts, where’s the pain? And what I learned was, they weren’t valued, respected, and appreciated by their employer. And spoiler, they weren’t paid fairly either.

So with those doctors, the first thing that I did is, I went around town to each of the competitors for their employer and I said, hey, I have the LeBron James of OB/GYN who are interested in exploring their opportunities. Are you interested? Spoiler, every employer in town is like, yeah, we’d love to talk to them, set it up. So I got those employers connected with those doctors, and then those doctors were able to say, we like all of these employers professionally, but we think that these two employers fit us best.

So what I did is I went back to their employer, to their CEO, and I said, hey, Mr. CEO, just so you know, these doctors believe they don’t have consistent clinical support, they’re never home to see their families, and they’re paid far less than their male counterparts for the same exact work. Can you do something?

The employer said exactly what I said when I was a hospital executive, which was, if we pay them $1 more we’re going to end up in jumpsuits. Or, their contract isn’t up for six months, we’ll talk about it then. Just completely got stopped.

I planned for that. So I said, OK, I thought you might say that. Just so you know, they’ve been approached by competitors in the market who are interested in hiring them, and they’re considering those options. And then the tone changes, and now they say, well, hold on, what do we have to do? Well, what about their non-compete? Yeah, I thought you might say that. We actually negotiated their non-compete penalty as a bonus from their new employer. So when they move, and if you decide to come after them, they’ll have that money as a lump sum bonus from their new employer.

But what I don’t tell them, I tell their financial advisor, is if the employer doesn’t sue you, you pocket that money. That’s a bonus that you now keep as a windfall.

So I’ll flash forward to the end of the story, where the employer calls me at 7:30 on a Tuesday night and says, Ethan, what number do we have to hit to make this work? And Kevin, I just said the biggest, silliest number I could think of, and that’s what those doctors got. Because they were willing to, one, lock arms with one another and say, we deserve better, our patients deserve the best version of us, and we cannot do that if we’re not sleeping and never home. We can’t do that if we have to see patients in seven and a half minutes, and we can’t do that if we’re constantly stressed about patients not having access to us.

Kevin Pho: How about the scenario where an employer would say, this is our standard contract? What kind of options then do physicians have?

Ethan Nkana: A doctor’s strongest option, which is not always available to them, I will be very candid about that, a doctor’s strongest option is their ability to walk away. So I always say, when you do a contract review, that’s very much like going to urgent care and them telling you you have a broken leg. That’s a diagnosis, but it doesn’t fix the broken leg.

So I often say, for doctors who work with us, we are not a fit for every doctor. So if you’re going to work with us, and if we’re going to work with you, the litmus test is, if you go to your employer with very reasonable requests and they say, you know what, Kevin, it’s a standard contract, we’re not making any changes, what will you do? If you say, OK, well I’ll just go back to my clinic and do my job, Google physician contract review, see what you find, we’re not for you. We work with the doctors who say, Ethan, I deserve to be paid fairly, I deserve to have a schedule that honors my lifestyle goals.

So you must be willing to explore your options. You don’t need to leave, but you must at least be willing to explore your options if you’re going to have your strongest chance for success. And it’s often like, if you think about clinical care with patients, there’s usually various treatment options which have different risks and chances for success. In my practice, doctors give themselves the best chance for success when they’re not emotionally invested in that specific offer and they’re willing to explore their options. Those are the doctors that have true power and can say, I deserve better.

Kevin Pho: We’re talking to Ethan Nkana. He’s a talent agent for physicians. Today’s KevinMD article is “How rookie doctors crush their first contract.” Ethan, we’ll end with some of your take-home messages you want to leave with the KevinMD audience.

Ethan Nkana: Yes. First and foremost, I want to say, you’re not crazy. And I say that specifically because of this past weekend. Completely unrelated, three doctors called me. Summary of the issues: one of them has been let go from his practice, the other has had his salary completely slashed, and I told you about Stephanie, who hasn’t been paid since February.

And each of those doctors did exactly what I know doctors to do, which is, they said, I’ll take it on, I’ll figure it out, I’ll make it through this. And I had to say to them, you are not crazy that this is happening to you. You don’t deserve for this to be happening to you. I know that, with the pain you’re experiencing, you don’t really know how to navigate it. I know that you may not feel like there’s a pathway to what you see as success, or if you were a patient, as full health. But trust me, these are the symptoms I see every day.

And so I just want to remind you, you have worked way too hard to not be able to see your family, or the people that you care about, or do things that you’re interested in with your free time. You don’t deserve to have inconsistent and unreliable clinic staff that makes it difficult for you to practice at the top of your license. And lastly, greedy is a dirty word. You’re not greedy if you’re asking to be paid fairly for your contribution to your organization.

Kevin Pho: Ethan, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Ethan Nkana: It’s been a delight to be with you, Kevin. Thanks for the time.