The Physician-Employer Relationship and Learning How to Say NO!

Negotiating and enforcing your employment contract never really stops. It certainly does not stop at the time you sign your contract. Physician employers can be relentless about asking you for more of everything. Saying YES to all your employer’s asks often leads to you doing a lot of free work, which improves the Compensation vs. Obligations vs. Leverage and Exit calculus in the employer’s favor. Your employer may like this, but it is not good for you and may lead to stress and burnout and unfairly low compensation. A burned-out physician is not good for patients.

Let’s break down why this occurs and strategies for how to push back and avoid this unfortunate scenario.

Residency match is Nothing like picking a post-training job

Residency match is nothing like picking your first post-training job. Residency match probably makes you feel like cattle getting sorted into barns. You may feel lucky to make it inside any barn at all. It is like the sorting hat at Hogwarts. You are sent to one house, have minimal say, and very rarely can you change. Your desires are considered a little bit when ranking employers, but you have no power to negotiate compensation, obligations, and you have little to no leverage or ability to exit.

Unfortunately for many residents, this may be the only other experience you have in obtaining employment.

Once you are finished with training, you are in control. You have the power to accept or reject employers, and in the majority of specialties you will likely have many options. You likely have leverage to negotiate, and can control your own career. You are more likely to have multiple employers competing for your services, not the other way around.

Residency conditions you to say yes to everything

Residency conditions you to say YES to everything. You are expected to jump at most or all learning opportunities presented to you. You are conditioned to not ask for any additional compensation for your time and it is often implicit that your personal time is not valuable. There are few set boundaries for separating work and life. There have been some meaningful efforts to avoid abusive practices toward residents, but many of those efforts have fallen way short.  

Employment should NOT be like residency. You have options to shape your live and career. You have exceptional training and skills that are highly valued in the healthcare marketplace. You have the power to construct a work-life balance that allows you to say YES to what you want and avoid being obligated to say YES to the things you do not want.

Physician employers know you are conditioned to say YES

Many employers will take advantage of this, constantly asking you to do more for free. More patients, more administrative duties in fewer designated times, more patient contact hours, more call, supervising more NPs and PAs, voluntarily give up PTO, work compression, etc., all for free. Saying NO is not easy for you because the last 7+ years of medical school and residency have only conditioned you to say YES. You have little to no practice saying NO. Some non-traditional medical students that worked between college and medical school may be a bit better equipped, but many physicians have never been in a job that required or allowed them to say NO.

Negotiate your first contract – start saying NO right away.

I see tons of value in starting the employer-employee relationship with a meaningful negotiation. You are setting the expectation that you are not a doormat. You are paying attention to your compensation and the obligations you must perform to obtain that compensation. You demonstrate you know something about leverage, your value, you know your options, and you are willing to push back. They know you are different than the majority and may be less inclined to voluntarily accept attempts to modify the compensation ÷ obligations calculus for your work. Physician employers often want more work for free, and they are more likely to try to get more from those who say YES.

Here are some creative ways to say NO

Saying NO without coming off like an ***hole can be challenging, but you can do it with practice. I love Chris Voss’ book, Never Split the Difference. It is the best book on negotiations that I know of. I use the techniques regularly and recommend every physician read it or listen to it on audiobook. It is very entertaining! If you believe that you, “are just not that good at this negotiation stuff” or say to yourself “I hate negotiating” then this book is for you.

The book is ostensibly about negotiation, but in practice it is about not getting taken advantage of throughout your life. It certainly applies to properly maintaining or improving the physician-employer relationship.

“How Am I Supposed To Do That?” – this is my favorite negotiating question and a centerpiece of Never Split the Difference. You say NO by making your negotiating opponent responsible for solving your problem. If your employer is asking you to do two things at once, label the thing and then ask, “How Am I Supposed To Do That?”

“I am hearing that you want me to see more patients, but you do not want to compensate me more. How Am I Supposed To Do That?”

“I am hearing that you want me to see patients during my administrative time, but my contract says 36 patient contact hours. (LONNNNNG UNCOMFORTABLE PAUSE… again, creatively saying NO by making your opponent solve your problem)”

“How do you propose I do _______, but also honor my contract that says _________?”

“How can we compensate me for _______?”

“How can we modify this task to bring it in line with my contract?”

The more you negotiate specific provisions into your contract on the front end, the more opportunities you will have later on to enforce them.

“What” questions are also quite helpful in forcing your opponent to explain asks that may be difficult to explain. “What is causing this proposed change in call schedule?” “What can we include in my contract that protects me from ___(unreasonable situation___?”

Also, be careful of using “Why” questions. “Why” is more likely to invoke an emotional response and may cause your negotiating opponent to fight harder against you. “Why are you making me do this?” Use of “Why” may make the dispute feel more like an personal fight instead of a collaboration.

Practice your NO skills

Attendings that never learn how to say NO often get trampled on. They often do a LOT of work for free.  For example, what may start out as 36 patient contact hours with 4 hours of admin time can end up being 40 hours of seeing patients, and charting at night from home. What started as one supervised NP or PA can quickly lead to five, and you are suddenly constantly interrupted and slowed down throughout your day with duties unrelated to the patient you just saw. The employer likely has an obligation to staff you properly and provide appropriate medical equipment and supplies, but you realize you are doing staffing work and you are made responsible for making sure equipment and supplies are organized. Maybe call schedule is technically “even” in numbers, but you happen to get more Friday evening and pre-vacation call than others that are better at saying NO. This process is unlikely to happen on Day 1. It happens slowly over time but can snowball such that you are actually doing 130% or more of what your contract says you are required to do!

I recommend working on your “NO” leverage and exit strategy from the very beginning. You should negotiate your first contract for many reasons, but an important reason is to set expectations with your employer that you are different. Once you start, you should be a little weary of agreeing to everything your employer asks, particularly if it violates any provisions of your contract. You can practice learning how to say “NO” more effectively, even if negotiating is not something you enjoy.



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