Your First Pediatric Job After Training: A Resident-Friendly Guide to Getting Hired, Getting Paid, and Staying Free

We recently had the privilege of presenting a virtual didactics for a pediatric residency program and wanted to share the key insights here! Thank you to Dr. Zhen Chan of Grapevyne for joining us on this opportunity. His insights about how pediatricians in training should approach the job search process were invaluable, and we are excited to share the key points here. If you’d like us to present to your program (any specialty, not just peds!), please reach out!

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Start with you: define your ideal before you chase listings

Before considering job boards, interfacing with recruiters, and taking interviews, take an honest look in the mirror. What do you want your career and daily life to look like over the next five years?

Think through practical and personal variables: the balance between teaching and clinical time, appetite for leadership, interest in research, support staff levels, how much administrative work you can tolerate (or would like to learn and take on!), and what professional development opportunities matter to you.

Layer in personal context like benefits for your family, school systems, commutes, and whether you would prefer to walk or drive to work. Then consider practice setting trade-offs:

• Independent private practice often means more autonomy and earlier opportunities to build programs, but also more administrative work and a need for basic business sense, especially if there is a partnership track.
• Hospital-employed roles are typically structured and predictable as a W-2 employee with defined hours and duties, but the system’s needs can override your preferences.
• Academic settings emphasize teaching and scholarship with more defined rank progression, but often different compensation expectations.

Write these priorities down rather than keeping them in your head. Use objective scoring systems like the Excel sheet provided at the end of the slide deck to score opportunities against your own priorities so you can compare apples to apples.

Preparing for interviews and why site visits matter

Most interviews will feel like a conversation. They want to understand your goals, how you handle difficult situations, and how you work on a team. Still, prepare for straightforward clinical questions and for the chance to state your longer-term interests.

If there is an on-site visit, go. You might move a family, buy a house, and invest years in this choice. Being in the clinic, feeling the pace, and speaking with people who are not on the interview loop gives you a truer picture. Ask to meet a frontline pediatrician who can describe a typical week. When they ask, “Do you have any questions for us?” never say no. Prepare questions that signal both diligence and commitment to the institution’s growth. Examples include:

• What are you looking for in an ideal candidate?
• Are there leadership roles you hope a candidate might be able to fill in the future?
• What are the nurse and MA ratios, and who rooms patients?
• How many clinical hours are expected, and how much true administrative time is protected?
• How is newborn rounding assigned across hospitals?
• How is NP/PA supervision handled and compensated?
• How are quality metric bonuses defined, and what percentage of physicians actually receive them?
• (If it’s important to you) Do you have physicians who do reduced FTEs?

Start licensing and credentialing early

Licensing and payer credentialing are heavy on paperwork and slow by nature. Average timelines run 90 to 120 days. Fresh grads tend to be closer to 90, but some states take longer. If you know your destination state six to nine months before graduation, start then.

Practical tip: create a digital “wallet” folder. Snap photos or scan degrees, training certificates, transcripts, W-2s, awards, background checks, and anything else you might need. Title files clearly so they are searchable. Many requirements repeat across states and payers. If your target states participate in the Interstate Medical Licensure Compact, an anchor license can streamline additional licenses.

Moving, communities, and real life

If relocation is on the table, factor in housing, commutes, schools, and family needs. Ask the employer about relocation support, malpractice coverage details, and whether there are resources that help physicians integrate into the community. In some rural markets, the hospital or practice will actively welcome you into civic life because you may be the only subspecialist within a region. That matters for both lifestyle and professional success.

Keep learning the business of medicine

Clinical learning never stops. Do not let the business learning stop either. Understanding insurance, access barriers, social determinants, and obviously physician contracts and compensation, will make you a better pediatrician and a better colleague, and it sets you up for leadership. Medicine has often under-taught this side of the profession. Teach yourself and utilize trusted resources.

Physician contracts in plain language

So, let’s switch gears a bit. You have navigated the pre-interview process, interviewed well, and you’re getting formal offers. Now what?!?

Let’s first dispel a key myth about physician contracts. You will often encounter employers who claim their terms are “standard” or “boilerplate.” Employers use these terms to suggest that the contract is non-negotiable and uniformly applied. However, this is not always the case. While they rarely let me rewrite their contracts, they are often open to reasonable modifications. While it might be 98% consistent with those of your peers, the remaining 2% — often in the details — can significantly impact your professional life. These differences could be anything from your specific responsibilities, on-call duties, or even termination clauses. Hence, it is crucial to scrutinize every aspect of the contract and understand that many items are negotiable.

Please note that some employers may not change anything in their contracts for you. This is no reason to ignore the contract. The vast majority of you will have the option of comparing more than one offer, so you need to know how the contracts between prospective employers differ and which option is the best fit for you. Also, ALL of you need to understand your contract so you can make an informed decision. The goal is clarity, not necessarily winning changes.

Lastly, it’s important to understand the employer’s motivations here, to have some empathy for their position and how they approach physician employment contracts. Employers of physicians must make a significant investment in physician recruitment and onboarding. According to the American Medical Association, the cost of replacing a physician is estimated to be between $500K and $1M. This figure accounts not just for the recruitment process but also for the loss of productivity, patient care continuity, and potential revenue that a departing physician takes with them.

It’s understandable that employers structure contracts to mitigate this risk. As a physician, you need to recognize that while employers are protecting their interests, you too must protect yours, particularly regarding exit strategy issues related to leaving a job within the first few years. This starts with understanding why certain clauses exist and what their implications could be for your career.

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The Three Big Questions of Physician Contracts

Here’s what you need to know about this next stage, and how to navigate offer letters, contracts, negotiation, juggling multiple offers, finalizing a deal, and making sure you start on time!

When we evaluate and negotiate physician contracts at Michael Johnson Legal, we frame everything around three big questions:

1. Work Obligations: What are you required to do?
2. Compensation: How are you paid, especially long-term?
3. Exit Strategy: How do you pivot without wrecking your life or your finances?

1) Work obligations: get the key interview promises in writing

Interview conversations tend to focus on day-to-day duties. That is good. Turn those promises into contract language. Common pediatric specifics include:

• Clinical hours. Outpatient roles often range from 32 to 36 clinical hours per week. Some try to push to 40 clinical hours. Know the norm.
• Call responsibilities. Clarify frequency, in-house vs at-home, and compensation.
• Work locations. Which clinic sites, how many, and how often can they move you?
• Newborn rounding. Which hospitals, how the schedule is shared, and whether it counts as a call or a separate duty.
• Supervision of NPs and PAs. Is it expected? How many? How is time and liability covered? Is there a stipend?

If they promised 32 clinical hours and 8 administrative hours, ask that the contract reflect it or, at a minimum, place guardrails around unilateral changes. Watch for clauses that say schedule and duties are at the employer’s sole discretion. Almost every physician contract has an “Entire Agreement” clause that says any promises made to you during the interview process are NOT enforceable. Use the contract negotiation stage to clarify which interview promises are ‘aspirational’ and cannot be fully relied upon when making your final decision, vs. which promises are real. Obtaining clarity here can help you decrease the odds that you’re surprised by unexpected expectations.

2) Compensation: do not stop at base salary and signing bonus

Most offers open with a base salary and a signing bonus, and they will be very exciting to you after a long haul of eating ramen noodles. Those are important, especially as you transition and build a panel, but your long-term compensation is usually driven by clinical productivity and sometimes quality metrics.

For hospital-employed pediatrics, a common model ties a work RVU total to a $/wRVU rate after an initial guarantee period. A bread-and-butter visit like 99214 is 1.92 wRVUs. A typical pediatric wRVU rate often falls in the low-to-mid $40s/wRVU. Think of it this way: that 99214 would generate roughly 1.92 times your $/wRVU rate in dollars. Many employers highlight base and bonus while keeping wRVU details vague or separate. Ask directly for the rate, the trigger, and when the production model applies – this often comes at the offer letter or contract stage, and it’s critical to know this key aspect of compensation before you proceed.

Two leverage points often matter more than adding a few thousand to the signing bonus:

• The wRVU rate itself. Moving a rate from $40 to $44 is a 10 percent raise on the largest slice of your long-term pay. Over five years, that is a six-figure difference for many pediatricians.
• The timing and access to the production model. Some contracts allow you to start earning production bonuses as soon as your production outpaces base pay. Others force you to wait until a future date, no matter how productive you are. Earlier access is often negotiable.
• Do you have a perpetual minimum base salary? This can be helpful in some instances, and we sometimes negotiate for this. However, most employers need a certain amount of clinical volume to make the underlying economics of employing you actually work. Many pediatricians falsely believe that they can produce under volume expectations and maintain their job… however, in the firm, we don’t see this happening consistently. Most employers will either force-feed you more volume to avoid losing money, will consider termination, or won’t give you raises and let inflation reduce your compensation.

In a physician-owned private practice, compensation may be keyed off the percentage of collections rather than the wRVUs. Percentages vary by market and model. The questions are similar: what counts toward collections, what is the split, who bears overhead, and how quickly are you reconciled?

On quality metrics, many primary care service lines attach an additional bonus, particularly in hospital-employed models. Ask what is measured, how it is tracked, and what percentage of physicians actually earn the payout. Some metrics are well designed. Others unfairly tie pay to factors outside your control. It is better to learn that before you sign, but also be prepared to advocate for fair metrics as you move forward. These are often tweaked annually by the employer, and we recommend physicians band together to present a unified front when working on these metrics.

Finally, recognize that many employers reserve the right to change compensation plans unilaterally in the future. You may not be able to eliminate that right, but you can plan for it by strengthening your exit protections.

3) Exit strategy: six big rocks to protect your options

We would love to lock in super clear guardrails around your work obligations and an automatically increasing compensation plan in every physician employment contract. However, absent the unicorn deal, this is likely unrealistic, and you should be prepared for an employer to want to adjust these over time. If a change to compensation or work obligations in the future turns out to be unattractive, you need to know your exit strategy! The importance of an Exit Strategy is often wildly underconsidered for pediatricians coming out of training, and a key reason to get legal help from a lawyer who knows you personally and deeply understands physician contracts!

Roughly four in ten physicians change jobs in the first five years. Even if you plan to stay, evaluate and consider negotiating your physician contract as if you might need to leave in the first few years. Exit provisions often matter more to your finances than the shiny front-end incentives, like base salary and signing bonus. Here are the six areas to understand and, where possible, improve:

• Termination rights. You want a without-cause termination right that applies from day one, usually with 90 to 180 days of notice. Watch out for asymmetric notice periods where you must give 90-180 days, but the employer can end the relationship on 30 days. Because licensing, privileges, and payer credentialing take months, a short notice period on their side can create a real income gap on yours. Missing 2-4 months of income can become a $50K-$100K problem, and it happens more often than you may initially think! A financially protected off-ramp is super helpful in protecting your freedom and ability to change jobs.
• Noncompete clauses. These restrict where you can work during and after employment. Most states still permit them in some form, and most contracts use radius miles measured from one or more practice locations with a duration of one to two years. Map the radius against real geography. In some markets, reducing 20 miles to 10 changes nothing because there are no viable jobs between the city and the cornfields. Other markets are dense, so a few miles matter a lot. Look to negotiate duration, trigger, and carve-outs such as removal if the employer terminates you without cause. Laws vary by state, and some states carve out primary care differently, so treat whatever is written as if it will be enforced exactly that way. The only safe way to sign any contract, including physician employment contracts, is to assume they are enforceable exactly as written, and negotiate and plan to comply accordingly.
• Nonsolicitation clauses. Even without a noncompete, a broad nonsolicit can block you from practical practice options. Clauses may restrict accepting referrals from anyone who referred to your former group, reaching out to prior patients, or even seeking privileges at any hospital where any physician in the group has privileges. Push for fair language. In many systems, you can advertise generally and accept patients who follow you on their own accord, but you cannot directly ask former patients to move with you. Try to remove enforcement if you are terminated without cause. This clause is super important if you want the option of ‘taking your practice’ with you when you leave, or being required to start from scratch.
• Malpractice tail coverage. Almost all employers pay your malpractice premium during employment. The question is who pays for tail if a claim is made after you leave. Hospitals often pay for tail. Private practices often do not. Tail can run into five-figure costs and tends to increase with years of service and state risk profiles. Clarify who pays and under what circumstances, and ask for employer-paid tail right away or after a defined period of service. Consider negotiating for the employer to pay for tail if they are terminating you.
• Exclusivity and moonlighting. Many contracts restrict outside clinical work and sometimes outside professional activities. If moonlighting and outside professional activities matter to you, seek a carve-out up front for the specific work you plan to continue, such as pediatric urgent care shifts or telehealth. It is much easier to negotiate permission now than after you sign.
• Compensation clawbacks and waiver issues. Front-end money often comes with strings attached. A common pattern for a $30,000 signing bonus is 100 percent repayment if you leave in year one, two-thirds in year two, one-third in year three, then fully earned after that. Push for a true time-served reduction and for the removal of repayment if they terminate you without cause. Check for other clawbacks that might appear in relocation, student loan assistance, or advanced compensation draws. 

Put these six together and compare jobs beyond base salary. Two offers that look identical on the surface can be dramatically different once you add exit costs, tail, and the real impact of geographic restrictions. Do the math and make sure you understand what the legal and financial penalties are upon exit, particularly if you determine this is not a good fit early on. 

Timing: start earlier than you think

Negotiating your contract 18-9 months before you plan to start gives you substantial leverage. It is the time when you can entertain multiple offers and have the freedom to walk away if the terms do not meet your expectations. This cushion allows you to negotiate from a position of strength rather than necessity. Our experience in the firm suggests hiring managers have more room to increase compensation and improve terms when the physician can comfortably entertain multiple offers and walk away. With millions on the line and extensive negotiation experience, they know their leverage, and so should you! If you have these offers around the same time, your ability to clearly understand the best deal and use another to potentially improve it can substantially improve outcomes.

If you find yourself short on time with a job offer that does not fit your career goals and life plans, seriously consider a locums position instead of signing a bad deal. Many find ample job satisfaction in locums, and even comment that it fills some experiential gaps that might not be provided in your residency or fellowship program. The compensation is also often quite attractive, and some elect to continue with locums throughout their career.

Offer Letters, Contracts, what’s the difference, and when do we negotiate?

Many employers push physicians to make a final decision at the offer letter stage with very limited information, but we often counsel physicians that this is not best practice. They will often make you feel like this is the only time to ask for anything, and the only thing you can ask about is a small increase in signing bonus. They often lead with the idea that the contract is sacred and cannot be touched. Our experience is that this is not often true.

Offer letters are a brief, attractive snapshot of the most exciting aspects of the job. Think of it as their Bumble profile picture… They often include items that make you excited, like base salary, signing bonus, relocation stipends, training stipends, time off, and CME budgets. They often do not include anything about Exit Strategy and future compensation models, and are not the full picture.

We highly recommend that you contact your lawyer at the offer letter stage or earlier. We often recommend that you negotiate the offer letter on hard dealbreakers, of which there should only be a few, but reserve further discussion until you have fully evaluated the contract. We also often recommend that physicians signal to employers that approving the offer letter does not represent their final decision and ask for the contract and all external compensation plans and benefits packages. We also typically recommend pausing on credentialing with the employer and turning away other offers until the contract is in hand and is negotiated and signed.

Academics could be an exception to the above. Some academic institutions may only have an offer letter, and the other details could be housed in an external document like a faculty practice plan, faculty compensation plan, employee handbook or policy and procedures, or the like. Even though it sounds like ‘just an offer letter,’ this could be the final document, and you may want to negotiate at this moment. Again, obtaining counsel at this stage (or earlier) is best practice.

Please note that your situation could be different from these general points, and you should defer to your legal counsel to consider deviating from this.

Bringing it all together

1. Define your ideal and write it down.
2. Use job boards but prefer direct contact and in-house recruiters.
3. Network intentionally with people actually doing the work.
4. Polish the CV, skip the photo, and be ready with thoughtful interview questions.
5. Start licensing and credentialing early and keep a digital wallet of documents.
6. Learn the business and contract/legal side.
7. During contract evaluation, anchor on the three questions: Work Obligations, Compensation (special focus on long-term pay), and Exit Strategy.
8. Protect your exit with fair termination rights, sensible geographic and non-solicit limits, employer-paid tail when possible, reasonable moonlighting flexibility, and clawback terms that credit time served.
9. If something feels unclear, ask for it in writing. If a promise matters to you, it belongs in the agreement.

A simple scoring exercise to compare offers

Create a one-page grid of your priorities down the left and prospective jobs across the top. Give each cell a 1 to 5 score and write one sentence explaining why. Include both life and work: support staff, clinical hours, call, newborn rounding, location count, wRVU rate or collections split, quality metrics, production start, termination notice symmetry, noncompete radius and duration, nonsolicit scope, tail coverage, moonlighting carve-outs, and financial clawbacks. Add up the columns. Numbers do not tell the whole story, but they force clarity and make trade-offs visible.

Final encouragement and next steps

Your first job sets the tone for your early career, but it does not have to lock in your whole future. You can make a good decision now and still preserve options later. Ask questions. Get specifics in writing. Start early enough that you can walk away if something does not align with your goals.

If you want guidance from the interview stage (best practice!), a thorough evaluation of an offer letter and contract, or help with ongoing employment issues, that is what we do all day at Michael Johnson Legal.

• Michael Johnson Legal LLC helps physicians evaluate and negotiate employment agreements nationwide, with litigation support in a handful of states. Set an initial consult at www.michaeljohnsonlegal.com
• We review with you in mind, not just a template. Two residents with the same paper contract may need different negotiation strategies. You deserve a personalized evaluation and negotiation strategy, not copy and paste basics.
• We also publish free resources and deeper dives on our blog and on Instagram at @physiciancontracts.
• For a deeper educational dive, check out my comprehensive course, Mastering Physician Contracts, at www.physiciancontracts.com 

If you have an offer on the table or are in your interview process, consider a short consult, and ideally a compensation consult, before you sign anything. We will walk through your interview promises, clarify compensation math, map your noncompete, and craft targeted, respectful negotiation requests that match your priorities.

Additionally, having access to a supportive and encouraging community can set you apart. Consider joining Grapevyne, a free digital community that empowers autonomy and supports well-being among physicians and medical students. Grapevyne helps you build warm connections within the medical profession based on your interests and goals, and provides educational programming and resources to support your professional development and understanding of healthcare beyond just medicine. From figuring out ways to connect about research or join an advocacy initiative, to finding clinical and non-clinical job opportunities, to getting help launching your own practice or startup venture, Grapevyne’s community is here to help.

Visit https://grapevyne.health and click Join to access the community today!

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