Mastering Physician Contract Negotiation: A Med-Psych Residency Guide

Understanding the Unique Landscape of Med-Psych Physician Contracts

Entering your first job after a med psych residency is both exciting and intimidating—especially when that first employment contract lands in your inbox. Medicine-psychiatry combined training opens an unusually wide range of opportunities, but it also creates more complexity in physician contract negotiation.

As a dual-trained internal medicine and psychiatry physician, you are often asked to fill multiple roles at once: hospitalist, CL psychiatrist, outpatient psych prescriber, addiction specialist, primary care for patients with serious mental illness, or program builder for integrated care. Your contract needs to reflect that complexity—fairly and clearly.

This guide will walk you through:

• How med-psych roles differ contractually from traditional single-specialty jobs
• Key compensation and workload issues to clarify before signing
• Specific negotiation strategies for medicine-psychiatry combined positions
• Red flags in employment contract review
• Practical scripts and examples you can use when talking with employers

The goal is to help you move from “I hope this is fair” to “I understand exactly what I’m agreeing to and why.”

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How Med-Psych Roles Shape Your Contract

1. Dual Scope = Dual Expectations

Most standard physician employment agreements are built around a single specialty. As a med-psych physician, your scope usually spans:

• Internal Medicine (inpatient, outpatient, or both)
• Psychiatry (CL, emergency, inpatient, outpatient, addiction, collaborative care, etc.)

Common med psych residency exit roles include:

• Hospital-based:
  • CL (consult-liaison) psychiatry with hospitalist shifts
  • Medical director for behavioral health units caring for high-acuity medical patients
• Outpatient/integrated:
  • Primary care provider in a behavioral health home
  • Psychiatrist embedded in primary care, focusing on complex medical-psychiatric comorbidity
• Hybrid:
  • Split FTE between internal medicine clinic and outpatient psychiatry clinic
  • Time-limited program development plus some direct clinical work

Each of these models has different implications for:

• Compensation structure (salary vs wRVU vs hybrid)
• Call expectations (medicine call vs psychiatry call vs both)
• Liability and malpractice coverage (which scope? which sites?)
• Productivity metrics (are you benchmarked as an internist, psychiatrist, or both?)

Your employment contract review must begin with a crystal-clear role description. If you cannot easily explain to a colleague “what I actually do week-to-week” based solely on the contract language, it is too vague.

2. Title and Departmental Home Matter

Titles and departmental alignment affect:

• Compensation benchmarks (IM vs psychiatry vs hospitalist vs CL)
• Promotion criteria (especially in academic centers)
• Incentive structures and RVU targets
• Administrative support and leadership pathways

Common arrangements for med psych grads:

• Primary appointment in Psychiatry, secondary in Medicine
• Primary in Medicine, with psychiatry duties written in as “service”
• Joint appointment in both, with one “home” department for HR/comp
• Employed by a hospitalist or behavioral health service line, not a department

When you’re negotiating, ask explicitly:

• Which department (or service line) “owns” my FTE and my budget line?
• Which specialty benchmarks will determine my salary and productivity expectations?
• Who is my direct supervisor and who completes my evaluations?

If those answers are unclear, the contract should not be signed yet.

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Compensation and Workload: What’s Different for Med-Psych?

1. Salary Benchmarks: What Are You Compared To?

For med psych residency graduates, the benchmark question is fundamental. In many institutions:

• Internal medicine hospitalists have one set of ranges and RVU expectations
• General psychiatrists have a different (often higher salary-per-RVU, lower RVU target) model

You may be doing a mix of both.

When evaluating an offer:

1. Ask which survey/benchmark they used
   • MGMA, AAMC, SullivanCotter, etc.
   • Specialty category used: “Internal Medicine”, “Hospitalist – Internal Medicine”, “Psychiatry – General”, “Psychiatry – CL”
2. Ask what percentile your offer represents
   • Base salary at what percentile?
   • Target compensation at what percentile?
3. Compare that to your actual scope of work
   • If you’re covering high-intensity consults, complex medical-psychiatric patients, and program development, a bottom-25th percentile offer (based on general psychiatry) may not be appropriate.

Remember: you are not obligated to accept an “average” psychiatry salary when you are providing two specialties worth of clinical expertise—especially if the system is billing for both high-complexity medical and psychiatric services.

2. wRVU Targets and Productivity Models

A key challenge in attending salary negotiation for med-psych physicians: traditional productivity structures often don’t capture the true work of integrated care.

Common problems:

• Counting only billable visits in RVU calculations while you spend substantial time:
  • Coordinating care with primary teams
  • Family meetings
  • Interdisciplinary rounds
  • Short “hallway consults” that don’t generate a billable note
• Splitting RVUs between departments in unclear ways
• Expecting full productivity metrics for both IM and psychiatry within a single FTE

In contract negotiation, ask for clarity in writing on:

• Annual wRVU target (if any)
• How wRVUs will be assigned for:
  • Informal consults
  • e-consults
  • Team huddles/collaborative care supervision
• How dual-coded visits (IM + psychiatry) are handled
• Whether non-RVU work (teaching, leadership, program-building) is tied to productivity expectations

If your role is heavily integrated and team-based, you may be better served by:

• A primarily salary-based compensation model with modest or no RVU component
• An RVU target adjusted downward to reflect non-billable but essential work
• An explicit “protected time” allocation for non-clinical duties

3. Workload: FTE Breakdown and Clinical Mix

A robust physician contract negotiation for a med-psych role includes a detailed breakdown like:

• 0.6 FTE inpatient medicine (hospitalist service, 12 shifts/month)
• 0.2 FTE CL psychiatry on medical floors
• 0.2 FTE program development and teaching (non-clinical)

Or for outpatient/integrated roles:

• 0.5 FTE integrated primary care clinic (panel size defined, # of visits/day reasonable)
• 0.3 FTE outpatient psychiatry for SMI or medically complex patients
• 0.2 FTE administrative/leadership/teaching

Insist that the contract—or, at minimum, an attached job description referenced by the contract—spell out:

• Expected number of half-day clinics or shifts per week
• Expected patient load (new vs follow-up, typical visit length)
• Balance of internal medicine vs psychiatry
• Administrative, teaching, and leadership responsibilities and time

Vagaue phrases like “as assigned by the Chair” or “to meet service needs” without boundaries invite overextension, especially for versatile med psych residency graduates who can plug many gaps.

4. Call Responsibilities: Medicine, Psychiatry, or Both?

Call coverage is often a hidden pain point in medicine psychiatry combined positions.

Clarify in your employment contract review:

• Are you covering medicine call, psychiatry call, or both?
• Is call in-house or from home?
• Call frequency (e.g., 1:6 weekends, 7 nights/month)
• Whether call pay is included or additional
• What happens when call mixes scopes, e.g.:
  • Overnight psychiatry call with responsibility for medically complex patients on psych units
  • Internal medicine backup for psychiatric inpatients with deteriorating medical status

If you are taking on dual-scope call, physician contract negotiation should address:

• Higher call stipends or reduced base clinical hours to compensate
• Explicit limits on maximum call frequency
• Clear backup and coverage expectations

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Core Legal and Contract Terms Every Med-Psych Physician Should Review

While many provisions are similar across specialties, some clauses matter even more when your skill set is niche and in-demand.

1. Term, Renewal, and Early Termination

Key questions:

• Length of the initial term (often 1–3 years)
• Automatic renewal or renegotiation intervals
• Without-cause termination clauses:
  • Typical notice is 60–90 days
  • Shorter notice periods can destabilize both you and your patients
• For-cause termination:
  • Ensure reasons are clearly defined, not overly broad

Because your role may be program-critical or hard to replace, consider negotiating:

• Longer notice periods for employer termination without cause
• Guaranteed minimum severance if terminated without cause after relocation

2. Non-Compete and Geographic Restrictions

Med psych physicians often practice in relatively small and specialized markets (e.g., the only integrated med-psych clinic in a region). A harsh non-compete clause can severely limit your options.

Investigate:

• Is there a non-compete clause at all?
• Radius (e.g., 5–20 miles) and duration (e.g., 1–2 years)
• Whether restrictions apply to:
  • All medicine and psychiatry practice
  • Only similar integrated services (e.g., CL, collaborative care)
  • Specific sites or service lines

In physician contract negotiation, you can often:

• Narrow the scope (only prohibits working in competing psychiatric services, not general IM or telepsychiatry)
• Reduce the radius or time frame
• Exclude academic, VA, or public sector roles from the non-compete

Given the growth of integrated care and your niche skills, limiting overly broad non-competes is especially important.

3. Malpractice Coverage and Tail

Dual-scope practice affects your risk profile. Confirm:

• Coverage type: claims-made vs occurrence
• Who pays for tail coverage if you leave
• Whether all your activities are covered, including:
  • Internal medicine hospitalist work
  • Psychiatry consults and outpatient practice
  • Telehealth services
  • Administrative leadership (if involving clinical decisions)

Because you are crossing traditional departmental lines, ask in writing:

“Please confirm that all professional activities described in my job duties, across both internal medicine and psychiatry, are fully covered under the malpractice policy.”

If the employer expects you to pay for tail on departure, that’s a major financial liability and a point for further attending salary negotiation or additional sign-on/retention bonuses.

4. Benefits, CME, and Support for Your Dual Role

Beyond base salary, med psych physicians should pay special attention to:

• CME funds: Are they sufficient for maintaining two boards?
• CME days: Enough time to attend both internal medicine and psychiatry conferences if desired
• Board certification support:
  • Fees for initial certification and maintenance in both specialties
• Licensure and DEA fees: For multiple states if telehealth or outreach included
• Support staff:
  • Access to embedded social work, case managers, and nursing
  • Adequate MA/RN support to handle complex med-psych patients

Ask explicitly:

• “Will CME funds and days be increased to reflect my dual-board status?”
• “Are there dedicated resources for integrated care (behavioral health staff, care coordinators, etc.)?”

These details may not be fully negotiable, but they signal how seriously the organization values your dual expertise.

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Practical Strategies for Successful Physician Contract Negotiation

1. Prepare Your Value Proposition

Before you negotiate, clearly articulate the concrete value you bring as a medicine psychiatry combined specialist, for example:

• Ability to manage medically and psychiatrically complex inpatients, reducing transfers and length of stay
• Capacity to bridge primary care and behavioral health, improving quality metrics (A1c, BP, depression remission rates)
• Reduced consult delays by handling both medicine and psychiatry issues in one visit
• Program-building in integrated care, addiction, or SMI primary care that can attract grants or improve payer contracts

Quantify when possible:

• “In residency, our med-psych consult team reduced median LOS for high-utilizer patients by X days.”
• “Integrated care models have been shown to reduce ED use and inpatient utilization—my role is designed specifically around these outcomes.”

Use this framing to justify:

• Higher base salary or sign-on bonus
• Reduced RVU targets with program-building expectations
• Additional protected time for interdisciplinary work

2. Get a Professional Employment Contract Review

Even if you are comfortable with medical jargon, legal language is different. Given the complexity of dual-scope work, invest in professional review:

• Health care attorney familiar with physician contracts and local laws
• Contract review services used by your specialty societies
• Mentors or senior med-psych faculty who have negotiated similar roles

When you pair legal review with content expertise from a mentor, you can navigate both:

• Legal risk (malpractice, non-compete, termination clauses)
• Professional risk (unreasonable workload, poor alignment with career goals)

3. Use Collaborative, Data-Driven Negotiation

Approach the conversation as a problem-solving dialogue, not a confrontation. Some useful language:

• “Given that this role combines internal medicine and psychiatry responsibilities, I’d like to understand how the compensation was benchmarked.”
• “The RVU target seems closer to full-time internal medicine expectations, but the role includes substantial non-billable integrated care work. Could we explore adjusting the target or increasing protected time?”
• “Because I’ll be board-certified in both IM and psychiatry and covering dual-scope call, I’m hoping we can bring the total compensation to the Xth percentile of psychiatry benchmarks.”

Bring data:

• MGMA or AAMC benchmarks (if available to you)
• Sample contracts from peers (de-identified)
• Specialty society recommendations

4. Decide Where to Flex and Where to Hold Firm

You probably will not get everything you ask for. Pick priorities in tiers:

High-priority (rarely compromise):

• Unsafe or unsustainable schedule
• Ambiguous malpractice coverage for both scopes
• Excessive non-compete blocking you from practicing in your community
• Wildly misaligned compensation relative to expectations

Medium-priority (negotiable):

• Sign-on bonus vs relocation support
• CME amount vs administrative support
• Exact RVU target vs academic/promotion pathways

Lower-priority:

• Title wording (within reason)
• Minor differences in CME days or small bonus percentages

If the employer will not move on a deal-breaking issue—especially something like non-compete breadth or malpractice—be prepared to walk away. As a med-psych physician, your skills are rare and in demand.

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Common Pitfalls and Red Flags for Med-Psych Physicians

1. Vague job descriptions like “duties as assigned by Chair of Medicine and Psychiatry” with no FTE breakdown.
2. Full-time expectations in both specialties hidden inside “1.0 FTE” language.
3. No recognition of dual-board status in compensation or CME support.
4. Call burden not spelled out—especially for combined medicine/psychiatry call.
5. RVU targets based on full-time hospitalist or full-time psychiatrist metrics, despite a mixed or integrated role.
6. Non-compete that covers any practice of medicine or psychiatry within an excessively large radius.
7. Tail coverage fully on you, especially if you anticipate changing jobs in a few years.

When you see these, raise them explicitly and ask for revisions before you sign.

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Putting It All Together: A Med-Psych Contract Scenario

Imagine this proposed role for a new med psych residency graduate:

• Job title: “Integrated Medicine-Psychiatry Hospitalist”
• Duties:
  • Inpatient internal medicine hospitalist, 12 shifts/month
  • Med-psych consults on psychiatry and medical floors
  • 0.1 FTE for program-building (no protected time clearly specified)
• Compensation:
  • Salary benchmarked to 50th percentile IM hospitalist
  • Standard hospitalist RVU targets
  • Psychiatry call 1:6 weekends with no additional stipend
• Contract:
  • Non-compete: 2 years, 30-mile radius, any practice of medicine or psychiatry
  • Malpractice: claims-made, tail at physician’s expense

Issues to negotiate:

• Clarify FTE breakdown: Define explicit time for consults and program-building, perhaps shifting hospitalist shifts down (e.g., 10 shifts/month + 0.2 FTE CL + 0.1 FTE admin).
• Compensation adjustment: Because of dual-scope work and call, request salary closer to 60–75th percentile psychiatry or med-psych hybrid benchmark, plus a stipend for extra psychiatry call.
• RVU expectations: Lower RVU target or partially salary-based model acknowledging non-billable consult/program work.
• Non-compete: Narrow to integrated med-psych or hospitalist-psychiatry roles within a 10–15 mile radius and max 1 year.
• Tail coverage: Employer to pay full or shared tail if terminated without cause.

Through structured, data-driven discussion, this scenario can shift from a potentially exploitative arrangement to a sustainable, career-launching role.

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FAQs: Physician Contract Negotiation in Medicine-Psychiatry

1. Should my contract treat me as an internist, a psychiatrist, or both?
Ideally, your agreement should explicitly acknowledge your medicine psychiatry combined training and describe your actual clinical mix. For compensation, many employers will default to a single benchmark (often psychiatry if much of your work is in behavioral health). You can—and should—negotiate based on the combination of responsibilities, especially if you’re performing hospitalist-level medicine or high-acuity consults alongside psychiatry.

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2. How can I tell if my offer is fair for a med-psych role?
Compare the offer to:

• Local IM hospitalist and psychiatrist salaries and RVU expectations
• Your call and after-hours duties
• Whether you’re doing program development, leadership, or teaching in addition to clinical work

If you’re working at the level of two specialists, a bottom-of-market salary based on only one specialty is a sign to push harder—or walk away. Consider a professional employment contract review to benchmark your offer.

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3. What’s the biggest contract mistake new med-psych attendings make?
The most common mistake is accepting a vague, overloaded job—“just help wherever needed”—without defined FTE breakdown, call expectations, or realistic RVU targets. This often results in burnout and difficulty saying “no” later. Insist on detailed role description and boundaries in writing before signing.

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4. When should I involve a lawyer in my physician contract negotiation?
For any first attending job—especially one as complex as a med psych residency graduate taking an integrated role—you should involve a healthcare-focused attorney or contract review service before signing. They can flag problematic clauses (non-compete, tail coverage, termination) and help you structure reasonable requests. Pair this legal review with advice from med-psych mentors who understand the clinical realities of the role.

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Effective physician contract negotiation is not about being difficult; it’s about aligning your rare and valuable med-psych skill set with a contract that lets you practice safely, sustainably, and in a way that supports your long-term career. Taking the time to negotiate thoughtfully up front will pay dividends for years to come.