The Ultimate Guide to Physician Contract Negotiation in Neurology

Physician Contract Negotiation in Neurology is one of the most consequential steps you’ll take as you transition from training to practice—or move between positions as an attending. Your neurology residency and fellowship may have prepared you to diagnose complex disorders, but they almost certainly did not train you to interpret non-compete clauses, RVU models, or partnership tracks.

This guide is designed to help neurology residents, fellows, and early-career attendings approach the neuro match and post-match period with a clear framework for evaluating offers, negotiating effectively, and protecting your long-term career.

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Understanding the Big Picture: Why Neurologists Must Negotiate

Neurology is a rapidly evolving specialty, with demand increasing across subspecialties such as stroke, epilepsy, movement disorders, neuromuscular, neuroimmunology, and neurocritical care. This demand strengthens your position when it comes to negotiation—if you understand your value and the levers available.

Why negotiation matters specifically in neurology

1. Growing demand, limited supply

   • National shortages in general neurology and several subspecialties.
   • Aging population with increasing incidence of stroke, dementia, and neurodegenerative diseases.
   • Expansion of teleneurology, stroke call coverage, and neurohospitalist models.

2. High burnout risk

   • Heavy cognitive workload, frequent inpatient consults, and complex outpatient management can easily become overwhelming in poorly structured jobs.
   • Negotiating call schedules, visit lengths, and support staff isn’t just about lifestyle—it directly affects patient safety and your longevity in the field.

3. Wide variation in compensation models

   • Neurology compensation structures vary widely:
     • Academic vs. private practice
     • RVU-based vs. salary + bonus
     • Hospital-employed vs. multispecialty group vs. single-specialty neuro group
   • These differences can dramatically affect your income trajectory and day-to-day work.

4. Your contract is the floor, not the ceiling

   • The contract defines your minimum protections and expectations, not your aspirations.
   • A weak contract can trap you in:
     • Unfair non-compete clauses
     • Excessive call demands
     • Uncompensated work (e.g., RVUs without support)

A thoughtful employment contract review and structured negotiation process are essential to protect your interests.

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Core Components of a Neurology Employment Contract

Before you negotiate, you need to understand the anatomy of a typical neurology contract. Each of these sections has negotiable pieces; knowing what to look for can help you prioritize.

1. Position description and scope of practice

Key elements to look for:

• Clinical setting
  • Outpatient general neurology vs. subspecialty clinic
  • Neurohospitalist vs. mixed inpatient/outpatient
  • Telehealth expectations
• Subspecialty support
  • Will you be allowed to build a subspecialty practice (e.g., epilepsy, movement disorders)?
  • Is there dedicated clinic time or EEG/EMG/EMUs, etc.?
• Procedures and diagnostic work
  • EMG, EEG reading, botulinum toxin injections, LPs, intraoperative monitoring.
  • Are these included in your expected duties and compensation structure?

Actionable tip: Ask for a written description of expected clinic templates (e.g., 60-min new, 30-min follow-up), inpatient census expectations, and percent of time for subspecialty vs. general.

2. Compensation structure

Neurology compensation can be confusing. Common structures:

• Straight salary (more common in academics, early years of employment)
• Salary + productivity bonus (often RVU-based)
• Pure productivity model (RVU or collections-based, often after a “guarantee” period)
• Partnership track (in private groups, where compensation changes substantially after partnership)

Key terms to understand:

• Base salary
  • Guaranteed amount per year.
  • Often set for 1–3 years before major changes.
• RVU (Relative Value Unit) model
  • You may receive:
    • A base salary plus RVU bonus over a certain threshold, or
    • A pure RVU-based payment per work RVU.
  • You must know:
    • RVU target
    • RVU conversion factor ($ per wRVU)
    • Historical RVU production of similar neurologists in that practice.
• Bonus structure
  • Quality metrics (stroke door-to-needle, readmission rates, etc.).
  • Patient satisfaction scores.
  • Department or system performance.

Actionable tip: Ask for actual anonymized compensation and RVU data for neurologists in similar roles at that institution, not just “market rate” claims.

3. Benefits and non-cash compensation

Benefits often represent a substantial portion of your effective compensation:

• Health, dental, and vision insurance
• Disability and life insurance (especially important for neurologists given exposure to complex procedures and call)
• Retirement contributions (e.g., 401(k) or 403(b) matches; pension plans in some systems)
• CME funds and days (conferences, board prep, specialty courses)
• Licensing, DEA, and society dues (AAN, subspecialty societies)
• Malpractice coverage (claims-made vs. occurrence; tail coverage responsibilities)
• Student loan repayment or signing bonus

Actionable tip: When comparing offers, create a simple spreadsheet that includes both base salary and estimated cash value of benefits so you can compare total compensation fairly.

4. Call responsibilities and schedule

For neurology, call is often the most misunderstood and under-negotiated element:

• Inpatient neurology vs. stroke call coverage
• Telestroke responsibilities
• Frequency of weekday and weekend call
• In-house vs. home call, and response-time requirements
• Compensation for:
  • Extra shifts
  • Additional stroke call coverage
  • Holiday coverage

Actionable tip: Ask specific questions:

• “How many nights per month will I be on stroke call?”
• “Is there backup coverage?”
• “How often is call unusually busy?”
• “Is there dedicated recovery time post-call?”

5. Non-compete and restrictive covenants

Non-compete clauses are particularly important in neurology, where referral patterns and hospital affiliations matter.

Key elements:

• Geographic radius (e.g., 5–20 miles from your primary practice locations)
• Time period (often 1–2 years after departure)
• Scope (neurology in general vs. specific subspecialty; hospital vs. outpatient work)

Actionable tip: Negotiate to:

• Narrow the radius.
• Limit restrictions to specific locations you primarily work in.
• Shorten the duration.
• Ensure non-compete does not apply if the employer terminates you without cause or materially changes your job.

6. Termination, due process, and contract length

• Contract term (typical: 1–3 years, with automatic renewals)
• Termination “for cause”
  • Know exactly what is defined as cause.
• Termination “without cause”
  • Typically 60–180 days’ notice required.
• Due process (critical for hospital-employed or procedural roles)
  • Steps that must be followed before privileges or employment are removed.

Actionable tip: Ensure there is mutual termination without cause language (you and the employer can terminate with notice) and clearly defined due process protections.

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How to Approach Physician Contract Negotiation as a Neurologist

Once you understand what’s in the contract, the question becomes: how do you negotiate effectively and professionally?

Step 1: Do your homework on the market

Effective physician contract negotiation begins with data:

• Use multiple sources:

  • MGMA or AAMC (often accessed through your department chair or mentors).
  • Specialty-specific data from AAN or subspecialty societies.
  • State and regional physician salary reports.
  • Informal data: speak with recent grads in your subspecialty.

• Factors that affect neurology compensation:

  • Geographic region and cost of living.
  • Urban vs. rural setting.
  • Subspecialty (e.g., neurocritical care and stroke often command higher compensation due to call and acuity; cognitive neurology may be lower but with different expectations).
  • Academic vs. community vs. private practice.
  • Local competition and hospital needs (e.g., Comprehensive Stroke Center status).

Actionable tip: Build a short “market snapshot” for yourself:

• Typical base salary range for your role and region.
• Typical RVU targets for outpatient or inpatient neurology.
• Typical call expectations and their compensation.

This gives you an anchor point for attending salary negotiation.

Step 2: Get a professional employment contract review

Even if you understand the basics, having a health care contract attorney or specialized physician contract review service go through your document is invaluable.

What a good attorney/consultant does:

• Translates dense legal language into practical implications (e.g., “this non-compete would prevent you from working anywhere in this metro area for 2 years”).
• Identifies red flags that are common in neurology contracts (e.g., uncompensated telestroke call).
• Suggests specific edits and alternative clauses.
• Helps you prioritize what to push on vs. accept.

Actionable tip: Seek someone with experience reviewing neurology or hospital-based specialty contracts if possible; they better understand RVU, call, and procedural nuances.

Step 3: Clarify your priorities before negotiating

Not everything can or should be negotiated. You need to know what matters most to you:

Common priority domains:

1. Compensation
   • Base salary
   • RVU structure
   • Bonuses
2. Schedule and workload
   • Clinic volume
   • Call frequency
   • Number of hospitals covered
3. Career development
   • Protected academic or research time
   • Leadership opportunities (stroke program, EMU director, etc.)
   • Subspecialty clinic development
4. Location and flexibility
   • Ability to maintain family ties, childcare support, partner’s job.
   • Remote work options for teleneurology.
5. Exit flexibility
   • Reasonable non-compete.
   • Fair termination clauses.

Actionable tip: Rank your top 3 non-negotiables and 3–5 “nice to haves.” This keeps you focused during negotiation and avoids diluting your asks.

Step 4: Use professional, collaborative language

Negotiation is not confrontation; it’s a discussion to align expectations.

Example phrases to use:

• “Thank you for the offer. I’m excited about the opportunity. I have a few questions and proposed changes I’d like to discuss to ensure this is a sustainable long-term fit for both of us.”
• “Based on MGMA data and what I’ve learned from peers in similar neurohospitalist roles in this region, I was expecting a base salary closer to $X. Is there flexibility to move in that direction?”
• “Given the intensity and frequency of stroke call, would you be open to adding either post-call recovery time or a call stipend to reflect that workload?”

Avoid:

• Emotional or adversarial language (“This is unfair,” “I deserve more than this”).
• Ultimatums, unless you’re truly ready to walk away.

Step 5: Negotiate specific, concrete terms

Instead of broad complaints, propose specific alternatives.

Examples tailored to neurology:

• Call workload
  • From: “Every 3rd night stroke call”
  • To: “No more than 6 nights of stroke call per month with one full post-call day off for each overnight shift.”
• RVU targets
  • From: “RVU target will be set annually at administration’s discretion.”
  • To: “RVU target will be set annually by mutual agreement based on prior-year performance and benchmarks for similar neurologists, and cannot exceed X% of the 75th percentile MGMA for this region without written agreement.”
• Subspecialty access
  • From: vague promise of subspecialty development.
  • To: “At least 1 dedicated clinic day per week for movement disorders, with access to botulinum toxin injections and DBS programming within 12 months of start date.”

Step 6: Get all changes in writing

Verbal assurances are meaningless if they’re not reflected in the contract.

• If the recruiter/department chair says:
  • “We never enforce the non-compete.”
  • “We would never ask you to cover more than one hospital at a time.”
  • “We always support CME requests.”
• Then your follow-up should be:
  • “I appreciate that. To avoid misunderstandings, would you be willing to include that in the contract or an addendum?”

Do not sign until every agreed-upon term is written and you’ve had a chance for final review by your attorney or advisor.

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Neurology-Specific Red Flags and Negotiation Opportunities

Some issues show up across all specialties, but others hit neurology particularly hard. Recognize them early and address them in your physician contract negotiation.

1. Unlimited or poorly defined stroke call

Red flags:

• “Call as assigned by department.”
• No maximum frequency stated.
• No mention of compensation for expanded coverage or teleneurology.

Negotiation strategies:

• Define maximum:
  • “No more than X nights of primary stroke call per month.”
• Add compensation:
  • Stipend per call or per shift.
  • Extra compensation for covering additional hospitals.
• Protect rest:
  • Post-call clinic cancellation or half-day schedules following overnight call.

2. Ambiguous RVU expectations

Red flags:

• No explicit RVU target or conversion factor.
• Targets that exceed what others in the group have historically achieved.
• No support for efficient practice (e.g., no advanced practice providers, inadequate EMR templates).

Negotiation strategies:

• Request written targets and conversion factors.
• Ask for:
  • Historical data from similar neurologists.
  • Nursing/MA support ratios.
  • Scribe or APP support if high RVU expectations exist.
• Negotiate a ramp-up period:
  • Lower RVU expectations in year 1 to account for building a patient panel.

3. Non-competes that block all local neurology practice

Red flags:

• Non-compete radius that covers an entire metro region (or multiple hospitals spread throughout a city).
• Restrictions that apply to all neurology practice in the region, even if the employer has a narrow practice focus.

Negotiation strategies:

• Narrow the scope:
  • Limit non-compete to locations where you practice at least X days per week.
  • Restrict to your specific subspecialty if possible.
• Reduce duration:
  • Aim for 12 months instead of 2 years.
• Ask for release conditions:
  • Non-compete void if contract is not renewed or if terminated without cause.

4. Lack of support for subspecialty practice

Neurology careers often hinge on subspecialty identity—yet contracts may ignore it.

Red flags:

• Contract only lists “neurology services” without mention of your subspecialty.
• No explicit access to necessary equipment or time (EEG, EMG, EMU, botox, DBS clinic, etc.).

Negotiation strategies:

• Add specific language:
  • “Dr. X will have a minimum of Y clinic sessions per month dedicated to epilepsy care.”
  • “Access to at least Z EMG slots per week.”
• Establish a timeline:
  • If infrastructure is being developed (e.g., EMU), include timelines and expectations.

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Strategic Timing: From Neuro Match to First Attending Job

The arc from neurology residency and fellowship to your first attending role spans several key milestones. Your negotiation strategy should evolve along the way.

During residency and fellowship

• Educate yourself:
  • Attend contract negotiation sessions at AAN or your program.
  • Talk frankly with recent graduates about their mistakes and successes.
• Keep doors open:
  • Build relationships with mentors in varied practice settings (academic, private, hospital-employed).
  • Understand what they like and dislike about their contracts.

During the neuro match and job search phase

• Treat each interview as both:
  • An opportunity to showcase your skills.
  • A chance to gather detailed data about the role.

Ask structured questions at site visits:

• “What is the typical day like for your junior neurologists?”
• “What are your current challenges with neurology coverage or stroke call?”
• “How has the compensation structure changed in the last 3–5 years?”

After receiving an offer

• Do not rush to sign—even if pressured.
• Express enthusiasm and gratitude, then request:
  • A written offer.
  • A few days to a few weeks (commonly 7–14 days) to review with counsel.
• Begin a structured attending salary negotiation process:
  • Clarify unclear terms.
  • Propose reasonable, data-backed modifications.
  • Get all changes documented.

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Frequently Asked Questions (FAQ)

1. Should I always hire an attorney for employment contract review?

For most neurology positions, yes, especially for your first attending job. The cost of a knowledgeable healthcare attorney is typically a small fraction of what you might lose from a poorly structured contract (e.g., restrictive non-compete, unfavorable RVU model, or uncompensated call). Choose someone experienced with physician and preferably neurology or hospital-based specialty contracts.

2. How much can I realistically negotiate as a new neurology attending?

You may not be able to dramatically change a large hospital system’s entire pay structure, but you can usually negotiate:

• Base salary within a reasonable range.
• Signing bonus, relocation allowance, or loan repayment.
• Call responsibilities, including limits and compensation.
• CME funds and protected time.
• Non-compete scope and duration.
• Details of your subspecialty practice and clinic setup.

The more offers you have and the more in-demand your subspecialty or location, the greater your leverage.

3. What if the employer says the contract is “standard” and non-negotiable?

“Standard” does not mean “non-negotiable.” Some large systems have limited flexibility, but it’s rare that nothing can be changed. At minimum, you can often negotiate:

• Start date
• Specific schedule details
• Call distribution
• Tail coverage responsibilities
• Clarifying language that protects you

If an employer refuses to clarify or address significant concerns—particularly regarding non-compete, call, or termination clauses—that itself is valuable information that might prompt you to walk away.

4. How do I compare two very different offers (e.g., academic vs. private practice)?

Create a side-by-side comparison table including:

• Total cash compensation (base + bonus + likely call pay).
• Benefits value (retirement match, insurance, CME).
• Call burden and schedule.
• Non-compete terms.
• Career growth opportunities (promotion, partnership, leadership roles).
• Geographic and lifestyle considerations.

Then weigh them against your personal priorities: academic interest, research, long-term earnings potential, work–life balance, and location. An academic job might have a lower salary but better lifestyle and academic support; a private practice job might offer higher upside via productivity and partnership.

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Navigating physician contract negotiation in neurology is a professional skill you will use repeatedly throughout your career. Approaching it with preparation, data, and clarity about your priorities will help you secure not just a good first job, but a sustainable and satisfying neurology career.