Ultimate Guide to Physician Contract Negotiation for EM-IM Residents

Physician contract negotiation can feel more intimidating than the Match itself—especially when you’re transitioning from EM-IM combined residency to your first attending job. Yet this step may shape your schedule, compensation, professional development, and lifestyle for years.

This guide walks you through emergency medicine–internal medicine physician contract negotiation from the ground up: what’s negotiable, what’s dangerous, and how to approach discussions with confidence.

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Understanding the EM-IM Combined Job Market and Why Contracts Matter

Emergency medicine–internal medicine (EM IM combined) physicians occupy a unique niche. You are trained to manage acute pathology in the ED and complex medical issues on inpatient and outpatient services. That dual skill set affects your contract in several ways:

• Multiple practice settings: You might split time between:

  • Emergency department shifts
  • Hospitalist services (day or night)
  • ICU or step-down units (in some models)
  • Clinic or continuity practices

• Varied employer types:

  • Academic health systems
  • Community hospitals or regional systems
  • Contract management groups (CMGs) in EM
  • Hybrid roles (e.g., 0.6 FTE EM, 0.4 FTE hospitalist)

Because of this complexity, a “generic” EM or IM contract often doesn’t fit well. You must make sure the contract reflects your actual duties, expectations, and the value of your blended training.

Why your first attending contract is so important

1. Baseline for future negotiations
   Starting salary, RVU expectations, and FTE definitions often anchor your future raises and transition offers.

2. Lifestyle and burnout risk
   Poorly defined expectations for “flexible” EM-IM roles can lead to:

   • Extra call or cross-coverage
   • Creep of responsibilities into nights/weekends without compensation
   • Difficulty scheduling vacation or CME due to dual department needs

3. Legal and financial implications
   Non-compete clauses, tail coverage obligations, and repayment of signing bonuses can cost tens of thousands of dollars—or more—if you leave.

Investing time (and often paying for employment contract review by a healthcare attorney) is one of the highest-value decisions you’ll make as you transition to attending life.

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Core Elements of EM-IM Contracts You Must Understand

Before you negotiate, you need to understand what’s in the contract. For EM-IM combined physicians, certain sections require special attention.

1. Job description and scope of practice

Your contract should clearly specify:

• Clinical duties by percentage or FTE:

  • Example: “0.7 FTE emergency medicine, 0.3 FTE inpatient internal medicine”
  • Or defined by number of shifts or weeks per year in each setting

• Sites of practice:

  • Main hospital ED vs. free-standing ED
  • Community hospital vs. academic tertiary center
  • Any expectation to cover multiple hospitals in a system

• Procedural expectations:

  • EM side: intubations, central lines, procedural sedation, trauma codes
  • IM side: admissions, ICU co-management, rapid response team, codes
  • Clarify if you’re expected to perform ICU-level procedures, and whether support is available.

• Non-clinical duties:

  • Teaching responsibilities (residents, students, APPs)
  • Committee participation (ED ops, quality improvement)
  • Administrative roles (assistant director, medical directorships)
  • Research or scholarly activity expectations in academic settings

Red flag: Vague language like “responsibilities as assigned by the department chair” without boundaries. Ask for more concrete parameters or at least a defined process for adjusting duties with your consent.

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2. Compensation structure: EM-IM nuances

Emergency medicine internal medicine physicians are often paid differently for different buckets of work. Clarify:

• Base salary vs. productivity pay

  • Fixed salary by FTE
  • Hourly rate per EM shift and/or daily rate for hospitalist shifts
  • RVU-based pay, often more common on the IM side, but increasingly in EDs as well

• Differential rates:

  • Night, weekend, and holiday differentials
  • Higher rates for high-acuity EDs or critical access sites
  • Stipends for medical directorships or leadership roles

• Common EM-IM complication:
  EM shifts may be compensated at a higher per-hour rate than IM rounding, but inpatient or clinic work might have more predictable hours and fewer nights. Be sure you understand:

  • Total expected annual hours or shifts
  • Blended effective hourly rate across your combined duties

Benchmarks and ranges (approximate, vary widely by region)

• Straight EM (full-time): Often higher hourly compensation due to shift work and unscheduled care.
• Straight IM/hospitalist: Typically lower hourly rate but with more consistent scheduling and fewer nights depending on model.
• EM-IM combined roles:
  • Academic settings may pay a blended salary somewhat closer to IM with academic incentives.
  • Community settings may carve out separate EM and IM rates, or use a blended rate.

Use objective data (MGMA, AMGA, group-specific benchmarks, or specialty society data) to evaluate your offer; this also strengthens your position in attending salary negotiation discussions.

3. Schedule, FTE definitions, and workload

This is where EM-IM contracts can become convoluted if not carefully defined.

Key details to confirm:

• What constitutes 1.0 FTE?

  • EM: Often expressed in annual clinical hours or number of shifts per month/year
  • IM inpatient: Weeks per year or shifts per month
  • IM outpatient: Number of clinic sessions or days per week
    Your contract should specify how your mixed role adds up to a full FTE.

• Shift length and format:

  • 8-, 10-, or 12-hour ED shifts
  • Day vs. night vs. swing ED shifts
  • Hospitalist shifts (7-on/7-off vs. block schedules; day vs. night float)

• Protected time:

  • Administrative time
  • Teaching time, if billed as non-clinical
  • Research or QI projects, especially in academic roles

• Maximum expected load:

  • EM: Typical patient per hour expectations
  • IM inpatient: Average census per physician, cap, and coverage of admissions
  • Clarify whether additional pay or locums-adjusted rates are used for extra shifts.

Practical example:
You’re offered a 0.6 FTE ED + 0.4 FTE hospitalist role. Negotiate to have it written as:

• 8 ED shifts per month (12 hours each), mix of days and nights, with explicit night differential.
• 7 inpatient weeks per year, typical census capped at 16 patients.
• No unassigned “extra” cross-coverage without additional compensation.

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High-Stakes Clauses in EM-IM Contracts

Some parts of the contract may not seem exciting but can be financially and professionally decisive.

1. Non-compete and restrictive covenants

Non-competes limit where you can work after you leave.

Evaluate:

• Geographic radius:
  • 5–15 miles from primary site is common; 50+ miles across multiple counties or states is a red flag.
• Time period:
  • 6–12 months is more standard; 2+ years is more restrictive.
• Scope of practice covered:
  • Does it apply to any clinical work, or only EM at that hospital/ED?
  • For EM-IM physicians, push to limit the scope:
    • Example: Non-compete applies only to ED work at specified sites, not to hospitalist or clinic positions elsewhere.

Negotiation tip:
If the group refuses to remove a non-compete, try to:

• Narrow the radius
• Shorten the duration
• Limit the practice type (e.g., only ED work, only inpatient IM, not both)

2. Malpractice coverage and tail insurance

In emergency medicine internal medicine roles, malpractice risk spans both high-acuity ED cases and complex inpatient management.

Clarify:

• Type of coverage:

  • Claims-made vs. occurrence-based
  • Who pays for tail coverage when you leave?

• Tail coverage costs:

  • Tail can be 1.5–2.5 times your annual premium.
  • If you are responsible, this can be a major financial hit when changing jobs.

• EM-IM nuance:
  If you’re working in multiple departments or sites under one employer, ensure that the policy covers all of those activities. Confirm that any moonlighting within the system is covered—or whether separate coverage is required.

Negotiation strategies:

• Ask the employer to pay for tail coverage after a certain period of service (e.g., 2–3 years).
• Alternatively, request that a portion of the signing bonus be specifically earmarked for potential tail costs.

3. Termination, cause, and due process

Emergency medicine physicians—especially in CMG-run EDs—can sometimes be terminated without the protections typical in academic settings. EM-IM combined doctors may be vulnerable if one department is unhappy even if the other is supportive.

Review:

• Without cause termination:

  • What notice is required (60–180 days is common)?
  • Can either party terminate, or only the employer?

• With cause termination:

  • Define “cause” carefully (license loss, exclusion from Medicare, serious misconduct, etc.).
  • Avoid vague language like “loss of confidence” as cause.

• Due process (especially in ED work):

  • Is there a mechanism for peer review or appeal before termination?
  • This is especially critical for ED contracts at hospitals where medical staff bylaws may apply.

4. Bonus structure, sign-on, and loan repayment

Compensation beyond base pay can be meaningful—but often comes with strings attached.

• Sign-on bonuses:

  • Usually tied to a repayment obligation if you leave before a set period.
  • Ask that repayment be prorated by time served.

• Relocation assistance:

  • Clarify whether this is a bonus or reimbursed expenses—and whether taxes are withheld.
  • Confirm any repayment requirements.

• Quality or productivity bonuses:

  • Define specific metrics (RVUs, patient satisfaction, throughput metrics, readmission rates) and thresholds.
  • EM-IM physicians sometimes face conflicting metrics between ED and IM departments; clarify which metrics apply to you.

• Loan repayment:

  • Confirm whether it’s through federal programs (e.g., PSLF-eligible, NHSC) or employer-based.
  • Employer loan repayment often includes a clawback clause if you depart early.

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Step-by-Step Strategy for Physician Contract Negotiation

Once you understand the components, you can approach negotiation deliberately rather than reactively.

Step 1: Clarify your priorities

Before negotiation, list your top 3–5 priorities. For EM-IM residents transitioning to attending roles, common priorities include:

• Reasonable schedule and control over nights/weekends
• Non-competes that don’t block future options (especially if you have family ties to the area)
• Clear role balance between ED and IM that matches your career goals
• Competitive compensation structure that rewards your dual training
• Protected time for teaching, QI, or leadership development

You won’t get everything you want; knowing your must-haves vs. nice-to-haves keeps discussions focused.

Step 2: Gather data and context

You strengthen your attending salary negotiation position with data:

• National compensation benchmarks for EM and IM
• Local cost of living and regional salary norms
• Information from prior graduates of your EM-IM combined program about:
  • Typical pay and shift loads
  • Non-competes and malpractice terms
  • “Unwritten” expectations

Use these to frame requests such as:
“Given that my role is 0.6 ED and 0.4 hospitalist, and regional benchmarks for these are X and Y, I’d like to discuss a blended compensation structure that more closely matches market rates.”

Step 3: Separate exploration from hard negotiation

Early conversations are exploratory:

• Ask open-ended questions about expectations, culture, and flexibility in role design.
• Clarify how the departments (EM and IM) share responsibility for your schedule, evaluations, and promotion.

Only once you have a written offer do you proceed to formal negotiation.

Step 4: Get a professional employment contract review

Hiring an attorney with experience in physician contract negotiation—ideally familiar with emergency medicine internal medicine or at least hospital-based specialties—is usually worth the cost.

They can:

• Identify risky language and hidden obligations
• Suggest alternative wording or structures
• Explain state-specific legal rules (e.g., enforceability of non-competes)
• Help you prioritize which changes are most important

Share your priorities with the attorney upfront so the review is tailored.

Step 5: Plan your negotiation conversation

Approach it as a professional, collaborative process:

• Express enthusiasm for the role and the group.
• Present your requested changes clearly and succinctly.
• Group your requests into:
  • “Critical” (deal-breakers if not addressed)
  • “Important but flexible”
  • “Nice-to-have”

Example script for an EM-IM candidate:

“I’m excited about the opportunity to practice both emergency medicine and inpatient internal medicine. Before signing, I’d like to discuss four points:

1. Clarifying the exact split of ED and inpatient work by shifts and weeks,
2. Adjusting the non-compete to reflect only ED practice within a smaller radius,
3. Ensuring tail coverage is employer-paid after two years of service, and
4. Aligning the compensation more closely with current regional benchmarks for the EM and hospitalist components.”

Step 6: Use trade-offs strategically

If the employer is resistant, consider trade-offs:

• Accept a slightly lower base in exchange for more predictable shifts, fewer nights, or better non-compete terms.
• Trade a higher sign-on bonus for employer-paid tail coverage or better schedule control.
• Offer to take on additional teaching or committee work for protected time and leadership development.

Always confirm that any trade-off you agree to appears in writing in the final document.

Step 7: Don’t rush—set a timeline

It’s reasonable to request time to review and negotiate:

• Ask for 1–2 weeks to review the contract with legal counsel.
• Communicate your expected response timeline.

Avoid signing under pressure or because “another candidate is interested.” A responsible employer will respect thorough review.

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EM-IM Specific Pitfalls and How to Avoid Them

Dual-trained physicians face a few recurring traps in contracts.

Pitfall 1: “Flexible” role that becomes two full-time jobs

If the contract doesn’t define:

• Number of ED shifts
• Number of inpatient weeks
• Maximum hours per week

You may be pulled into staffing gaps in both departments.

Prevention:

• Write specific FTE allocations and caps on shifts or hours.
• Specify a process for adjusting your role (e.g., mutual written agreement required).

Pitfall 2: Conflicting departmental expectations

You may have:

• ED director expecting full participation in ED committees and metrics
• IM division chief expecting full hospitalist-level productivity and teaching

Prevention:

• Request a named primary supervisor and clear statement of how evaluations and promotions are coordinated.
• Ask for dedicated, scheduled time for required meetings and teaching rather than “on top” of clinical duties.

Pitfall 3: Single non-compete that covers both specialties

A broad non-compete might prevent you from practicing any EM or IM within a large area—even if you only leave one department.

Prevention:

• Split non-competes by role:
  • One limited to ED services at specific sites
  • One limited to inpatient IM, possibly at a smaller radius
• Ask for explicit permission to work in the non-overlapping field if you separate from one department but not the other.

Pitfall 4: Mismatched compensation for dual training

Some groups offer “hybrid” positions but pay closer to straight IM rates, even when expecting significant ED coverage (with nights, high acuity, and boarding challenges).

Prevention:

• Compare the offered structure to:
  • Pure EM opportunities in the region
  • Pure IM/hospitalist compensation
• Use this to justify a blended rate that acknowledges:
  • EM board certification and ED coverage
  • IM work that may be lower paying but more stable

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Frequently Asked Questions (FAQ)

1. Is it normal for an EM-IM physician to have different pay rates for ED and inpatient work?

Yes. Many employers use separate hourly or per-shift rates for:

• ED shifts (often higher due to night/weekend work and unscheduled care)
• Inpatient/hospitalist weeks or clinic sessions (often lower but more predictable)

If you’re offered a single blended rate, compare it against the expected mix of duties. Negotiate for either differentiated rates or a blended rate that fairly reflects the higher-value, higher-intensity ED work.

2. Should I always hire an attorney for physician contract negotiation?

While not absolutely mandatory, it is highly recommended, especially for your first job and for complex EM-IM combined roles. A healthcare attorney can:

• Identify problematic language around non-competes, termination, and tail coverage
• Explain state-specific rules
• Help you prioritize realistic changes

The cost is typically small relative to the potential financial and professional impact of the contract.

3. How much of my contract is actually negotiable?

More than many residents realize. Commonly negotiable items include:

• Base salary or hourly rates
• Signing bonus and relocation package
• Non-compete radius and duration
• Schedule structure and FTE definition
• Tail coverage obligations
• Bonus metrics and thresholds

Hospital system policies and CMG templates may limit flexibility, but even in those settings, terms like schedule, role balance (ED vs. IM), and some legal language are often negotiable.

4. When should I start talking about contract terms during my job search?

You don’t need to discuss contract minutiae on the first call, but you should:

• Ask early about approximate compensation range, FTE expectations, and schedule model.
• Clarify whether the role is purely ED, purely IM, or a true EM-IM combined position.
• Once mutual interest is clear, request a written offer and draft contract before committing verbally.

This timing allows you to compare offers and organize an informed employment contract review rather than reacting under time pressure.

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Careful, informed physician contract negotiation is a critical professional skill—especially for emergency medicine internal medicine physicians whose roles span multiple departments and practice settings. Understanding your value, clarifying expectations in writing, and advocating for fair, sustainable terms will help you launch a career that leverages your EM-IM training while protecting your time, finances, and long-term options.