Mastering Physician Contract Negotiation in PM&R: Ultimate Guide for Residents

Physician Contract Negotiation in Physical Medicine & Rehabilitation (PM&R) is one of the most consequential steps in your transition from residency or fellowship to attending life. Your first signed agreement can determine your income trajectory, work–life balance, future mobility, and long-term career satisfaction. Yet most residents receive minimal formal training in physician contract negotiation or employment contract review.

This guide is designed specifically for physiatry residents, fellows, and early attendings navigating the physiatry match to practice transition. We’ll walk through the structure of typical PM&R employment contracts, highlight common specialty-specific pitfalls, and offer concrete strategies for attending salary negotiation and non-salary terms that matter just as much.

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Understanding the Landscape: PM&R Practice Models and How They Shape Contracts

Before you can negotiate effectively, you need to understand who you’re negotiating with and how they get paid. In Physical Medicine & Rehabilitation, practice models are diverse, and that diversity drives contract structure.

Common PM&R Practice Settings

1. Academic Medical Centers

   • Focus on teaching, research, and complex inpatient rehab
   • Often include:
     • Lower base salary than private practice
     • Strong benefits (retirement match, CME, parental leave)
     • Protected academic/research time (sometimes negotiable)
     • Expectations for publications, teaching, committees
   • Compensation may be RVU-based but with guaranteed components

2. Private Practice (Outpatient or Mixed)

   • Musculoskeletal, sports, spine, EMG-heavy practices are common
   • Compensation structures:
     • Salary with RVU or productivity bonus
     • Partnership track vs. long-term employment
     • Ancillary income from physical therapy, imaging, injections
   • Contracts can vary widely; careful employment contract review is critical

3. Hospital-Employed Physiatry

   • Inpatient consults, general rehab, and post-acute care coordination
   • Typically:
     • Guaranteed base salary for 1–3 years
     • RVU benchmarks and tiered bonus structure
     • Call obligations and service line development expectations

4. Inpatient Rehabilitation Facilities (IRFs) and SNFs

   • Mix of employment and independent contractor models
   • Consider:
     • Volume-based compensation tied to census
     • Medical direction stipends
     • Compliance and documentation expectations (key in post-acute care)

5. Subspecialty & Niche Roles

   • Pain, sports, interventional spine, neurorehab, cancer rehab, EMG labs
   • Procedures and technical fees greatly influence compensation
   • Often more negotiation room around:
     • Procedural days vs. clinic days
     • Access to imaging, fluoroscopy, ultrasound
     • Support staff and MA/scribe availability

Why PM&R-Specific Knowledge Matters

Physiatry is uniquely multi-setting and team-based, which affects:

• RVU potential (eg, procedures vs. cognitive visits)
• Expectations for supervising therapists or APCs
• Call structure (inpatient rehab vs. consult service vs. none)
• Long-term specialty fit (eg, a “sports” job that is actually 80% general MSK)

Understanding these dynamics helps you benchmark offers and decide what is worth negotiating.

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Key Components of a PM&R Physician Contract

Your goal in employment contract review is to understand what is being promised, what is required of you, and what happens if things go wrong. Here are the essential sections and what to look for.

1. Job Description & Scope of Practice

Look for:

• Clinical duties
  • Inpatient vs. outpatient percentages
  • Procedures expected (e.g., EMG/NCS, injections, ultrasound, fluoroscopy, botulinum toxin, intrathecal pumps)
  • Patient population (spine, stroke, TBI, SCI, general rehab, pediatrics)
• Non-clinical duties
  • Teaching, research, administrative roles
  • Supervision of NPs/PAs, therapists, or residents/fellows
• Locations
  • Primary site and any satellite clinics or facilities
  • Maximum allowable travel time/distance
  • Clarity on whether new sites can be added unilaterally by the employer

Why it matters: Scope creep is common. A contract that simply says “duties as assigned” can evolve into an undesirable mix of tasks that don’t match your training or goals.

Actionable check: Ask for a brief addendum that outlines your core duties, including a maximum number of clinical sites and expected inpatient vs. outpatient percentages.

2. Compensation Structure

Compensation is usually a mix of:

• Base salary
• Productivity-based bonus (often RVUs)
• Quality or value-based incentives
• Medical director stipends (common in IRF/SNF roles)
• Signing bonus / relocation

Understanding RVUs in PM&R

PM&R can be heavily RVU-driven, especially for:

• Spine and MSK clinics
• EMG-heavy practices
• Interventional pain/spine

Key questions:

• What is the RVU conversion factor (e.g., $45–$60 per RVU)?
• What is the expected annual RVU target for bonus or to maintain salary?
• Is there a ramp-up period for new grads (eg, lower target in year 1)?
• How are procedural RVUs handled (eg, fluoroscopy-guided injections vs. office visits)?
• Are you credited for work done by supervised APPs?

Guarantees and Time Horizons

New grads should look for:

• 1–2 years of guaranteed base salary while building volume
• Transparent explanation of how compensation changes afterward
• Clarity on whether the guarantee is forgiven or treated like a loan if you leave early

Example red flag: “Your guaranteed salary will be forgiven after 3 years of continuous employment.”
Better: “Salary guarantee is not subject to repayment; productivity model begins in year 3.”

3. Benefits and Perks

Look beyond salary in your attending salary negotiation:

• Health, dental, vision insurance
• Retirement: 401(k)/403(b) match and vesting schedule
• Disability and life insurance
• Malpractice coverage (claims-made vs. occurrence-based; tail coverage details)
• CME funds and days
• Licensing/DEA fees, society dues, board fees
• Paid time off: vacation, sick days, parental leave, holidays

For PM&R, especially watch:

• Malpractice and tail for interventional procedures and pain/spine
• Coverage for multiple practice sites and fluoroscopy suites
• Adequate CME and procedure training allowances if your practice is evolving

4. Schedule, Call, and Workload

PM&R schedules can look deceptively mild on paper—until you add call, weekend rounds, and satellite travel.

Clarify:

• Clinic hours: start/end times, template (e.g., 20–24 patients/day)
• Inpatient rounding responsibilities
• Call
  • Frequency (eg, 1:4, 1:6)
  • Type (home call vs. in-house; consult vs. rehab unit only)
  • Call pay (if any)
• Telemedicine expectations (evenings/weekends?)
• Use of scribes or MAs to support documentation-heavy rehab notes

Negotiation tip: Instead of fighting over every dollar, negotiate tangible improvements in work–life balance: reduced call, scribe support, or more control over clinic templates.

5. Term, Termination, and “Exit Strategy”

Your contract should specify:

• Initial term (often 1–3 years) and whether it auto-renews
• Without-cause termination
  • Typical notice: 60–90 days
  • Shorter is usually better for you
• For-cause termination
  • Should be specific and objective (loss of license, DEA, hospital privileges, etc.)
• Severance (rare for new grads but possible in leadership roles)

Why it matters: An overly restrictive or vague termination clause can trap you in an unhealthy environment or complicate moves to a better opportunity.

6. Restrictive Covenants: Non-Compete and Non-Solicitation

Restrictive covenants may significantly impact your future mobility, especially in urban or single-hospital markets.

Key terms:

• Geographic radius (e.g., 10–20 miles)
• Time period (typically 1–2 years after leaving)
• Scope of practice (all medicine vs. PM&R vs. subspecialty only)
• Facilities covered (all employer sites vs. specific locations where you worked)

PM&R-specific concerns:

• If you’re doing niche work (e.g., SCI, TBI, spasticity, pediatric rehab), a broad non-compete could push you out of the region entirely.
• For procedural spine or sports roles, competing practices might be dense in urban areas; even a 10-mile radius can be career-limiting.

Reasonable target:

• ≤1 year duration
• 5–10 miles from your primary practice site(s) only
• Limited to your specialty (e.g., PM&R) or sub-specialty, not “any medical practice”

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How to Prepare for Physician Contract Negotiation in PM&R

Effective negotiation is not about confrontation; it’s about clarity and alignment. Preparation is your greatest leverage.

1. Know Your Market Data

Gather compensation benchmarks from multiple sources:

• AAPM&R and AAPMR member surveys
• MGMA, AMGA (often accessible through your program or faculty)
• Specialty-specific recruiters (with appropriate skepticism)
• Recent grads from your program or region

For each target city or region, clarify:

• Typical base salary ranges for:
  • Academic PM&R
  • Hospital-employed general rehab
  • Outpatient MSK/spine
  • Interventional/pain-emphasis
• Common RVU expectations and bonus structures
• Signing bonuses and relocation norms

Example:
A new grad interventional spine physiatrist in a mid-sized city might expect:

• $280–350K base in year 1–2
• 8,000–9,000 RVUs as a full productivity target
• $20–40K signing bonus
• Additional procedural revenue participation

2. Define Your Priorities Before You Negotiate

You can’t negotiate everything; decide what matters most:

• Top 3–5 priorities:
  • Geographic location or family considerations
  • Outpatient vs. inpatient mix
  • Procedural opportunities and fluoroscopy access
  • Academic vs. private practice culture
  • Income potential vs. lifestyle

Then identify:

• Non-negotiables (e.g., non-compete radius too large to keep kids in current schools)
• Nice-to-haves (eg, extra CME funds, hybrid telemedicine days)
• Trade-offs you’re willing to make (e.g., lower base for more procedure time or academic protected time)

3. Line Up Professional Help

At minimum, budget time and money for:

• Physician contract review by an experienced health law attorney
  • Ideally with PM&R or procedural specialty experience
  • They can spot risky clauses in malpractice, non-compete, and compensation language
• Optional but helpful:
  • Mentors or senior physiatrists who understand local practice dynamics
  • Financial planner or CPA for big-picture advice (loans, retirement, cost of living)

Note: An attorney can’t tell you whether a job is a “good fit,” but they can tell you whether a contract is unusually risky or out of step with norms.

4. Plan Your Negotiation Strategy

When you’re ready to negotiate:

1. Express enthusiasm first.
   “I’m very interested in this position—it’s a great fit clinically. I’d like to review a few details in the offer.”

2. Bundle your asks.
   Instead of dribbling out issues one by one, prepare a concise list of 3–5 requested changes, prioritized.

3. Be specific and data-informed.

   • “Based on MGMA and AAPM&R data for this region, would you be open to a base of $___?”
   • “Could we adjust the non-compete to 10 miles from the primary clinic rather than all sites?”

4. Use conditional language.

   • “If we can get to X base salary and clarify the tail coverage in writing, I would be comfortable signing.”

5. Know when to stop.
   Once major issues are addressed, avoid nitpicking small items that could sour the tone.

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Negotiating Key Terms: What Matters Most for Physiatrists

Some clauses are simply more important than others. Here’s where to focus your effort in physician contract negotiation for PM&R.

1. Base Salary and Attending Salary Negotiation

For new grads, your base salary sets:

• Your initial financial baseline
• Future raises and productivity thresholds
• Your negotiating anchor for future jobs

Tactics:

• Aim for the upper half of the local range if:
  • You bring subspecialty skills (EMG, interventional, SCI, peds)
  • The job is in a less desirable location
• Accept middle-of-the-range if:
  • The job offers exceptional lifestyle, mentorship, or academic opportunities
• Consider trading a slightly lower base for:
  • Better non-compete terms
  • Clear partnership track
  • Protected time for research or program-building

2. Productivity and Bonus Structures

In PM&R, RVU and productivity details can make or break long-term earnings.

Clarify and negotiate:

• Thresholds: Is the RVU target realistic based on current volumes?
• Credit: Are you credited for supervised APPs? Shared procedures?
• Time lag: How often are bonuses calculated and paid (quarterly vs. annually)?
• Transition: How does your compensation change after the guarantee period?

Example negotiation point:
“I’d like to see a gradual ramp-up of RVU expectations over the first two years, with a target of 5,000 RVUs in year 1, 7,000 in year 2, and full 8,500 in year 3.”

3. Malpractice and Tail Coverage

Especially critical if you are:

• Doing interventional spine or pain procedures
• Working as an independent contractor
• Joining a smaller private group without institutional backing

Ask:

• Is coverage claims-made or occurrence-based?
• If claims-made:
  • Who pays for tail coverage if you leave?
  • Can that obligation be forgiven after a certain tenure or if terminated without cause?
• Are all locations and procedures explicitly included?

Negotiation goals:

• Employer-paid tail coverage, or
• Tail cost shared or forgiven after X years of service

4. Non-Compete and Practice Mobility

This is especially high impact in:

• Dense urban markets with limited rehab/employment options
• Smaller towns with a single hospital system

Negotiation angles:

• Reduce the radius
• Limit to specific sites where you regularly worked
• Shorten the time period to 12 months
• Narrow the scope to PM&R or your subspecialty only

Example ask:
“Given my family’s ties to this area, would you consider limiting the non-compete to 10 miles from the primary practice location and to 12 months?”

5. Call, Inpatient Responsibilities, and Support

For inpatient-heavy or mixed roles:

• Clarify:
  • Average daily census
  • Presence of NP/PA or hospitalist support
  • Documentation expectations and rounding times
• Negotiate:
  • Reasonable call frequency
  • Compensation for additional call beyond base expectations
  • Protected time or reduced clinic after heavy inpatient weeks

For outpatient-heavy roles:

• Push for:
  • Reasonable clinic templates (avoid 30+ patients/day unless compensated)
  • Scribe or MA support
  • Protected admin time for notes, refills, and coordination

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Red Flags and Deal-Breakers in PM&R Contracts

While every situation is unique, certain patterns should prompt caution or further clarification.

Potential red flags:

• Extremely broad non-compete (e.g., 50 miles, 2–3 years, all medicine)
• Short without-cause termination notice heavily favoring the employer
• Vague compensation language (“bonus at employer’s discretion” without formula)
• Productivity targets vastly exceeding known norms for PM&R
• Requirement to pay back:
  • Salary guarantees
  • Signing bonus
  • Relocation costs
    in situations where you leave for legitimate concerns (eg, hostile environment)
• No written detail on:
  • Call frequency
  • Inpatient vs. outpatient percentages
  • Sites of service

If multiple red flags are present and the employer is unwilling to modify them, it may be safer to walk away—even from a seemingly attractive salary.

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Putting It All Together: A Strategy for New PM&R Attendings

Here’s a step-by-step approach you can follow from offer to signed agreement:

1. Receive the offer

   • Ask for the full written contract, not just a summary or LOI.

2. Do a first-pass read

   • Highlight:
     • Compensation
     • Non-compete
     • Termination
     • Malpractice/tail
     • Duties and schedule

3. Engage professional employment contract review

   • Send the contract to a physician-focused attorney.
   • Ask specific questions relevant to PM&R (procedures, multi-site coverage, etc.).

4. Clarify your negotiation priorities

   • 3–5 biggest points, with clear fallback positions.

5. Schedule a conversation with the hiring entity

   • Frame the conversation as collaborative and appreciative.
   • Present your prioritized requests with justification.

6. Review the revised contract carefully

   • Ensure verbal agreements are reflected in writing.
   • Watch for subtle wording changes that alter meaning.

7. Make a holistic decision

   • Balance:
     • Compensation
     • Career growth and mentorship
     • Geographic/lifestyle fit
     • Contract risk profile
   • Remember: The “perfect” contract doesn’t exist; aim for reasonable, safe, and aligned with your goals.

8. Sign—and keep a copy

   • Store a PDF and printed version.
   • Revisit terms before major transitions (eg, partnership, renewal, or considering a new job).

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FAQs: Physician Contract Negotiation in PM&R

1. Do I really need a lawyer to review my PM&R employment contract?
While not legally required, it is strongly recommended. Physician contracts—especially those involving procedural work, RVUs, or multiple practice sites—contain complex language around malpractice, non-competes, and compensation that can have long-term consequences. A lawyer experienced in physician contract negotiation and employment contract review can help you avoid costly mistakes and highlight terms that are out of line with norms.

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2. How much can I realistically negotiate as a new PM&R graduate?
You typically have more leverage than you think, particularly if:

• You are willing to work in a less saturated location
• You bring subspecialty skills (interventional, EMG, SCI, peds)
• The practice has a strong need or long-standing vacancy

You may not win every point, but you can often negotiate:

• Higher base salary or signing bonus
• Better non-compete terms
• More favorable call schedules
• Clarified RVU targets and ramp-up
• Employer responsibility for tail coverage or a compromise formula

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3. What’s more important to negotiate: salary or non-compete?
Both matter, but for many physiatrists, non-compete and exit terms are more consequential in the long run. You can often recover from a slightly below-market salary through raises or a future job change; a restrictive non-compete, however, can force you to move cities or abandon a local network you’ve built. Prioritize safety and flexibility first, then optimize income.

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4. How should I approach renegotiation once I’m already an attending?
Approach attending salary negotiation or contract renewal like a performance review:

• Gather data on:

  • Your RVUs, revenue, and patient volumes
  • Program-building you’ve done (new clinics, procedures, referral growth)
  • Quality metrics or leadership roles

• Time your request:

  • 6–12 months before contract renewal
  • After a period of demonstrated growth or contribution

• Propose:

  • Adjusted base salary or improved productivity formula
  • Expanded role with medical director stipends
  • More protected time or better support if you’ve taken on additional responsibilities

Frame the discussion around your value to the institution and future growth you can lead, rather than just personal need.

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Physician contract negotiation in Physical Medicine & Rehabilitation is a critical professional skill—one that will shape not only your income, but your day-to-day life and long-term career trajectory. Approach it deliberately, seek expert guidance, and remember that a fair, transparent contract benefits both you and your future patients.