The clinical question
The clinical question, if there is one, is this: how much of a surgeon's career is shaped by surgical technique, and how much by the contract signed before the first case. The answer, for most of us, is uncomfortable. A lot of attending decisions are downstream of a document negotiated in a hurried few weeks at the end of fellowship.
This episode is for the surgeon moving from training into first practice, and for the surgeon moving from a first practice into a second — which is, in our experience, when the real leverage shows up.
Key decision points
A contract is not one number. It is a system of numbers, and the one on the front page rarely tells you what the job actually pays.
- Base salary vs. total compensation. A $400k base with no RVU conversion looks different from a $250k base at 1.2× the national median wRVU. Model both.
- RVU thresholds. The inflection point — where you start earning per RVU — is the single most important number in an RVU model. A threshold set at the 75th percentile of your specialty, rather than the 50th, quietly cuts a year's worth of earnings.
- Call stipends and administrative time. Subspecialists routinely take call for the practice's general ortho group without separate compensation. Price the hours.
The contract is where the compensation conversation happens. By the time you're at the 45th day of your first year, the conversation is over.
What the literature shows
There is no peer-reviewed literature here in the clinical sense, but MGMA and AMGA publish annual subspecialty compensation benchmarks that are widely used and widely misread. Two things to know: the medians drift upward each year, and the spread inside a subspecialty is larger than the spread between subspecialties. Your neighbor at a different institution is not paid the same as you for the same work.
What Anish took away
Two things. First, that the contract conversation is a clinical skill — it rewards preparation, specificity, and the willingness to ask the uncomfortable question. Second, that the surgeons who negotiate best are not the most aggressive ones. They are the ones who understand exactly what they are worth to the practice, and who can describe that worth in the practice's own language.