What is the shortest list I will not sign without?

Five items: the post guarantee pay formula, clawback terms, who pays tail, noncompete radius and length, and the call schedule in writing. If any of those five is vague or missing, do not sign until it is fixed.

This is the pre signing checklist. These five decide whether the job is real, what it costs to leave, and whether you can work anywhere afterward. A recruiter will pressure you for an answer this week. A group that will not give you two weeks to review a contract is telling you about the culture.

1. The post guarantee pay formula

The first year number is usually a guarantee with a shelf life: one to two years, then pay resets to a formula. What the formula is decides your income for every year after year one. That is the job you are actually taking.

Good looks like this: the contract states the formula, the unit conversion factor, and how often the factor is reviewed. Something like "compensation after the guarantee period equals total anesthesia units multiplied by $58 per unit, reviewed annually." Red flag: the guarantee is in the contract and the formula is "to be determined."

Ask what the formula paid someone in your shoes last year. An anesthesiologist a year or two past the guarantee, similar call, similar sites. What did it produce? A $450,000 guarantee that resets to a formula paying $380,000 is a pay cut disguised as an offer.

2. Clawback terms

Sign on bonuses come with promissory notes, and the note controls. You need four answers: the total amount, the forgiveness schedule, the start date of the forgiveness clock, and what cancels repayment.

Good looks like this: a $100,000 sign on with monthly forgiveness over 24 months, forgiveness starting at your clinical start date, and repayment cancelled if the group terminates you without cause or loses the hospital contract. A cliff, where nothing is forgiven until month 24, means leaving at month 23 costs you the full $100,000. Monthly forgiveness means leaving at month 12 costs you about $50,000.

Know which date the clock uses. And check whether you could repay the unforgiven balance without borrowing. If a $150,000 bonus would take a loan to repay at month 10, it is not a bonus. It is a loan with a job attached.

Red flag: the note accelerates the full amount on any departure, the group can terminate without cause and still collect, or the forgiveness start date is undefined.

3. Who pays the tail

Claims made malpractice coverage needs a tail when you leave. Occurrence coverage and many self insured systems do not. The question is simple: if you leave at month 16, who writes the check?

Good looks like this: the employer pays the tail after a defined period, or on termination without cause, or the contract specifies a split. Anesthesia tail coverage runs into the tens of thousands of dollars, so get the obligation assigned to someone in writing.

Red flag: the contract is silent, which means you pay. Silence on tail is not neutrality. The default is that the departing physician buys their own tail, and a $25,000 to $50,000 tail bill arriving the month you leave is a surprise.

4. Noncompete radius and length

You cannot take the OR with you. The noncompete is about where you can work afterward, not what. Map the restricted radius against who actually employs anesthesiologists inside it. In a metro where one system owns most of the hospitals, a 15 mile radius can be 80 percent of the jobs (illustrative).

Good looks like this: a defined radius in miles, a defined duration in months, measured from specific facilities, with carve outs for hospital employment or academic posts. Red flag: the radius is measured from "any facility where the group provides services," which means every site the group adds extends your restriction.

Negotiate the carve outs before you sign. "Physician may accept hospital employment within the restricted area" is a sentence that has saved careers. You will never have more bargaining power than the moment before you sign.

5. The call schedule in writing

The schedule is the job. Get the sites, the shift count, the call frequency, and the coverage ratio in the contract as an exhibit, not in an email and not from the recruiter. A verbal "call is light" is worth nothing. "One in eight in house call with a post call day off" is worth something.

Good looks like this: maximum sites per week, a cap on late rooms with extras paid at the call rate, and a stated direction ratio with rooms closing before the ratio breaks. Red flag: "sites as assigned," "call as needed," or any schedule term the group will not write down.

What to do when one is vague

Do not sign and hope. Send the five items back in writing with a deadline: "I need the post guarantee formula, the note terms, the tail assignment, the covenant map, and the schedule exhibit by Friday to stay on track." Vague answers to specific questions are answers.

If they fix four and stall on one, decide what the one is worth. A fuzzy call schedule is a negotiation. A missing pay formula is not a detail. It is the job. Walk on that one.

And if the recruiter says the deadline is this week, remember: a deadline is a tactic. The contract will govern years of your life. It can survive two weeks of review.