The salary number is fixed. What else can I negotiate in my first attending contract?

Almost everything that decides what the job actually pays. The base salary is one line in a hospitalist offer, and it is often the least flexible one, because hospital systems set it from a compensation band they defend for internal equity. The lines around it are where the money moves: the sign on bonus and its clawback schedule, the per shift rate for extra shifts, the night differential, who pays the tail, the length of the guarantee, the scope of the noncompete, and whether the offer carries student loan repayment. A fixed salary with the right lines around it can be worth tens of thousands more a year than the same salary with the wrong ones, and the lines are negotiable precisely because they cost the employer less visibility than moving the band.

Part of the internal medicine hub.

The money lines beside the salary

Start with the shift economics, because hospitalist pay is shift pay wearing a salary costume. The Today's Hospitalist compensation survey puts the average adult hospitalist shift rate at $142 an hour, and full time hospitalists work about 14 to 16 shifts a month. Every extra shift clause in your contract is priced off numbers like those. Negotiate the extra shift rate in writing, negotiate how extra shifts are assigned and whether they are voluntary, and negotiate the night differential as its own line: the same survey puts nocturnists at a mean of $360,372 a year against $339,438 for adult hospitalists overall, a gap of about $21,000 that exists because nights are priced, not volunteered. If your contract bundles nights into the base at no differential, you are donating that gap.

Then the sign on bonus. The number matters less than the schedule attached to it: how much is forgiven per month or per year, whether forgiveness is prorated or all or nothing, and whether the clock starts on the sign date or the start date. A $50,000 bonus forgiven evenly over two years costs you about $2,083 of freedom for every month you might leave early, because $50,000 divided by 24 is about $2,083. The same $50,000 forgiven in a lump at the second anniversary costs you the whole amount for the same early exit. Same headline, different contract. The signing bonus question in this bank works the bonus against base salary directly.

The protection lines

Three clauses decide what leaving costs, and all three are negotiable at signing and nearly immovable after. Who pays the tail on a claims made malpractice policy is the largest: if the employer pays it when you leave without cause, or after a set number of years, your exit is clean, and if you pay it, your exit carries a bill that arrives at the worst moment. The tail coverage question works that clause on its own. The noncompete is the second: its radius, its duration, and whether it is measured from the hospital where you actually work or from every facility the system owns. The third is the termination clause: how much notice either side owes, and whether the employer can end the contract without cause on 30 days while you owe 180.

Student loan repayment belongs on this list too, and new attendings rarely ask. Employers can pay up to $5,250 a year toward your loans free of tax under the Section 127 education assistance exclusion, and larger repayment amounts can be negotiated as ordinary income. Against a median education debt of $200,000 for the class of 2025, a repayment line that runs three years is real money pointed at the exact liability the waterfall tells you to plan around. The loan repayment question prices it against the signing bonus it usually replaces.

How to run the negotiation

Ask for the lines in a bundle, in writing, after the offer arrives and before you sign, when your leverage is at its lifetime peak. Employers expect it at this step and budget for it; the recruiters surprise is the candidate who signs the first draft. Rank your asks by what they are worth to you, not by what sounds reasonable in the room. A hospitalist on a seven on seven off schedule should usually rank the extra shift rate, the night differential, and the tail above a small bump in the guarantee, because those lines pay every year you stay, while a guarantee bump ends when the guarantee does. Get every agreed line into the contract itself, not the offer letter and not an email: the contract is the document that survives the recruiter.