William N. Levine, MD, FAAOS
September 28, 2026
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One of the most important decisions you will make as a young orthopedic surgeon is also one of the decisions for which your training has probably prepared you the least: evaluating your first job offer.
After medical school, residency, and fellowship, we know how to evaluate patients and make increasingly complex surgical decisions. Then someone hands us an employment agreement containing a guaranteed salary, wRVU targets, call expectations, malpractice coverage, and 30 pages of contractual language, and somehow we are supposed to know whether it represents a good job.
Here is what I wish someone had told me when I finished training: do not evaluate a job by the salary alone.
A guaranteed salary of $700,000 may be a much worse opportunity than one paying $550,000. The real questions are what you have to do to earn that salary, what happens when the guarantee ends, and whether the institution is actually giving you the resources to build a successful practice.
1Understand How You Will Be Paid
If your compensation is based on work relative value units (wRVUs), understand the formula. What is your annual target? What is the conversion factor? When does incentive compensation begin? What happens if you fall below the target? How many dollars per wRVU does the practice pay (this number varies widely and is critical to understand).
More importantly, ask for real numbers. How many wRVUs did surgeons in your sub-specialty generate last year? What did recently recruited surgeons generate during their first few years? A compensation plan can look terrific on a spreadsheet and be almost meaningless if you cannot get patients into your office or obtain sufficient OR access.
Understand how credit is attributed. Ask how APP visits are handled and whether documentation requirements can affect your compensation. If collections rather than wRVUs are part of the formula, understand exactly how collections are calculated.
Have someone walk you through your proposed compensation using several realistic examples. If you do not understand how you will be paid, keep asking until you do.
2Call Is Part of the Job
Call expectations should be explicit. How often will you take call? Which hospitals are you covering? Is trauma included? Is call separately compensated, and if so, how?
Do not simply ask about the current call schedule. Ask what happens if someone leaves. Going from one-in-six to one-in-four call changes your life considerably.
For surgeons, there is another question that is often overlooked: what happens the next day? If you are operating most of the night, are you still expected to run a full elective OR or clinic the following morning? That may ultimately matter more than the call stipend.
3Understand Your Insurance
Malpractice coverage deserves particular attention. Determine whether your policy is occurrence-based or claims-made. With a claims-made policy, you may need “tail” coverage when you leave the practice. Tail coverage for an orthopedic surgeon can be expensive, so the contract should clearly identify who is responsible for paying for it and under what circumstances.
Review your health and disability insurance as well. Disability coverage is particularly important for surgeons. Your ability to earn a living depends upon your ability to perform surgery, and the definition of disability in the policy matters.
4Read the Parts Everyone Wants to Skip
Young surgeons understandably focus on compensation, but some of the most consequential provisions appear much later in the contract.
What happens if either side wants to terminate the agreement without cause? How much notice is required? Is there a restrictive covenant, and is it enforceable where you will practice? If you receive a signing or relocation bonus, do you have to repay it if you leave early? What happens to incentive compensation you have already earned but that has not yet been paid?
This is where having an attorney who regularly reviews physician employment agreements is money well spent.
5Evaluate the Job, Not Just the Offer
Some of the most important determinants of your success may never appear in the contract.
How much OR access will you have? Where will referrals come from? Is the office equipped and staffed to support the practice you are being recruited to build? If someone recently left the position, find out why.
I strongly encourage candidates to speak privately with young surgeons who joined the practice in the last few years. Ask them a simple question: Is the job you have today the job you thought you were accepting?
Finally, your first contract is not a referendum on your value as an orthopedic surgeon. You do not win because your starting salary is higher than your co-fellow’s. The better job is the one that gives you a realistic opportunity to build the career you want, surrounded by people you trust and respect.
You spent more than a decade preparing to become an orthopedic surgeon. Take the time to understand the job you are accepting before you sign your name.
DISCLOSURES: Dr. Levine is on the Columbia faculty. Dr. Levine serves as a paid consultant and surgeon designer for Zimmer Biomet. International Board of Shoulder and Elbow Surgery – Treasurer : Type: Board of Directors or committee member: Self
Read the AAOS Code of Conduct for Discussion Group Terms, Conditions and Disclaimers HERE.
Nothing in the post should be considered, or used as a substitute for, legal, financial, tax, accounting, investment, mental health, or other professional advice.
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