The Negotiation Game

With Lisa Nijm, Founder and Medical Director, Warrenville EyeCare and LASIK, Assistant Clinical Professor of Ophthalmology at the University of Illinois Eye and Ear Infirmary in Chicago, CEO of Women in Ophthalmology, Warrenville, Illinois, USA

So, you aced your job interview and you are offered a contract. You start reading and realize the terms are less than perfect. Maybe it’s the salary, maybe it’s the number of sick days; either way, you are not completely sold. Still, you want the job – so what do you do? You negotiate. But this is where it gets tough. How do you know what to push back against and what to accept? When to compromise and when to walk away? Lisa Nijm has (most of) the answers. Maybe because she is a rarity in the world of ophthalmology, holding the dual title of doctor and lawyer. Nijm has lectured on contract negotiation at over 40 residency programs across the country, and held workshops at some of the largest meetings in the US. In 2020, after seeing colleagues struggle with the fallout of negotiated contracts, she created an online resource for physicians to help them learn how to become better negotiators: MDnegotiation.com.

“My goal is not just to teach you how to negotiate one contract, but how to negotiate altogether, so you can utilize those skills in any scenario; low stakes or high,” says Nijm. “Negotiation skills are life skills. They aren’t just for your first work contract; they are something that can be helpful throughout your career – and the rest of your life.”

I ask Nijm for her tips on a successful contract negotiation, ask how young ophthalmologists can leverage their skills, and find out when to negotiate and when to walk away.

Why did you decide to become a MD/JD?
My dad was an internal medicine doctor, so I observed firsthand how he cared for patients, and how much joy he received providing care for them. I went into undergrad pre med thinking that my passion was to take care of patients. But I began to realize that things were changing in medicine. Managed care came into the US and my dad suddenly had to advocate for his patients when insurance companies were giving them a hard time about getting an MRI or CAT scan. It was up to physicians to serve as a voice for patients to receive proper care. Between this and a speech class I took in my second year, I began thinking there may be something else that I wanted to do in addition to practicing medicine. After a lot of career searching, I came upon the MD/JD program – medicine and law. The joint program I undertook at Southern Illinois University School of Medicine and School of Law was a six year program designed to train physicians who believed a legal education would augment their primary career goals. That felt right to me. I wanted to take care of patients not just in the office, but outside, as their advocate and voice in a larger arena

How do you become a good negotiator?
The truth is nobody is born a great negotiator, but you can learn how to become one. I like to think of negotiation as a muscle – and, like all muscles, you need to work it to make it stronger. Whether you realize it or not, you are negotiating on a daily basis. With your patients, your staff, your kids. It seems strange that we spend so long training on the medical side of practice, but receive little to no education regarding the business and legal aspects of medicine. This deficit puts us at a major disadvantage when it comes to high stakes negotiation, such as employment contracts.

What makes a successful negotiation?

Negotiation is fundamentally about building relationships. Many people think of negotiation as contentious – for me to win, someone else has to lose – but, in reality, the best negotiations occur when you take the time to communicate and form a relationship. The first step of the process is understanding what the other party is looking for to come to an agreement. And as we grow our communication skills and learn how to be more attentive to the other party’s needs on a more routine basis, those skills will become more natural to us as we enter into higher stakes negotiation. No ophthalmologist would go into surgery operating on the toughest monster of a cataract without having done cataract surgery previously; you would practice before you went onto something harder. That’s exactly what I wish to teach physicians in regard to negotiation – learn these skills, practice, and build them so you are ready when it really counts. This is actually one of the reasons why younger ophthalmologists may have difficulties when starting out, because that job offer will often be their first high stakes negotiation. To be successful, you want to have sharpened those skills over the years in low stakes scenarios in order to have developed the knowledge and the confidence needed to succeed when it becomes serious. In my negotiation workshop, I teach ophthalmologists the logical thought structure and process that they need to utilize to define your goals and come together with another party to reach an agreement.

What’s the most common mistake people make when they enter these conversations?
Not going in prepared. By that I mean, not understanding how to position yourself in the negotiation. You need to be prepared with not only what your goals are, but with an understanding of what the other party’s goals are. You have to evaluate the negotiation from all sides.

The second mistake is not looking at the bigger picture. You’re not going to be able to get everything you want in a negotiation, so try to figure out how you can negotiate your wants as a package – rather than a single figure – that will make your offer more attractive to the other party. It’s easier to reach an agreement on a package than a point. 

Research has found that women are less likely to negotiate salary when applying for jobs. Do you think women tend to fare worse in contract negotiations?
The concept of women negotiators is really interesting. Research from the Harvard Business Review found 20 percent of women never negotiate and just accept whatever is on their contract. As a result, they end up earning anywhere from $650,000 to $1,000,000 less on average over the course of their career. Studies have come out as to why women don’t give themselves enough credit in negotiation. Some of it has to do with skills, some to do with the perception that women have of themselves, and some the external factors working against them. Because of this, women need to be especially cognizant of any factors that may affect the environment in which they’re negotiating, and figure out ways to work around those. This is so common that I teach a specialized workshop for women negotiators that focuses on identifying these factors, overcoming counterproductive actions and boosting emotional intelligence. 

What are your top tips for a successful negotiation?
Preparation is key. The majority of the negotiation occurs well before you even receive the final written contract; it starts at the interview. When you talk to a prospective employer, it is important to identify which areas they consider important to see if there is commonality with your own. How do you do that? By doing your research, coming prepared with the appropriate questions, and defining your goals; after all, if you don’t, someone else will define it for you. But these questions don’t mean anything if you don’t listen to the answers. Too often we get caught up in what we’re looking for and forget that, for an agreement to work, both sides have to have a vested interest in the outcome. Always be willing to hear the other side.

What should a prospective employee be looking out for?

Research has found that the top three areas young ophthalmologists regret not negotiating more is salary, vacation, and call schedule. I would highly suggest coming in with an idea of what the practice is like, what their expectations are of you, what they’ve looked for with past associates, what the typical call schedule is, and what the vacation package is like. On your part, go in with an understanding of your desired salary range and what is typically being offered in this area for some of these other benefits as well, because there are many things in a contract that can make or break how happy you are day-to-day.

Are there any benefits that make up for potential loss in salary?
Yes, but the extent to which you are comfortable with that depends on your personal goals. To give an example, a colleague of mine once signed a contract that gave her zero sick leave. That meant anytime she was ill, she had to make up those hours by taking a vacation day or working a 70-hour week, which was a huge stress on her. I can understand how this happens. After so many years of schooling and so much debt, we often feel so lucky to have a well-paying job that we focus less on the other factors that come into play. And that’s not to say you should downplay salary – it is certainly important – but, when you are in practice, other factors can make a big difference as to whether you are satisfied or not. It comes down to feeling that you are being paid what you are worth. You can find data on average salaries from recruiters, residency programs, or online sites like doximity.com. You can also ask alumni to get an average range, taking into account location and subspecialty; that way you can get an idea if they are making a fair offer. Not every practice is trying to lowball you. So, if they are making you a fair offer, how much more would you expect a candidate to negotiate if you were on the other side of the table?

When do you compromise and when do you walk away?
Good question. That comes down to your BATNA – your Best Alternative To a Negotiated Agreement. The stronger your BATNA, the greater your ability to walk away from a negotiation. Again, you have to determine for yourself what you are willing to compromise on. Having other offers will give you more confidence to adjust your negotiation plan.

Pay discussions are often framed as inherently difficult. Do you have any tips on making it feel more positive for both parties?
First of all, get used to the idea that discussions on salary are expected, so shake off the negative associations you may have around money conversation. This is business and negotiations are an appropriate and expected part of that. The other thing is to remember that it is a team discussion. Bringing on new associates is expensive for practices, so they want you to want to be there – and if it is the right practice for you, let them know.  wWhen discussing salary, preface it by saying what you can bring to the practice, and how you can help it grow. Think of it as taking a more communal strategy than an individual one, with the understanding that if all this works well, you are going to be on the other side of the table at some point interviewing some new associate in the exact same position. It helps to make it a positive experience for everyone involved.

Any tips for overcoming negotiation anxiety?
The first step is recognizing your value. You would not be in this position unless you had something the other party is looking for, so don’t underestimate yourself. The second thing is practice. I say this a lot, but the more you implement your negotiation skills, the more confident you will become – to the point your nervousness will go away. You have the tools that you need to be a great negotiator, and you will be with proper education and practice.

What can a newly qualified ophthalmologist bring to a practice?
A lot – so leverage your skills! Most young ophthalmologists have the advantage of having trained with cutting-edge devices, which is a huge benefit to practices that have not adopted these new technologies yet. The other thing you have to offer is you – and that’s where personality can play a big part. Are you a “somebody” who is going to work hard, stay late to see patients, and be happy to come in on the weekends? For the first six months to a year when you start with a new practice, you are under a microscope. If you really want to put your best foot forward, you need to show the practice that you are going to do your best to help build your practice and in turn, help the overall practice survive, thrive, and grow.

What areas of the contract should young ophthalmologists focus on?
The role, the salary, the benefits, and the exit strategy. In any contract, you should have a good understanding of what the expectations are going to be for what you’re getting in return. Part of that is knowing what will happen if things don’t work out. Your first job might not be your last, so it’s worth looking into things like restrictive covenants and tail coverage for malpractice insurance. Likewise, if the job does go the way you planned and you want to become a partner, you will also need to have an idea of what the transition from being an associate would be like (typically two separate agreements in the US). Many residents tend to go back to their hometown, and bring their family. The kids move to a new school, everybody starts to get settled, and then something doesn’t work out with the practice. If that’s the case, is the contract written in a way that you are able to stay there or do you have to move? If you’ve done your due diligence, it may not work out that way – hopefully you end up on the partnership track – but, if not, you have to be aware of what could happen. It pays to think long-term.

Outside of financial gain, what are the advantages of being a better advocate for yourself and for others?

When somebody is a good negotiator, you end up with not only financial success, but with success in informing the long-lasting relationships that will help you along in your career. When parties are able to come together in an agreement – and base that agreement in a relationship of trust and understanding and confidence, you can work together to achieve mutual goals. And that goes a long way. You’ll not only achieve financial success, but you’ll be able to achieve happiness in your practice in understanding how to work with patients to get them to comply with care, so that they have better outcomes. It also makes it easier to keep your employees satisfied so that you are working together as a team to provide the best care for your patients. Becoming a better communicator and working out how to negotiate in a way that brings parties together – not apart – is equally beneficial in your personal life.

If you could give one piece of advice, what would it be?
Remember, negotiation is a muscle; you build it with practice. Take action and ownership of that skill. Invest the time in learning and practicing in an environment that’s comfortable, so that you feel confident in your skills by the time you get to a high-stakes scenario.

What's next for MDnegotiation?
I’ll be hitting the road, giving workshops at university programs across the country over the next few months. Then, in September, I’m going to be an entirely virtual program for young ophthalmologists that expands beyond negotiations. Very exciting. I’ve been working with young ophthalmologists for years and I realized the same question keeps coming up: how do I successfully transition from being in training to being in practice? In other words, how do I successfully transition to the real world? So that’s what it will be called, “Real World Ophthalmology: The Top 10 Things I Wish I Knew Sooner.” It will include all the things myself and my colleagues wish we had known sooner – from choosing fellowships to finding the right job to distinguishing yourself as a new ophthalmologist to utilizing new technologies plus the realities of building a successful practice while avoiding burnout. I’m also bringing in experts from around the country to share their tips too. It will be the first virtual meeting entirely dedicated to young ophthalmologists with opportunities for networking and asking all the questions you need to know when starting practice.  The Real World Ophthalmology meeting will be complimentary for all young ophthalmologists in training and within their first several years of practice. Check out .realworldophthalmology.com to learn more and register. 

I’ve been lucky enough to have a lot of incredible mentors who helped me along the way. Now it is my turn to make that transition easier for others.