How to negotiate it all: An employed position that allows entrepreneurship

When I finished training, I, like many new physicians, was faced with a familiar fork in the road: take an employed position versus work for yourself in an independent practice. This already challenging decision was further complicated by the fact that the landscape in which physicians practice medicine and generate revenue has dramatically changed. In order to navigate this and potentially have it all, an employed position that allows entrepreneurship, I had to strategically negotiate my contract. In this article, I will review the evolving practice of medicine, highlighting the benefits of having an employed contract that authorizes entrepreneurship and the steps to obtain this contract. 

For generations, physicians entered partnerships or built small-group practices, but the profession has shifted dramatically. According to a 2025 report, only 42% of physicians now work in private practice, down from 60% in 2012.¹ The remaining majority are employed by health care systems, hospitals, corporate groups, or private-equity-backed entities.

The appeal of the employed model is obvious: predictable income, minimal administrative burden, paid time off, and institutional support. For early-career physicians with loans, it can feel like the safest and most rational choice, especially if the employer will pay off educational loans. However, this stability often comes at the cost of autonomy, creativity, and long-term financial upside. While the startup journey carries risk, the data suggests the risk is worth it. By mid-career, private-practice physicians typically out-earn their employed peers; figure one suggests that single specialty group practice physicians earn about 8.5% more than employed hospital physicians.² Beyond finances, there is an intangible reward in building something aligned with and authentic to your vision.

As physician reimbursement continues to decline and regulatory pressures increase, more clinicians are exploring side ventures. In a 2025 survey, 38% of physicians reported that they already run or are seriously considering starting an entrepreneurial endeavor outside of their clinical work (Figure 2).³ I count myself among them.⁴

Interviewing for an employed position and pursuing my own venture required thoughtful boundaries. I wanted to honor my commitments as an employed physician while protecting my right to build something outside that ecosystem. That is where the negotiation process — and the lessons learned — became invaluable.

In medical school and residency, we learn how to diagnose and treat diseases, not how to read contracts or evaluate business risk. Few of us receive formal training in the legal, financial, or operational realities of employment. So when that first job offer lands in your inbox, thick with indemnity clauses, productivity bonuses, and intellectual-property provisions, it becomes easy to feel overwhelmed. The truth is your employment agreement is one of the most consequential documents of your career. It governs not just your pay, but your freedom to create, consult, and innovate. Given this, I put together some helpful tips to help you manage the contract negotiation process and best position yourself for success. 

Step 1: Know yourself before you negotiate

Before you even think about red-lines or legal clauses, take an honest inventory of your own temperament. Entrepreneurship and medicine require very different muscles.

Physicians are trained to eliminate uncertainty; entrepreneurs learn to live inside it. As Voltaire famously wrote, “the best is the enemy of the good.”⁶ If you wait until you have every answer, you will never take the leap.

Ask yourself:

• What is my risk tolerance?

• How much time and capital am I truly willing to invest?

• What does success look like if this venture never replaces my clinical or research income?

Your clarity on these questions will shape how firmly you negotiate  and whether you are willing to walk away. For me, protecting my ability to build my own venture was non-negotiable. That conviction made every contract conversation easier, because I knew where my line was drawn.

Step 2: Enter the negotiation strategically

Academic centers, health care companies, hospitals, and private equity firms negotiate contracts every day. You probably do not. That imbalance alone means you must approach the process strategically, and do not underestimate your ability to modify the contract; contract terms are often not fixed. The time of hire is your single strongest moment of leverage — you have not yet signed, and they have already invested resources into recruiting you. 

A few strategic tips:

Do not rely on verbal assurances. You are not negotiating with a person; you are negotiating with an institution. If it is not in writing, it does not exist. 

Understand their interests. Administrators care about compliance, revenue, and reputation. If your requests reduce perceived risk in those areas, the employer will be more willing to compromise. For example, if your side venture involves providing health care to patients, be prepared to cover your own medical malpractice for your business that is separate from the medical malpractice the employer provides.

Bring professional help. Hire an attorney experienced in physician employment contracts. The few hundred dollars spent could save you hundreds of thousands later. Remember, your attorney not only can read your contract and offer suggestions, but they also can talk directly with the future employer’s attorneys. While this can be expensive, this tactic works well in modifying contract language that the future employer is initially resistant to changing.

• Understand if there is a person that the future employer has hired with a similar ask, as you may be able to take that contract and modify it to meet your needs. This works well because starting with a template that has previously been approved is easier to push through the system with modifications than starting from scratch.

Step 3: Protect your entrepreneurial interests

If you are starting, or even considering, a side venture, these are the key areas to scrutinize.

1. Exclusive billing clauses. Many contracts include language granting the employer exclusive rights to bill for your medical services. That is fine if you only plan to work for them. But if your startup includes a clinical component that bills payers, this could block your ability to bill. Negotiate language clarifying that you may render and bill for medical services outside of your employed hours and outside of employer-owned facilities.

2. Non-compete and geographic limits. Non-competes are standard, but their scope is often negotiable. Most reasonable clauses limit practice within 10-15 miles for a period of 1-2 years after termination. Ensure the exact practice address is listed; otherwise, the restriction could apply to every satellite in the system. Push for explicit carve-outs if your venture is digital or operates in a distinct subspecialty (e.g., “the non-compete does not apply to telemedicine services under your brand”). Define what constitutes “competition” before it becomes a dispute. In my case, the final language restricted me from discussing my venture or purposely trying to take a patient I encountered in the employer’s health care system from the employer; however if one of the employer’s patients found my side business on their own, I could see the patient at my business without penalty.

3. Intellectual Property (IP) ownership. This is one of the most overlooked — and dangerous — sections for entrepreneurial physicians. Some contracts have a “work for hire” clause, which claims ownership of any intellectual property you create while employed, even if done on personal time and unrelated to clinical work. I once received a contract with this “work for hire” clause in it. Going back to Step One, knowing yourself before you negotiate, I quickly walked away from this contract when the potential employer stated the “work for hire” clause was non-negotiable, and could not be reworded or removed. Insist that any IP created outside of your listed work hours, independent of allocated employer resources (computer, etc.) is solely yours.

4. Outside business designation. If you already have an established business, it should be described in an addendum to your contract, including its name, nature of work, and assurance that the business will not interfere with your clinical duties. If your venture is still conceptual, consider forming a simple LLC or sole proprietorship for “medical content and consulting services.” This creates a legal entity you can reference and protects your personal assets. Your attorney can help structure this appropriately.

Step 4: Don’t be afraid to walk away

At one point, I turned down an offer that looked ideal on paper, but contained restrictive clauses that would have made my venture impossible. It was difficult at the moment, but it turned out to be the best decision I could have made. 

Negotiation is not confrontation; it’s clarification. If a future employer values you, they will find ways to accommodate reasonable boundaries. If they will not, that is useful data about the relationship you are stepping into.

Closing thoughts

If you are a resident, fellow, or early-career physician with entrepreneurial curiosity, start learning now about contracts, business structures, and intellectual property. You do not need to have the perfect idea yet. You just need to start protecting your optionality.

Push back when something does not feel right, ask questions, hire help, and remember - the best time to negotiate is before you sign. 

Medicine is changing, but so are we. The future of health care will belong to physicians who combine clinical expertise with creativity, adaptability, and ownership. Starting something new may feel risky, but so does letting someone else decide your ceiling.

References

1. Garvey G. Smaller share of doctors in private practice than ever before. AMA-Private Practices. 2025. Accessed Nov. 2025. https://www.ama-assn.org/practice-management/private-practices/smaller-share-doctors-private-practice-ever?

2. Doximity 2025 Physician Compensation Report. Doximity. 2025. Accessed Nov. 2025. https://www.doximity.com/reports/physician-compensation-report/2025

3. McKenna, J. 'I Get to Be Creative Again - That's the Juice. Medscape. 2025. Accessed Nov. 2025. https://www.medscape.com/slideshow/2025-docs-as-entreprenuers-6017932?icd=login_success_email_match_norm#2

4. Shen, N. Easy Belly. 2025. https://www.easybelly.com

5. Doximity 2023 Physician Compensation Report. Doximity. 2023. Accessed Nov. 2025. https://press.doximity.com/reports/doximity-physician-compensation-report-2023.pdf

6. Voltaire. Questions sur l'Encyclopédie, par des Amateurs. 1770. Vol. 2. P. 250. Geneva, Switzerland: (publisher not named).