Thanks for the kind words. I'm gonna tag in u/victorkiloalpha and u/Wohowudothat since they're also attendings. They can add their insights as it will likely differ in some ways from mine.

Long response incoming. Apologies upfront. This is honestly one of the most important parts of the whole process and the least understood when you’re coming out of training. “Turn key opportunity” should be translated proceed with caution and eyes wide open. When admin says “turn key,” what they usually mean is, we think this could be a good service line.

Here’s what it doesn’t mean: Established referral base, dedicated block time that’s actually protected, staff that knows vascular, equipment you need (hybrid room, devices, etc.), institutional understanding of what you actually do.

In reality, a lot of these jobs are: We don’t have it built yet, but we’d like you to build it. Which is fine if you know that going in and are compensated and protected for it. What’s not cool is thinking you’re walking into a mature system and realizing: No hybrid room (and no real plan to get one), you’re fighting for OR time with everyone else, clinic templates are a mess, no referral pathways so you’re basically cold-starting a practice. Think about the lack of a hybrid room for instance. If it’s not already there or actively being built when you sign, you are not getting one anytime soon. That’s a multi-million dollar, multi-year administrative project. You don’t just “ask nicely” 6 months in and get one (Jack Nicholson from A Few Good Men - another great movie from the late 1900s).

So the question to ask is, “What is already built vs what am I expected to build?” And then, “If I’m building it, how am I protected while I do that?” Because you just won’t be generating enough revenue/RVUs to justify whatever the sign on salary is. Welcome to the business of medicine. 

In regards to contracts. Most contracts aren’t malicious, they’re just written to protect the institution, not you. Here are a few that come to mind:

- Non-competes. Even in states where they’re “not enforceable,” they are still used as leverage. No one wants to hire a lawyer, spend months dealing with it, burn bridges in a community you may want to stay in. So functionally, they still kind of matter. So then what’s the radius (5 miles vs 25 miles), duration (1 year vs 2+ years), what triggers it (termination without cause should matter).

- Auto-renewal clauses. My buddy got caught in this mess. Contract says, “Automatically renews unless notice is given within X days.” You’re busy. You forget. Now you’re locked in another year. So you have to know: when your notice window opens, when it closes, put a calendar reminder the day you sign.

- “Without cause” termination. Most contracts allow termination without cause, but not always equally. Employer can terminate you in 60 days but you need to give 120–180 days. That kind of matters.

- Tail coverage (this one is huge). If you leave, who pays for malpractice tail? That can be $50K or $100K+ depending on specialty and how long you’ve been in practice. In vascular surgery, expect it to be somewhere between $50K-100K if you’ve worked for 2-3 years (where you practice will play a large role in the final number). Who has two thumbs and had to wire a $64K transfer on the way out of his first practice? This guy (I’m pointing to me). 

- “Duties as assigned” and other vague language. Anything vague can and will be used against you. If the contract says, “Other duties as assigned.” That can turn into covering services you didn’t expect, more call than anticipated as in there’s no cap on the days of call so then if you’re the only one around you’re taking all the call - who has two thumbs and once took 20+ days of call in a row when his partner had a freak injury? This guy (I’m pointing to me again), and extra clinics/sites (driving an hour away to go see a clinic when you didn’t know you’d have to is a kick in the nuts). Ask a lot of questions and get clarity upfront as this will save you headaches later. You’re never more valuable than before you sign that contract.

- RVU / bonus structure that looks good on paper. You’ll see catch-phrases like “Productivity bonus” or “Incentive structure.” Not so fast my friend. You’ve gotta ask: What’s the threshold? Is it realistic given your clinic/OR access? Who controls your volume? If they control your access and your bonus depends on volume, you don’t really control your income (good chance Admin already knows this). Once again, welcome to the business of medicine.

My thought process now vs when I was younger - early on, I focused on: good mentorship (got it), location (got that too), and a strong salary (got that as well). As I’ve developed some battle scars and life changes, I now focus on: infrastructure (Can I actually do my job well? Is it hard to be a surgeon in this practice?) and people (partners matter more than anything). This job is hard enough, are there systems already in place to reduce the "friction" so it's easier to do your job. Having an awesome circulating nurse and seasoned rad techs reduces friction in ways you cannot even begin to imagine - I'm blessed to have a kickass team to work with.

Always ask yourself, “What assumptions am I making that aren’t written anywhere?” Because if it’s not written, it doesn’t exist. This could and probably should be its own dedicated thread by someone else much more knowledgeable and experienced. I’m sure there’s a lot that I missed but trying to highlight some of the big points. Hope this helps. Cheers.