PhysEmp Insights

You have two offers on the table. One is a Kaiser Permanente attending job with a published salary range and a path to partnership. The other is an academic position that pays less up front but lets you pick up outside shifts. Most residents compare salaries and miss the term that decides how much room you will have for five years: exclusivity. This post, part of our guide to surviving residency, is about pricing that term before you choose.

Residents on Reddit raised versions of this all week. A graduating radiology resident was weighing Kaiser against academics. Another asked which U.S. systems besides Kaiser and the VA expect physicians to work only for them. A third, whose spouse wants to stay in the area, was choosing between staying on as faculty, local groups with poor reputations, and remote work that new graduates are told to avoid. When you cannot move, exclusivity stops being a clause and becomes your whole job market.

It shows up in three places, often in different documents. The first is an outside-activities clause: whether you can moonlight, consult or read for a teleradiology company, and whether each needs written approval. The second is the noncompete, which governs life after you leave. The third is the benefits structure, which forbids nothing but makes leaving expensive: partnership tracks, pensions and vesting schedules that pay off only if you stay.

Large integrated groups lean on the third. A current Southern California Permanente Medical Group physician listing says physicians are eligible for partnership after three consecutive years of full-time employment, or six years part-time, and that partnership brings higher compensation, retirement and life insurance benefits plus voting rights. The Northern California group’s profile lists three retirement plans, including a pension and a 401(k), and requires board certification and at least 24 hours a week to become a shareholder. None of it restricts you on paper; all of it makes year two an expensive time to leave.

The VA works differently, because its physicians are federal employees under federal ethics rules. In 2023 the VA proposed supplemental standards that would require written approval at least 14 days before outside work for a “prohibited source,” such as a company that does business with the VA, or for a veteran-focused organization. Ask which rules are in force and how moonlighting requests are handled in practice.