The Offer Was Good, the Internet Said Otherwise: When Bad Advice Costs More Than a Bad Contract

A colleague of mine spent the better part of 6 months recruiting a fellowship-trained Mohs surgeon. The colleague built the offer from scratch: tiered production-based compensation starting in the mid-40s percent range with escalators over 3 years, a first-year guarantee north of $850,000, a $100,000 sign-on bonus, 2 dedicated histotechnicians, a fully equipped onsite Mohs lab with 2 state-of-the-art cryostats, and a customized schedule built around the surgeon’s preference of 3 to 4 surgical days per week. What set the offer apart was the proof behind it: Six years of verified collected receipts from the existing surgical practice and a fully booked surgical schedule waiting on day 1. Not projections. Not forecasts. Six years of actual money that had come through the door on the same case mix the new hire would inherit.

The surgeon had a competing offer from an academic-affiliated practice in a different region. Bigger sign-on at $250,000. Hard guaranteed salary instead of production. A 401(k) match 2 percentage points higher, which, on an income north of $850,000, works out to about $7500 a year. No comparable production data. No fully booked surgical schedule waiting. No verified receipts to model against. Just a slightly lower guarantee and a brand. The value of the production at the small private practice, based on real Mohs receipts, was $1,390,000 per year. Their other offer was $875,000. Over 3 years of a contract, this is a delta of $1,545,000.

They took the other offer. Literally.

My colleague’s practice lost a surgeon they had spent 6 months recruiting. The surgeon lost a position that would have paid more, in a more competitive market, with the strongest evidentiary support any offer could provide, in a boutique, private practice setting. Both sides negotiated in good faith. Nobody was the villain, but the outcome was bad for everyone.

Here is the part I keep coming back to, and it is the part that makes this column necessary.

We wear white coats. The coat is not decoration. It signifies a tradition of allopathic, scientific, evidence- and data-based reasoning that each of us was trained in. We are taught to evaluate data on their merits, to distinguish signal from noise, to resist anecdote when the data point elsewhere, and to recognize when our own bias is shaping our interpretation. That training is the entire reason we are trusted to make decisions about other people’s bodies.

And then we make decisions about our own careers, and we abandon all of it.

We latch onto what a friend told us at dinner. Give weight to a forum post from someone we have never met in a market we have never worked in. Let an emotional preference for a guaranteed number override a higher production projection that the data actually support. We get upset when our patients trust Dr Google or Nurse Sally Neighbor more, yet 71% of us do not use an attorney to review a contract. If a patient showed us a treatment plan based on a Reddit thread and a conversation at a barbecue, we would chart the counseling that would likely ensue. When it is our own contract, we call it “doing our research.” That is confirmation bias stacked on top of the Dunning-Kruger effect: We seek out opinions that confirm what we already feel, and we do it without expert help because we assume our clinical training makes us qualified to evaluate a legal and financial document. It does not.

The Mohs surgeon did not lack training. They simply did not apply it to the question in front of them. That happens more frequently than the profession wants to admit. Much, much more frequently.

While recruiting a new physician associate (PA) for my own practice recently, I had the chance to sit down with Michelle Sullentrup, CEO of myDermRecruiter, and talk through the current supply/demand challenges facing dermatology employers and the providers they were seeking to hire. Sullentrup has placed hundreds of physicians and advanced practice providers (APPs) in dermatology positions across the country, and her vantage point on how offers are evaluated, misunderstood, accepted, and blown up is unlike anyone else’s I have encountered. We hit it off. We decided to collaborate on this column. Her perspective runs through what follows.

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Where the Bad Advice Comes From

Sullentrup sees this from the recruiting side and puts it plainly: “The number someone posts in a Facebook group is almost never the full picture. It might include a one-time sign-on bonus, a one-time relocation package, or a percentage of collections with a threshold that’s actually unrealistic to ever reach. By the time that number reaches the person reading it, it’s become a benchmark, a truth. And that unrealistic benchmark is costing people good opportunities.”

She is right. And there are layers to why.

People embellish. A colleague says they are making $380,000, and maybe they are. Or maybe that number includes a sign-on amortized over 2 years, a relocation package, and one exceptional production quarter that will never repeat. People round up when they talk about money. They leave out context. They report the peak, not the average. And the provider sitting across from a perfectly fair offer is now measuring their offer against a number that may not be real.

Forums reward confidence, not accuracy. The loudest voice in a professional forum is rarely the most informed, and based on my time as a major contributor on forums with the Society of Dermatology Physician Associates, they are increasingly anonymous responses. Instead, these responses are the most certain. Someone who collected 35% in a high-volume urban practice with a favorable payer mix and no supervision costs posts that number as if it applies everywhere, to all 5000 dermatology PAs in the US. It does not. One data point from one market with one set of variables is not a compensation study. It is a bias that reads like gospel because it was stated with authority by a peer colleague.

And then there is the part nobody wants to say out loud: Some of the people giving advice are projecting. They signed a contract they did not understand, got burned, and now every offer looks like the one that burned them. That is not market intelligence. That is trauma dressed up as mentorship.

When the Provider Is the Problem

The Mohs surgeon’s story is about a good provider making a bad decision with incomplete information. This next one is about something else entirely.

A PA I provided consulting services to was earning collections-based compensation between 33% and 35% receipts, well over $900,000 annually. By any national benchmark, that is exceptional for an APP. This income places the PA in the top 1% to 3% of all PAs in the country—every specialty, not just dermatology. The practice was well-run. The schedule was full. The support staff was competent. The relationship with the supervising physician was functional and professional.

Then the PA started reading forums. Started comparing notes with a friend from school who claimed to be making more at a different practice in a different state with a completely different payer mix. Looked at the grass on the other side of the fence and started to feel underpaid. Went to the employer and demanded a percentage increase that, when you added the physician supervision cost the practice was already absorbing, would have put the total provider cost above what a full physician dermatologist would cost the employer. The employer, bound by confidentiality in their physician supervision agreement, could not explain why the number did not work. The PA interpreted the pushback as greed and “refusing to give me what I earned.” The PA (against my advice) left for what looked like a better opportunity on paper.

Six months later, the production reality hit. Thinner patient panel. Worse payer mix. Scheduling that could not support the volume. Much worse administrative support. The take-home was lower. The PA asked me to contact their old employer, but it was too late; the position they had walked away from was filled.

The Questions That Actually Matter

“The harder questions are the ones nobody thinks to ask. How many MAs [medical assistants] will support me? How many rooms am I working out of? Is this volume target something a provider is already hitting at this practice, or is it a number someone put in a spreadsheet that has never been tested against reality?” Sullentrup said. “Those questions change everything about whether an offer is actually what it appears to be.”

She draws a distinction most providers miss: “There’s a meaningful difference between a practice saying ‘Our providers see 30 patients a day’ and a practice saying ‘We’d like our new provider to see 30 patients a day.’ One is a proven operational model. The other is an aspiration. Candidates deserve to know which one they’re walking into.”

The same logic applies to compensation. A collections percentage without underlying volume data is a math problem with no inputs. A guarantee with no production environment to support the ramp is a salary with an expiration date. A sign-on bonus with exit provisions that claw it back under conditions the provider did not carefully read and understand is not a bonus; it is a loan with bad terms.

And this is where the employer side deserves equal scrutiny. Practices that recruit with volume promises they cannot deliver are doing the same thing the forums are doing: substituting aspiration for data. “Ten Mohs cases a day.” “Fully loaded panel, 34 patients per day for the new PA.” Those numbers sound specific, which makes them feel credible. But if the volume does not exist, they are projections with no receipts behind them. The same applies to partnership tracks with no contractual commitment and production-based models built on spreadsheet math rather than verified collections. If the practice is selling you a number it has never actually produced, that is not a compensation offer. It is a recruiting pitch. Substituting aspiration for data. The provider who gets lured into a Mohs position with promises of high volume and shows up to find a half-empty surgical schedule and pressure to fill days with general dermatology has been sold a fiction. Not a negotiation failure. A bait-and-switch.

Although I have seen potential employees walk away from exceptional offers out of fear, I have seen just as many walk into horrid ones due to some intangible requirement for a job. They will not live anywhere but San Diego, the Bay Area, Dallas...wherever the lifestyle fantasy points them. Employers in those markets know it. The candidate pool is deep, the leverage is theirs, and the offer reflects it. The provider signs anyway because the zip code matters more than the math. That is not a negotiation. It is a self-imposed discount.

Information vs Emotion

Sullentrup identifies what I think is the core of this: “The hardest part of my job isn’t finding good opportunities. It’s watching someone make an emotional decision that isn’t in their best interest, dress it up as a financial one, and have no understanding of the implications.”

The Mohs surgeon took the worse offer because the guaranteed number felt safe. The PA left a top 2% position because a friend’s anecdote made them feel underpaid. In both cases, the data said one thing and the feeling said another, and the feeling won. That pattern is not unique to those two people. It is the default setting for how clinicians approach their own career economics, and it costs them more over a career than any single bad clause in a contract.

“Most candidates are confronting these questions completely alone,” Sullentrup said. “They have an offer, a forum, and a friend who thinks they know. What they don’t have is someone who can walk them through what that offer actually looks like on a Tuesday afternoon in that building.”

That someone does not have to be a recruiter. It can be a contract attorney who knows the specialty. A consultant who has seen enough offers to know which numbers are real and which are set decoration. A mentor who has sat on both sides of the table. What it should not be is a stranger on the internet who does not know your market, your payer mix, your state’s supervision laws, or the difference between a collections percentage on paper and one that is achievable in the building you are about to walk into.

No single vantage point tells the whole truth. Not a recruiter’s. Not a consultant’s. Not mine. Sullentrup and I talked openly about this, and it is one of the reasons I trust her data: She knows where her line of sight ends. Recruiters often hear the provider’s version of why a placement did not work out, which is not always the complete story. A provider who was difficult, unrealistic, or unable to deliver what they promised during hiring will tell a very different story than the practice experienced. But the same asymmetry runs in every direction. Employers shade the narrative when they lose a good hire. Consultants overweight patterns from their own caseload. Forum posters report the peak and bury the context. Everyone is working from partial information. The value is in triangulating and seeking someone with multiple points of view.

The offer was good. The internet said otherwise.

As someone who has reviewed, to date, almost 600 MD, PA, and nurse practitioner contracts, the internet is almost always wrong.

Joseph (Joe) Gatti, DMSc, MPAS, MBA, PA-C, is a board-certified dermatology physician associate, West Point graduate, and co-owner of a high-volume dermatology clinic and full-service medical spa. Through Azimuth Consultants, he advises clinicians nationwide on employment contracts, compensation strategy, and practice operations.

Disclosure: Gatti is the founder of Azimuth Consultants and maintains active ownership interests in a dermatology practice and medical spa.