A Medical Student’s First Contract: the GME Residency Agreement

By: Dhruvil Patel, MD

Published: Feb 8, 2023

📂 Physician Perspectives

Written for:

✅ Medical Students

✅ Residents and Fellows

✅ Early Career Physicians

Understanding contracts is not at the top of the medical school curriculum. However, as medical students become residents, who then become practicing physicians, the benefits, rules and stipulations in contracts they sign increasingly influence careers. For most graduating medical students like myself who are going onto residency training, we will soon be expected to sign our first contract - colloquially known as the General Medical Education (GME) Residency Agreement. As I started to review my contracts to make my decisions about where I want to train for residency, I began to find invaluable information.

I’m finding that these contracts explain points that would not only affect my daily experience but also inform long-term decisions.  Sure – there are the standard and fairly obvious inclusions about job responsibilities and professional and ethical expectations, but there is also valuable information about protections, support, and benefits offered to me, and in some cases even to my family.

Although some of these things may not make or break your rank list – here are some things I have found while reviewing these contracts that I believe will be of interest to other medical students:

1/ Contracts Can Save You Money!

Resident salaries are nothing to envy. In response to this, some programs have included financial support clauses that may include a living allowance and relocation pay which is subject to the change from negotiations. Selecting for such features when deciding between programs that are already high on the rank list may be important for some, and for others who may not see it in their contracts, could be important to ask programs about before finalizing rank choices.

Other programs that I interviewed at had some surprising features that were not mentioned during  the interview presentation. For example; there were some agreements that offered incentives to pursue advanced degrees during residency training whereby essentially a discount or stipend was provided. In some cases, these same benefits also extended to the resident’s spouse and their children.

With the average age of incoming residents  in the United States being in their  late 20’s or early 30’s, incentives like these can help reduce financial stress as we all face many expenses on the road to becoming practicing physicians  

2/ You Cover Your Patients - Programs Will Cover You

Specifics on the coverage for health insurance, dental insurance, disability insurance and life insurance are readily found within residency agreements. You should read carefully whether your program pays for all coverage, or whether you will be responsible for a portion, or whether one specific type of coverage is excluded completely.. Knowing these differences are important to manage and budget your expected costs of living, as well as protecting your future income.

Support for both physical and mental health coverage was also stated in some agreements I reviewed. This includes coverage for mental health services without any burden of cost to the resident . Such features can immensely help a resident feel at peace that they are about to join a supportive environment. Ultimately I belive that happier and healthier residents likely contribute to a better patient care experience and in turn also help the program and institution with recruitment and retention efforts.

3/ Burning the Midnight Oil: Moonlighting

Moonlighting - which is working extra shifts at outside institutions other than your own during residency - was also an extremely commonly addressed component of these agreements. Unsurprisingly, a unifying expectation was that a resident must first obtain approval from their program director, with many contracts stating that moonlighting hours must be reported to the program themselves. Total hours worked as resident and during these moonlighting shifts combined must not exceed the Accreditation Council for Graduate Medical Education (ACGME) required 80-hour work limit, or otherwise moonlighting activities will not be sanctioned. 

The option to moonlight may be extremely important to residents with dependents or other financial pressures; so it is important to know if your program explicitly prohibits moonlighting. 

An important point to note is that malpractice insurance that is provided by the residents training institutions would not cover issues that occur during moonlighting at an outside institution. This is a very common statement layered into all residency agreements that I have come across and must be considered among those thinking about moonlighting as they plan their financial strategy during residency. It is important to make sure you have confirmed the medical malpractice and tail coverage will be paid by the institution where you are picking up moonlighting shifts.

4/ References to Other Resources

Often found within these residency agreements are common references to the program handbook, institutions general medical education (GME) guides, and the policies and procedures document that expand on benefits, protections, reasonability, and coverage. Reviewing these, while tedious, can also provide pearls that may influence your rank order list.

For those on their way to making their rank lists, knowing your residency training agreement will help you discover your  responsibilities, protections, benefits, and restrictions - so that there are no surprises when you commit yourself to the next years of training. If you're not able to find a sample recent agreement online, I encourage you to contact program directors from institutions if you have specific questions.

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