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.
Where exclusivity hides in an offer
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.
The case for the exclusive system, and its cost
A defined salary scale, a known partnership date, a pension and a published call schedule are worth a lot if you want predictability and one employer for a long time. If you are settled where the group is strong, exclusivity costs you little.
The cost lands if your plans change. Leave before the partnership date and you give up the step-up you were working toward. Leave before vesting and part of your retirement stays behind. If outside work needs approval, you lose the cheapest way to test a second path, whether that is telehealth, consulting or a part-time practice of your own.
The case for a job that allows outside work, and its cost
The appeal is optionality. Outside shifts raise income and build relationships with other employers in your city. For a resident who is location-locked, those relationships can be worth more than a modest salary gap.
The catch is that this freedom can be thinner than the recruiter makes it sound. Ask whether outside clinical income flows through the department, whether each activity needs sign-off, and whether outside hours affect your productivity targets. A private group may allow moonlighting yet carry a noncompete that blocks you from the very hospitals where you moonlight.
How state noncompete law changes the math
There is no federal backstop. The FTC voted in September 2025 to drop its appeals and accept vacatur of its nationwide noncompete ban, shifting to case-by-case enforcement. Days later it sent warning letters to health care employers and staffing firms about the length and reach of noncompetes for physicians and nurses.
States are moving faster. According to a Littler summary, Indiana bars noncompetes between physicians and hospitals or hospital systems for agreements signed on or after July 1, 2025. Montana bans post-employment physician noncompetes in contracts made or renewed after January 1, 2026. Texas, for agreements from September 1, 2025, limits physician noncompetes to one year and five miles, caps the buyout at a year’s salary, and voids them if you are terminated without good cause. Colorado and Oregon passed their own limits in 2025. If you are staying put, your state may matter more than the employer.
Five questions to answer for each offer
Write the answers down side by side:
- Can I do outside clinical work, and does it need written approval from someone who can say no?
- What are the noncompete radius, length and buyout, and does my state limit them?
- On what date do partnership, pension vesting and any retention bonus fully belong to me?
- What do I forfeit or repay if I leave at 18 months?
- If family keeps me in this city for ten years, which offer leaves me more than one possible employer?
Then ask each employer: “Before I sign, can you send me the outside-activities policy and the partnership or vesting schedule in writing? I want to understand my options at year two and year five.” How completely they answer tells you something.
This is general education, not legal or financial advice. A physician contract attorney can review both agreements in a few hours, and that fee is small next to a noncompete you can’t escape or a partnership you walk away from.
If you cannot move, the exclusive offer has to be good enough to be your only job for years, because in practice it will be. If you can move, the freedom to work elsewhere may be worth less than it feels like today. Decide which describes you, then price the offers that way.