Depends how you define tier 2 cities. If you're thinking metro of 1-2 million, then I define rural as at least 1 hour away.
From what I've seen most jobs out there at least offer some form of "productivity" with the exception of academia. (stay away from academia if you want to make more than an NP) Employers will be divided into private practice (usually single specialty), hospital based, or multi specialty group. The latter two usually like to pay physicians based on the wRVU model which is uniform across the country. The way they decide the pay per wRVU is dependent on the internal financials of their organization, i.e. what their payor mixes are and overhead. With these organizations, I would always recommend finding out the specific details regarding what you are getting paid for your work. Many of them will offer a guaranteed salary up front and a "productivity bonus" on top of it. What you need to ask them is where does the productivity bonus kick in in terms of wRVUs and after that, what is the pay per wRVU. From that point, you need to do some math. If they're expecting you to produce 6000 wRVUs before you make the bonus, and they're giving you a base of $250k, then you're looking at $41/wRVU for the first 6000, which is far below market value for rheumatology (average of 50-60 for rural). This is an example obviously but the point here is the concept. Always seek the high pay for productivity, which will help you out in the long run. The guaranteed salary is usually the organization wanting to pander to your fears of making little money coming out of fellowship, but after that, they are usually profiting off you. That's why the ideal situation is a place that is in dire need of a rheumatologist (or PCP), and you can hit the ground running. Ask them to estimate how many pts will be on your schedule starting from day 1.
The single specialty groups are harder to find, but that's basically a business run by your partners and you. You deal with the overhead. You deal with payers. You deal with your accounts receivable. You deal with regulatory red tape. Not that this is all bad, since it's the true private practice dudes that are making BANK if they run a tight business with lots of ancillary services.
