Your Essential Guide to Starting a Private Practice in Cardiothoracic Surgery

Understanding the Landscape: Is Private Practice in Cardiothoracic Surgery Still Viable?

Cardiothoracic surgery is one of the most resource‑intensive and regulated specialties in medicine. Because of that, many residents and fellows wonder whether starting a private practice in cardiothoracic surgery is even realistic in the current era of hospital employment, integrated health systems, and large multispecialty groups.

The short answer: it can be viable, but it’s not for everyone—and it looks very different from the solo private practices of previous generations.

Current Models in Cardiothoracic Surgery Practice

When thinking about heart surgery training and your career path, it helps to understand the main practice models you’ll see:

1. Hospital Employment

   • You’re a salaried employee of a hospital or health system.
   • System handles billing, marketing, infrastructure.
   • Often includes productivity bonuses, quality incentives, and call expectations.
   • Most common model for early‑career cardiothoracic surgeons today.

2. Academic Employment

   • Employed by a university or academic medical center.
   • Focus on complex cases, teaching, and research.
   • Promotion and salary often tied to academic productivity and institutional needs.

3. Private Group Practice

   • Independent cardiothoracic group contracting with hospitals.
   • May cover several facilities; revenue comes from professional fees and call coverage contracts.
   • Internal partnership track and profit sharing.

4. Solo or Small-Group Private Practice

   • You own the practice (alone or with a few partners).
   • Full control over staffing, operations, and business decisions.
   • Highest potential autonomy, but also highest financial and operational risk.

Most “pure” solo practices in cardiothoracic surgery have disappeared, but small independent groups are still common, especially in community and regional centers. The growing prevalence of value‑based care and hospital consolidation means that private practice vs employment is a strategic decision that impacts lifestyle, income stability, autonomy, and burnout risk.

When Private Practice Makes Sense

Cardiothoracic surgeons may find independent practice attractive if they:

• Want strong control over their schedule, staff, and clinical pathways.
• Are entrepreneurial and willing to manage business risk.
• Prefer community practice over heavily academic or bureaucratic settings.
• Practice in a market with:
  • Sufficient population density and cardiac disease burden.
  • Limited competition from large hospital-employed CT groups.
  • Hospitals seeking coverage and willing to negotiate favorable contracts.

If you’re in residency or fellowship now, you don’t need to finalize this decision immediately. But you do need to plan early—your training choices, networking, and case mix can position you better for independent practice later.

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Foundation During Training: Preparing for Future Private Practice

The seeds of a successful private practice are planted during residency and fellowship. While your primary focus is becoming an excellent surgeon, you can deliberately build the skills and profile that make private practice feasible.

Clinical Skills: Breadth, Reliability, and Efficiency

In private cardiothoracic surgery practice, you’re not just a subspecialist; you’re often the primary local expert for a broad variety of thoracic and cardiac pathology. Consider:

• Bread-and-butter cardiac cases

  • CABG, valve repair/replacement, aortic surgery.
  • Associate closely with pump time, complication rates, and length of stay—key performance metrics used later in hospital negotiations.

• Thoracic surgery

  • Lung resections (VATS/robotic), mediastinal masses, pleural disease.
  • If you can offer both cardiac and general thoracic services, you’re more valuable to smaller hospitals.

• Endovascular and structural heart exposure

  • TAVR, TEVAR, EVAR, MitraClip, structural heart teams.
  • Even if you won’t perform them yourself in private practice, understanding these programs helps you integrate into heart teams and negotiate hybrid roles.

• Emergency and call coverage

  • Type A dissections, trauma thoracotomies, post‑MI mechanical complications.
  • Comfort with high‑acuity cases is essential; hospitals judge coverage contracts on your ability to handle emergencies 24/7.

During training, ask explicitly for:

• Rotations that include community practice exposure.
• Case logs that demonstrate volume and diversity.
• Involvement in ER call coverage and night cases.

Nonclinical Skills: Business Literacy and Leadership

Private practice requires skills that are rarely part of formal heart surgery training:

• Basic knowledge of:
  • Billing and coding (CPT, ICD‑10, documentation for complex cardiac procedures).
  • RVUs and payer mix (Medicare, Medicaid, commercial, self‑pay).
  • Contracts and negotiations (employment, call coverage, medical directorships).
  • Quality metrics (STS data, mortality and readmission rates, length of stay).

Ways to build this base during residency/fellowship:

• Take elective courses in healthcare management or an MBA/MPH component if your institution offers it.
• Attend hospital committees (OR utilization, quality improvement, heart team conferences) not just as an observer but as a learner in operations.
• Seek a mentor in private practice (CT or another specialty) who can explain their business model.
• Read targeted resources on:
  • Physician compensation models.
  • Private practice management.
  • Healthcare finance and value-based care.

Networking with Future Referral Sources

No private practice survives without referrals. During training:

• Build relationships with:
  • Cardiologists (interventional and non‑invasive).
  • Cardiac intensivists and anesthesiologists.
  • Pulmonologists, oncologists, and primary care physicians.
• Join local and national societies:
  • STS, AATS, state cardiothoracic and cardiac societies.
  • Hospital medical staff committees where you rotate.

Even as a trainee, your reputation for:

• Work ethic
• Operative skill
• Collegiality
• Communication with teams and families

will follow you. Many private practice positions and later partnerships evolve from word‑of‑mouth recommendations by colleagues you met in training.

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Strategic Planning: Location, Market Analysis, and Practice Model

Moving from the idea of starting a private practice to a viable plan begins with strategy, not paperwork.

Step 1: Clarify Your Desired Scope of Practice

Ask yourself:

• Do you want to practice primarily:
  • Adult cardiac?
  • Adult thoracic?
  • A mix of both?
  • Include structural heart or endovascular?
• Are you comfortable being on call very frequently in early years?
• What complexity of cases do you want to handle in your primary hospital setting vs refer to tertiary centers?

Your clinical scope informs:

• Required hospital capabilities (ICU level, perfusion support, level of cath lab, structural heart program).
• The minimum case volume you need to maintain competence and board eligibility.
• The equipment and staffing you must negotiate with hospitals.

Step 2: Choose a Region and Analyze the Market

Key factors in site selection:

1. Population and disease burden

   • Look for areas with older demographics and high cardiovascular disease prevalence.
   • Review publicly available data (state health department, CMS, hospital utilization reports).

2. Existing competition

   • Number of existing cardiothoracic surgeons and groups.
   • Are they hospital-employed or independent?
   • Are any nearing retirement? Is there unmet call coverage?

3. Hospital needs and strategic plans

   • Are local hospitals trying to build a heart program or preserve one?
   • Are they losing cardiac patients to tertiary centers in bigger cities?
   • Do they currently outsource CT call coverage?

You can gather this information by:

• Talking to cardiologists in the region.
• Requesting informational meetings with hospital CEOs, CMOs, and service line directors.
• Reviewing hospital quality reports and community needs assessments.

Step 3: Decide on Your Practice Structure

“Opening medical practice” in cardiothoracic surgery can mean several different structures:

1. Solo Practice with Hospital Support

   • You form a professional corporation (PC/PLC) and contract directly with one or more hospitals.
   • Hospitals may provide:
     • Call stipends.
     • Income guarantees for 1–2 years.
     • Office space and staff support.
   • Highest degree of control, but also financially riskiest.

2. Small Group Practice (Independent)

   • Join or form a two- to five-surgeon group.
   • Shared call, pooled revenue, and often established referral streams.
   • Partnership track for new surgeons after 2–5 years, based on performance and fit.

3. Private Practice Hybrid (Group + Hospital Employment Mix)

   • Employed by hospital, but your group maintains some independence (e.g., separate billing entity, co‑management agreements).
   • Requires strong legal and contractual clarity.

4. Multispecialty Group with CT Division

   • You join a large independent multispecialty group that provides infrastructure:
     • Billing, HR, marketing, IT, compliance.
   • You may have less autonomy over business decisions but avoid much of the administrative burden.

When weighing private practice vs employment:

• Consider risk tolerance, family priorities, loan burden, and your appetite for nonclinical work.
• Many cardiothoracic surgeons start in hospital employment and later transition to more independent models once they understand local dynamics and build reputation.

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Building the Practice: Legal, Financial, and Operational Steps

Once you’ve chosen a location and basic structure, you move into the implementation phase of starting private practice. This section outlines the major steps and timelines.

Step 1: Legal Entity and Licensing

Work with a healthcare attorney and accountant to:

• Choose an entity type:
  • Professional Corporation (PC), PLLC, or equivalent depending on state law.
  • Consider a separate management entity for staff and overhead, if appropriate.
• Obtain:
  • State medical license.
  • DEA registration.
  • NPI (National Provider Identifier).
  • State and local business registrations.
• Draft key documents:
  • Bylaws or operating agreement.
  • Partnership agreements (if in a group).
  • Buy‑in and buy‑out formulas (for future partners).
  • Call coverage and service contracts with hospitals.

Step 2: Malpractice Insurance and Risk Management

Cardiothoracic surgery carries high liability risk; your malpractice decisions can make or break your practice financially.

• Select:
  • Coverage type: claims‑made vs occurrence.
  • Adequate limits for your state and typical CT risk environment.
• Understand:
  • Tail coverage obligations if you change insurers or leave a group.
  • Premium subsidies or support hospitals may offer as part of recruitment.
• Implement:
  • Standardized operative checklists.
  • Robust informed consent processes.
  • Consistent documentation templates for high‑risk cases.

Step 3: Contracts with Hospitals and Payers

You’ll need contracts with both hospitals and insurance plans.

Key hospital agreements may include:

• Medical staff privileges:
  • Delineation of privileges appropriate to your training and experience.
  • OR block time arrangements.
• Call coverage contracts:
  • Stipends for being on call (especially nights/weekends).
  • Definitions of response times and availability.
• Service line or medical directorship:
  • Compensation for administrative duties like program development, quality improvement, and outreach.

Payer contracting:

• Credential with Medicare and Medicaid.
• Contract with major commercial payers.
• Understand:
  • Fee schedules for common CT procedures.
  • Preauthorization and documentation requirements.
  • Out‑of‑network policies and their impact on patient collections.

Step 4: Financing and Start‑Up Budget

Opening medical practice in cardiothoracic surgery can involve substantial start‑up costs, even if you rely on hospital facilities for OR and ICU.

Typical expenses:

• Legal and consulting fees.
• Malpractice premiums (often a large up‑front cost).
• Office lease or buildout (even if small).
• Office staff salaries (admin, billing, maybe a PA/NP in clinic).
• IT infrastructure:
  • EMR (or interface with hospital EMR).
  • Scheduling and billing systems.
  • Secure communications and telehealth options.

Construct a 12–24 month pro forma:

• Estimate:
  • Monthly operating expenses.
  • Expected procedural volume.
  • Payer mix and collections timeline.
• Plan for a conservative ramp‑up in case volume; CT surgery referrals take time to build.
• Consider:
  • Bank lines of credit.
  • Hospital income guarantees (forgivable loans based on years of service).
  • Personal financial cushion for the first 6–12 months.

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Running the Practice: Clinical Operations, Referrals, and Growth

Once your doors open, success in cardiothoracic surgery private practice depends on a balance of excellent outcomes, efficient operations, and relationship management.

Clinical Workflow and Team Design

Elements to structure:

• Clinic operations

  • New consult slots reserved for time‑sensitive referrals.
  • Efficient pre‑op evaluation: imaging, cath data, labs, anesthesia clearance.
  • Clear patient education materials for procedures and recovery.

• OR and inpatient coordination

  • Close collaboration with:
    • OR scheduling staff.
    • Cardiac anesthesia.
    • Perfusion team.
    • ICU staff and hospitalists.
  • Protocols for:
    • ER-to-OR triage of emergencies (e.g., dissection).
    • Post‑op pathways (fast-track extubation, early mobilization).

• Allied health professionals

  • Advanced practice providers (NPs/PAs) in clinic and inpatient care can:
    • Improve throughput.
    • Enhance continuity.
    • Free you for OR and complex decision making.

Building and Maintaining Referrals

Your practice lives or dies by referrals from cardiologists and other physicians.

Strategies to build strong referral networks:

• Direct outreach

  • Meet with cardiology groups and hospitalists shortly after arriving.
  • Offer your cell number for urgent consults.
  • Be highly responsive in the first year; word spreads quickly.

• Communication quality

  • Provide clear and timely consult notes.
  • Call referring physicians with operative plans and updates.
  • Send post‑op summaries and long‑term follow‑up notes.

• Program development

  • Help develop or strengthen:
    • Heart team conferences.
    • Multidisciplinary thoracic tumor boards.
    • Structural heart programs.
  • These become natural referral hubs.

Market your value:

• Emphasize quality outcomes and availability, not just technical skills.
• Promote:
  • Short lengths of stay.
  • Low complication rates.
  • Patient satisfaction.

Be cautious with direct‑to‑consumer marketing; in cardiothoracic surgery, physician referrals and hospital reputation are far more influential than billboards.

Quality, Data, and Continuous Improvement

Participation in data registries, especially the STS (Society of Thoracic Surgeons) database, is critical:

• Track:
  • Operative mortality and morbidity.
  • Readmission and reintervention rates.
  • Compliance with evidence‑based bundles (e.g., beta‑blocker, statin use).
• Use data to:
  • Negotiate better contracts.
  • Demonstrate value to hospitals and payers.
  • Identify opportunities for improvement and growth.

Integrate quality into the culture:

• Regular M&M conferences with cardiology and anesthesia.
• Post‑case debriefs and OR process improvement initiatives.
• Transparent communication about complications and outcomes.

Lifestyle, Burnout, and Long-Term Sustainability

Heart surgery training prepares you for intensity, but private practice adds the weight of business responsibility.

To protect longevity:

• Structure call schedules realistically (perhaps shared across multiple hospitals or groups).
• Delegate administrative tasks to:
  • Practice managers.
  • Billing specialists.
  • Legal and financial advisors.
• Set boundaries:
  • Patient access doesn’t have to mean 24/7 personal availability.
  • Build systems (triage nurses, APPs, on‑call rotations) that support your life outside the hospital.

Many surgeons adjust their practices over time:

• Shifting case mix (more thoracic, fewer emergencies).
• Developing niche expertise that commands referral volume without constant crisis management.
• Moving toward leadership roles in service lines or hospital administration.

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Transitioning from Training to Private Practice: A Practical Roadmap

For a cardiothoracic surgery fellow considering starting a private practice within a few years, a staged roadmap is useful.

During Final Years of Training

• Clarify your clinical scope and preferences.
• Seek mentorship from:
  • At least one private practice CT surgeon.
  • A hospital administrator familiar with cardiac programs.
• Join STS and AATS committees or working groups if possible.
• Begin informal geographic preference discussions with your family.

12–24 Months Before Practice Launch

• Start exploring regions and hospitals:
  • Use job boards, but rely heavily on direct networking.
• Ask targeted questions in interviews:
  • “What is your current CT surgical volume and how is it trending?”
  • “What are your unmet needs in call coverage and referrals?”
  • “Are you open to independent or group-based models rather than pure employment?”
• Engage a healthcare attorney for initial contract reviews and advice on entity formation.

6–12 Months Before Launch

• Finalize:
  • Hospital affiliations and medical staff credentialing.
  • Basic business plan and pro forma.
• Apply for:
  • Malpractice coverage.
  • Medicare, Medicaid, and major payer credentialing.
• Secure:
  • Modest office space (can be co‑located with cardiology or hospital campus).
  • Basic staff (administrator, scheduler, MA or nurse).
• Plan your launch messaging:
  • Announce to cardiologists and primary care networks.
  • Schedule meet‑and‑greet visits or educational talks.

First 12–24 Months in Practice

• Focus on:
  • Availability and responsiveness.
  • Impeccable communication with referrals.
  • Safe, efficient surgical care with meticulous documentation.
• Track:
  • Monthly case volume.
  • Referral patterns (who is sending cases and why).
  • Financial performance versus your pro forma.
• Reassess:
  • Whether to hire additional staff or partners.
  • Opportunities to formalize or expand contracts with hospitals.

Over time, your practice will evolve. The critical factor is starting with a clear, realistic plan that aligns your surgical skill, market opportunities, and personal values.

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FAQs: Starting a Private Practice in Cardiothoracic Surgery

1. Is it realistic for a new graduate to start a solo cardiothoracic surgery private practice today?
It’s possible but uncommon, and usually high‑risk. Most new graduates either:

• Join an established private group with a partnership track, or
• Begin in a hospital-employed role, then transition toward more independence once they understand local dynamics.
  A completely solo model is more feasible in communities with strong unmet CT needs, minimal competition, and hospitals willing to provide robust support (income guarantees, call stipends, infrastructure).

2. How many years after heart surgery training should I wait before starting my own practice?
There is no fixed number, but many surgeons benefit from 3–5 years of experience in a stable setting (employed or group) before starting their own practice. This allows you to:

• Hone your operative skills independently.
• Learn hospital politics and workflows.
• Understand financial and referral patterns.
  That said, if the right opportunity and mentorship exist, earlier independence can work with careful planning.

3. What are the main advantages of private practice vs employment in cardiothoracic surgery?
Key advantages of private practice:

• Greater autonomy over schedule, staffing, and clinical pathways.
• Potentially higher income upside if you manage volume and costs effectively.
• Ability to innovate quickly in how you deliver care and build programs.
  Disadvantages include higher financial risk, administrative burden, and the need to manage business issues like payroll, compliance, and contracting.

4. Do I need formal business or MBA training to open a cardiothoracic private practice?
An MBA is not required, but basic business literacy is essential. You can gain what you need by:

• Working with experienced healthcare attorneys and accountants.
• Taking short courses in practice management and healthcare finance.
• Learning from mentors who have built successful practices.
  The most important step is recognizing your own limitations and deliberately building a team of advisors and staff who can help you run the business side while you focus on surgery and patient care.

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Starting a private practice in cardiothoracic surgery is ambitious, demanding, and absolutely possible for the right surgeon with deliberate preparation. By integrating business literacy into your heart surgery training years, making data‑driven decisions about location and structure, and relentlessly focusing on quality and relationships, you can build an independent career that is both clinically excellent and professionally fulfilling.