Starting a Private Practice in General Surgery: Your Essential Guide

Starting a private practice in general surgery is both exciting and daunting. As the landscape of healthcare shifts toward consolidation and large health systems, solo and small-group practices are less common—but still absolutely viable for surgeons who are strategic, business-minded, and committed to autonomy.

This guide walks through how to think about private practice during residency, how to prepare for the surgery residency match if you already know you’re entrepreneurial, and how to move from training into opening medical practice as a general surgeon. We’ll also address private practice vs employment, financial and legal considerations, and practical steps to launch and grow a successful surgical practice.

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Understanding Private Practice in General Surgery Today

Before sketching out a business plan, you need a clear, realistic view of what general surgery private practice looks like in 2025 and beyond.

The current landscape

Key trends you should be aware of:

• Increasing consolidation
  Many general surgeons are now employed by hospital systems or large multispecialty groups. Independent practices are fewer, but those that remain often thrive by:

  • Differentiating their services
  • Building strong referral networks
  • Maintaining lean operations

• Shift toward subspecialization and niche practices
  Many “general surgeons” build practices that are still broad but have defined niches:

  • Hernia and abdominal wall reconstruction
  • Breast surgery
  • Colorectal / minimally invasive surgery
  • Foregut / bariatric
  • Oncologic general surgery in community settings

• Regulatory and administrative complexity
  Billing, coding, prior authorizations, quality reporting, and compliance requirements are increasingly demanding. Independent surgeons must be willing to either:

  • Learn these systems in detail, or
  • Invest in competent management and support staff

Why consider private practice?

Common motivations include:

• Clinical autonomy
  You control your surgical schedule, case mix, operative techniques, and how you structure patient visits. You’re not beholden to system-wide metrics as much as employed physicians might be.

• Entrepreneurial control and upside
  In private practice, you own the revenue streams you help create. Over time, well-run practices can be more financially rewarding than employment, especially in markets with favorable payer mixes and reasonable call burdens.

• Culture and team-building
  You shape the practice culture: how support staff interact with patients, how quickly messages are answered, what your patient experience feels like, and how aggressively you adopt new technology.

• Strategic flexibility
  You can:

  • Open satellite offices
  • Partner with ambulatory surgery centers (ASCs)
  • Bring on partners or advanced practice providers (APPs)
  • Adjust your clinical niche to fit your interests and market demand

Private practice vs employment: trade-offs

You don’t need to choose forever—many surgeons move between models—but you do need clarity on priorities.

Private Practice Pros

• More control over:
  • Schedule and clinic templates
  • OR block allocation (depending on hospital politics)
  • Staff hiring and workflow
• Income potential that scales with:
  • Volume
  • Payer mix
  • Business decisions (e.g., office procedures, ASC ownership)
• Branding and reputation are tied directly to you and your practice.

Private Practice Cons

• Personal financial risk:
  • Startup costs
  • Income volatility in the first 1–3 years
• Administrative burden:
  • HR, payroll, leases, contracts, malpractice negotiation
• Need to manage business functions:
  • Marketing
  • IT and electronic health record (EHR) systems
  • Billing and collections

Employment Pros

• Predictable salary (often with a guarantee for 2–3 years)
• Institutional support:
  • Established referral pipelines
  • Centralized billing and IT
• Fewer administrative tasks; more clinical focus early on.

Employment Cons

• Less autonomy in:
  • Clinical protocols
  • Scheduling and time off
  • Strategic decisions (e.g., adding an office procedure or buying new equipment)
• Compensation may be capped or heavily RVU-driven with limited ability to control overhead.

A realistic approach is to understand that starting private practice in general surgery requires not just surgical skill but an entrepreneurial mindset. Residency and fellowship are the time to decide whether that appeals to you.

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Laying the Groundwork During Residency and Fellowship

If you’re still in training or approaching the surgery residency match, you can begin preparing now.

Choosing a program with private practice exposure

When applying for general surgery residency, if you already suspect you’ll want to open a practice, pay attention to:

• Program practice mix
  Look for programs where the faculty include community-based or hybrid private practice surgeons, not only academic surgeons. Ask:

  • “How many recent graduates went into private practice vs academic?”
  • “Do residents rotate at community hospitals or with private groups?”

• Operative autonomy and bread-and-butter exposure
  A future private practitioner needs:

  • Strong skills in common urgent and elective procedures (cholecystectomy, hernia, appendectomy, bowel resection, scopes where applicable)
  • Comfort with trauma or acute care if on-call responsibilities in your future market will demand it

• Electives with business focus
  Some programs allow:

  • Electives in practice management
  • Time with billing and coding departments
  • Rotations with private surgeons who will discuss contracts and finances openly

Skills to cultivate beyond the OR

Even as an intern or junior resident, you can build competencies that later support opening medical practice:

• Basic business literacy

  • Understand revenue vs profit
  • Learn how payers work: Medicare, commercial insurance, self-pay
  • Become familiar with RVUs and how surgical procedures are valued

• Coding and documentation

  • Ask coders to review your notes
  • Understand evaluation & management (E/M) levels
  • Learn correct CPT/ICD-10 pairing for common cases

• Communication and leadership

  • Practice leading multidisciplinary teams
  • Manage small projects (e.g., quality improvement initiatives)
  • Learn to give and receive feedback constructively

• Networking

  • Cultivate relationships with:
    • Local surgeons in private practice
    • Hospital administrators
    • Anesthesiologists and OR nursing leaders
  • Attend hospital business or quality meetings as a resident when possible

Building a long-term vision

During senior residency / fellowship, start thinking concretely:

• What kind of practice do you envision?

  • Solo surgeon with one APP and a focused scope?
  • Small group practice with 3–5 general surgeons covering a community hospital?
  • Niche-focused practice (e.g., hernia and abdominal wall) partnered with an ASC?

• Where do you want to live and work?

  • Urban vs suburban vs rural
  • Proximity to family/support
  • State-specific regulatory and malpractice climates

Write this down. Your future decisions about contracts, loans, and location should align with this vision.

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Planning and Designing Your General Surgery Practice

Once you’re close to finishing training or leaving an employed position, it’s time to transition from concept to plan.

Step 1: Clarify your business model

There are several structural options when starting a private practice in general surgery:

1. Solo practice

   • You are the only surgeon; may employ APPs.
   • Highest autonomy; highest personal risk.
   • Works best in:
     • Smaller markets with unmet surgical demand
     • Niche-focused practices that can draw regional referrals

2. Partnership or small group

   • Join one or more surgeons to share overhead.
   • Lower startup cost per person.
   • Shared call and more sustainable work-life balance.
   • Requires clear partnership agreements (buy-in, buy-out, decision-making).

3. Hybrid models

   • Private group with:
     • Professional services agreement (PSA) with a hospital
     • Partial employment relationships
   • You retain some independence while leveraging institutional resources.

4. Practice within a multispecialty group

   • You’re an owner within a multispecialty partnership (rather than a hospital employee).
   • Strong built-in referral base.
   • Shared back-office infrastructure (billing, HR, compliance).

Your choice should balance your tolerance for risk, desire for autonomy, and preferred lifestyle.

Step 2: Market and location analysis

Before you sign a lease, determine whether your intended location can support your practice:

• Assess demand

  • How many general surgeons are already in the area?
  • What are hospital volumes like (ED visits, surgical cases)?
  • Are there subspecialty gaps you can fill (breast, minimally invasive, colorectal)?

• Study payer mix

  • Contact hospital administrators or local medical society for data on:
    • Commercial vs Medicare vs Medicaid vs uninsured
  • Markets with strong commercial payer presence are generally more favorable for independent surgery practices.

• Analyze competition and collaborations

  • Identify:
    • Existing private practices
    • Large health system-employed groups
    • Established ASCs
  • Consider where you can:
    • Differentiate (e.g., faster access for hernia evaluations)
    • Collaborate (ASC equity, call coverage agreements, cross-coverage)

Step 3: Legal structure and entity formation

Work with a healthcare attorney and accountant to:

• Choose an entity type (varies by state):
  • Professional corporation (PC)
  • Professional limited liability company (PLLC)
  • Limited liability partnership (LLP)
• Draft foundational documents:
  • Operating agreement or bylaws
  • Shareholder agreements
  • Buy-in / buy-out terms if you have partners
• Obtain:
  • Employer Identification Number (EIN)
  • State business registrations
  • City or county business licenses (as required)

Step 4: Financial planning and startup capital

A realistic startup budget for a general surgery practice often includes:

• Upfront expenses

  • Legal and accounting fees
  • Office buildout or renovation
  • IT systems and EHR
  • Office furniture and medical equipment
  • Initial marketing (branding, website, signage)
  • Three to six months of operating expenses (rent, salaries, malpractice premiums)

• Working capital

  • It can take 3–6 months (sometimes longer) from the time you see your first patients to receiving steady insurance payments.
  • Plan to cover:
    • Your own living expenses
    • Practice payroll
    • Malpractice and health insurance
    • Utilities and suppliers

Funding sources may include:

• Bank loans (often with SBA backing)
• Personal savings
• Lines of credit
• Investor or partner contributions (if in a group)

Work with a healthcare-focused accountant to build:

• A 12–24 month cash flow projection
• Revenue assumptions based on:
  • Projected patient volume
  • Payer mix
  • Average reimbursement per case

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Operational Setup: From Licenses to the First Patient

Once your strategic plan and financial framework are in place, you’ll move into execution.

Credentialing, licensing, and hospital privileges

You can’t generate revenue until you’re credentialed and able to bill. Start early:

• State medical license
  Ensure it’s active and in good standing; initiate new licenses 6–12 months in advance if moving states.

• DEA and state controlled substance registrations
  Required for prescribing post-op meds and managing in-office procedures.

• Hospital medical staff privileges

  • Apply to all hospitals and ASCs where you plan to operate.
  • Prepare:
    • Case logs
    • Letters of reference
    • Board certification/eligibility documentation
  • Identify:
    • On-call obligations
    • Required committee participation

• Payer credentialing

  • Enroll with:
    • Medicare
    • Major commercial insurers in your area
    • Medicaid (depending on your market and mission)
  • This process often takes 90–180 days; start early.

Facility, equipment, and technology

For a general surgery outpatient clinic, you’ll need:

• Space considerations

  • Reception and waiting area
  • 2–4 exam rooms (more if you anticipate high volume or multiple providers)
  • Procedure room if doing minor procedures (e.g., skin lesion excisions, port removals)
  • Staff workstations and physician office

• Equipment

  • Exam tables, scopes (if applicable), minor procedure instruments
  • Autoclave or sterilization solution for instruments
  • Basic ultrasound (increasingly useful for hernias, soft tissue masses) if financially justifiable

• Technology

  • EHR system (cloud-based systems can be cost-effective for small practices)
  • Practice management software for scheduling and billing
  • Secure patient communication tools:
    • Patient portal
    • HIPAA-compliant messaging
  • Telehealth capability (for post-op checks, initial consultations when appropriate)

Staffing and workflows

Staffing is a major determinant of your practice culture and patient experience. Common roles include:

• Front desk / patient coordinator

  • Scheduling
  • Insurance verification
  • Check-in and check-out

• Medical assistant or nurse

  • Rooming patients
  • Vital signs
  • Wound care and dressing changes
  • Suture/staple removal
  • Patient education

• Practice manager / office administrator

  • Overseeing daily operations
  • HR and payroll
  • Vendor contracts
  • Basic financial reports

• Billing and coding

  • In-house biller vs outsourced revenue cycle management (RCM) company
  • For a new or small practice, outsourcing can be cost-effective, but ensure they:
    • Understand surgical coding
    • Provide transparent reporting

Design workflows for:

• New patient intake and referral tracking
• Pre-op evaluation and surgical booking
• Post-op follow-up and complication tracking
• Communication with referring physicians (notes, phone calls, secure messaging)

Malpractice insurance and risk management

As a general surgeon, malpractice coverage is a significant recurring cost:

• Decide between:
  • Claims-made vs occurrence policies
  • Tail coverage if moving from an employed role
• Evaluate coverage limits typical for your state and specialty.
• Implement risk-reduction practices:
  • Standardized informed consent processes
  • Consistent documentation templates
  • Morbidity and mortality reviews (even within a small practice)
  • Clear post-op instructions and 24/7 contact mechanisms

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Growing and Sustaining a Successful General Surgery Private Practice

Establishing the practice is just the beginning. The next challenge is growth and long-term sustainability.

Building referral networks and reputation

In general surgery, referrals are your lifeline. Strategies include:

• Primary care outreach

  • Visit local primary care offices, OB/GYNs, oncologists, and ED groups.
  • Provide:
    • Direct contact info
    • Same-week or urgent appointment slots for time-sensitive cases
  • Send prompt consult notes and operative reports.

• Hospital presence

  • Be visible in the hospital:
    • Attend medical staff meetings
    • Participate in committees
    • Engage respectfully with nursing and ancillary staff
  • Consistent professionalism in the OR and wards drives word-of-mouth referrals.

• Digital presence

  • Professional website highlighting:
    • Services and areas of expertise
    • Hospital affiliations
    • Insurance plans accepted
    • Patient education material (e.g., about hernia surgery, gallbladder disease)
  • Manage online reviews:
    • Encourage satisfied patients to leave feedback.
    • Respond professionally to negative reviews (without revealing PHI).

Clinical scope and strategic differentiation

To stand out and stay energized, consider how you’ll define your practice scope:

• Broad-based general surgery

  • Strong in bread-and-butter:
    • Hernias, gallbladders, appendectomies
    • Basic colorectal, soft-tissue masses
  • Works well in smaller communities with fewer subspecialists.

• Niche-focused practice

  • Examples:
    • Complex hernia and abdominal wall reconstruction
    • Breast surgery with oncoplastic techniques
    • Advanced minimally invasive / robotic procedures
  • Requires:
    • Extra training (often a fellowship)
    • Intentional branding and referral cultivation

Whatever your scope, emphasize:

• Timely access
• Clear communication
• Evidence-based care and outcomes

Financial management and metrics

A private practice is a small business. At a minimum, track:

• Monthly key performance indicators (KPIs)

  • Charges vs collections
  • Accounts receivable (AR) days
  • Denial rates and reasons
  • Payer mix
  • Surgical volume by site (hospital vs ASC vs office)

• Cost control

  • Negotiate:
    • Supply contracts
    • Rent terms and renewals
    • Service contracts (EHR, IT support)
  • Regularly reassess:
    • Staffing levels vs volume
    • Benefits costs (health insurance, retirement plans)

• Growth decisions

  • When to:
    • Add an APP
    • Open a satellite clinic
    • Buy into or open an ASC
  • Model the impact on:
    • Call burden
    • Revenue and overhead
    • Lifestyle

Balancing work, life, and long-term career satisfaction

Private practice can be exhilarating but consuming. Protect your longevity by:

• Designing a call schedule that’s sustainable.
• Setting boundaries on clinic days and OR days.
• Scheduling regular time for:
  • Family and personal life
  • Professional development
  • Strategic work on the practice (not just in it)

Many surgeons ultimately find a hybrid approach works best: a stable core of bread-and-butter general surgery plus a focused niche, combined with a deliberate approach to call and clinic load.

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Frequently Asked Questions

1. Is it realistic to plan for private practice while still in general surgery residency?

Yes. You don’t need to have every detail figured out, but you can intentionally prepare by:

• Choosing a program that exposes you to private practice surgeons.
• Learning basic business, billing, and coding concepts.
• Networking with community surgeons.
• Reflecting on where and how you want to practice.

Your awareness of private practice vs employment trade-offs during training will help you make better career and contract decisions later.

2. How long does it take for a new general surgery private practice to become profitable?

Timelines vary by market and strategy, but common patterns:

• First 6–12 months: Building volume, completing credentialing, and stabilizing cash flow.
• 12–24 months: Practice often approaches or reaches breakeven if:
  • Demand exists
  • Referral networks are actively cultivated
  • Overhead is managed well

Your upfront financial planning should assume a slower start and build in sufficient working capital.

3. Should I start solo or join an existing private group first?

This depends on your risk tolerance, experience, and market:

• Join a private group first if you want:

  • Mentorship in both clinical and business aspects
  • Shared call and overhead
  • An established referral base

• Start solo if you:

  • Have strong local relationships and clear demand
  • Highly value autonomy
  • Are prepared for higher initial risk and administrative responsibility

Many surgeons spend a few years in group practice before starting private practice as their own entity, once they understand their market and preferences.

4. How does starting a private practice affect my ability to do complex or advanced cases?

Private practice does not limit you to simple cases—many community general surgeons perform sophisticated laparoscopic and oncologic procedures. Your ability to do complex cases depends more on:

• Your training and comfort level
• Hospital resources (ICU, oncology services, interventional radiology)
• Availability of multidisciplinary support

If complex cases are central to your interests, look for communities with robust hospital ecosystems and consider partnership with larger centers for selected referrals.

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Starting a private practice in general surgery is not the easiest path, but with deliberate preparation, sound planning, and a commitment to both clinical excellence and business fundamentals, it can offer unmatched autonomy, professional fulfillment, and impact on your community.