Starting Your Private Practice After Preliminary Medicine Year: A Guide

Understanding the Role of a Preliminary Medicine Year

A preliminary medicine year (prelim IM) is a one-year internship in internal medicine that does not lead to board eligibility in internal medicine by itself. Instead, it is usually:

• A required clinical year before an advanced residency (e.g., neurology, anesthesiology, PM&R, radiology)
• A transitional step for applicants planning to reapply to categorical internal medicine or another specialty
• Occasionally a choice for those exploring long-term clinical directions

When thinking about starting a private practice with only a prelim IM year, it’s crucial to understand the structural limitations and realistic pathways.

Can You Open a Practice With Only a Prelim IM Year?

In nearly all U.S. jurisdictions:

• You must complete an ACGME-accredited residency that leads to board eligibility (usually 3 years for internal medicine) to practice independently in internal medicine.
• A single preliminary medicine year is typically not sufficient for:
  • Unrestricted medical licensure in most states
  • Hospital privileges
  • Credentialing with major insurers and Medicare/Medicaid
  • Marketing yourself as an internist in private practice

A prelim IM internship alone is best thought of as:

• A foundation year that builds inpatient and outpatient skills
• A stepping stone toward:
  • A categorical internal medicine residency
  • An advanced specialty
  • Occasionally, non-clinical careers (health policy, consulting, pharma, tech)

Why This Matters for Private Practice

To run an internal medicine practice—whether general medicine or a subspecialty—you typically need:

1. Completed residency training (usually 3 years in IM, plus fellowship for subspecialties)
2. Board eligibility or certification
3. State medical license that allows independent practice
4. Credentialing with insurers and hospitals

Your prelim year is only Year 1 of that journey. You’re not losing time by not opening a practice now; you’re investing in the clinical authority and legal standing you will need later.

Key takeaway:
Your preliminary medicine year is not the time to start a standalone private practice, but it’s the perfect time to prepare deliberately for a future in private practice.

---

Building a Foundation for Future Private Practice During Your Prelim Year

You can treat your prelim IM year as a launchpad for private practice, even if the practice itself is several years away. The residency demands are intense, but small, strategic actions now will pay off later.

1. Clarify Your Long-Term Career Vision

Ask yourself:

• Do I envision myself in traditional internal medicine primary care or hospital medicine?
• Am I targeting a subspecialty (cardiology, GI, pulmonology, etc.) with a potential private practice model?
• Am I more drawn to private practice vs employment (health system/academic) or a hybrid model?

During prelim year:

• Journal your experiences: What clinical settings energize you? What frustrates you?
• Observe practice models:
  • Private groups vs hospital-employed
  • Academic vs community
  • Large multispecialty groups vs solo/duo practices
• Informational interviews:
  • Ask attendings, especially community physicians:
    “What led you to private practice vs employment?”
    “If you could do it over, what would you do differently?”

This exploration will help you determine whether opening medical practice later aligns with your values around autonomy, financial risk, and lifestyle.

2. Develop Key Clinical and Non-Clinical Skills

During your prelim IM year, prioritize:

• Clinical Breadth and Efficiency
  • Gain comfort with bread-and-butter internal medicine problems
  • Learn to prioritize and triage—critical in outpatient settings
  • Practice concise documentation that still tells the clinical story
• Communication and Rapport
  • Build skills in explaining diagnoses and plans at a 6th–8th grade level
  • Pay attention to how strong attendings handle difficult conversations and shared decision-making
• Systems Awareness
  • Learn how consults, referrals, and follow-up are coordinated
  • Understand discharge processes—these map directly to outpatient transitions of care
• Practice Operations (Micro-Level)
  • Ask nurses and MAs how clinic flow works
  • Pay attention to EHR workflows, order sets, messaging systems
  • Observe how pre-visit planning and post-visit communication are handled

You’re not just learning to be a competent intern; you’re building the operational mindset that will make a future clinic run smoothly.

3. Network Intentionally With Private Practice Physicians

Your prelim year is an ideal time to build relationships with doctors who have taken different career paths.

Practical steps:

• Identify community attendings or group practice preceptors:
  • Ask to meet for coffee or a brief Zoom call
  • Prepare 3–4 specific questions (e.g., “What surprised you about running a practice?” “How do you balance clinical work and management?”)
• Attend local medical society meetings or hospital medical staff gatherings
• Keep a simple contact list (spreadsheet or note app) with:
  • Name, specialty, practice type
  • Contact info
  • One or two notes about your conversations

Working relationships during prelim can later become mentorships, job leads, or even partnership opportunities when you’re ready to transition into independent practice.

---

Mapping the Training and Licensing Pathway to Private Practice

Before you can realistically think about starting a private practice, you need a clear pathway from where you are as a prelim to an independently practicing physician.

Step 1: From Prelim IM to Full Training

Your options typically include:

1. Transition to a Categorical Internal Medicine Residency

   • Either at your current program (if internal transfer is possible)
   • Or via reapplication to other categorical IM programs
   • End goal: Board eligibility in internal medicine, ideal for primary care or hospitalist private practice

2. Continue Into an Advanced Specialty

   • If your prelim year is tied to an advanced program (e.g., neurology, anesthesiology)
   • Many advanced specialties also have opportunities for private practice (e.g., neurology groups, anesthesiology groups, PM&R groups)

3. Reapply or Pivot

   • If your initial specialty didn’t work out, your prelim year can strengthen your application
   • Categorical IM remains a flexible path with broad practice options

Throughout this phase, keep in mind: your long-term goal is eligibility for independent clinical practice in a field where your desired practice model is viable.

Step 2: Licensure and Board Eligibility

For most U.S. states, to independently run an internal medicine practice you need:

• Completion of at least 3 years of ACGME-accredited residency (or equivalent)
• Passing all USMLE/COMLEX steps
• A full, unrestricted state medical license
• Board eligibility or certification in your specialty (not technically mandatory everywhere, but strongly preferred by:
  • Insurers
  • Hospitals
  • Many patients)

While in residency/fellowship after your prelim year:

• Learn your target state’s licensing requirements early
• Track:
  • Case logs
  • Procedure documentation
  • CME and training certificates
• Maintain a clean professional record (professionalism, documentation, communication)—issues now can delay or complicate licensing later.

Step 3: Deciding on Private Practice vs Employment

By your PGY-2 or PGY-3 year, you should be actively thinking about private practice vs employment for your first post-training job.

Employment (hospital/health system/academic):

• Pros:
  • Salary stability
  • Built-in infrastructure (billing, HR, IT)
  • Less financial risk
• Cons:
  • Less autonomy in scheduling, clinical protocols, and business decisions
  • Potential pressure for RVU/volume productivity

Private practice (solo, small group, or larger physician-owned group):

• Pros:
  • Greater autonomy and control over clinic culture and operations
  • Potential for higher long-term income, especially with ownership
  • Flexibility in service offerings (e.g., procedures, niche clinics)
• Cons:
  • Financial risk and upfront investment
  • Need to manage business aspects (HR, compliance, contracts, overhead)
  • Income variability, especially early on

Many physicians choose a hybrid approach:

• Start in an employed role to gain experience and financial stability
• Transition into buying into a group or opening medical practice once clinically and financially ready

Your prelim IM year is early, but it’s not too early to observe which model matches your personality and risk tolerance.

---

Planning the Business of Your Future Practice

Once you’ve completed training and are near the end of residency or fellowship, you can move from abstract planning to concrete steps toward starting a private practice. Even during prelim year, you can learn the language and concepts so they’re not new later.

1. Choosing a Practice Model

Common models for an internal medicine-trained physician:

• Solo Private Practice
  • Maximum autonomy; you own everything
  • Requires comfort with risk and business management
• Partnership in a Small Group
  • Shared overhead, call, and decision-making
  • Potential to buy into ownership over time
• Joining a Larger Physician Group
  • Some are physician-owned, some are corporate-backed
  • Less control but often more resources and stability
• Concierge or Direct Primary Care (DPC)
  • Smaller patient panels, retainer or membership-based revenue
  • Requires a clear value proposition and strong patient relationships

As a prelim-year resident, start noting:

• Which attendings seem happiest with their practice model?
• Who appears most burned out, and why?
• Are there models (e.g., concierge IM) that especially appeal to you?

2. Developing Basic Business Literacy

You don’t need an MBA, but you do need functional business knowledge. During downtime in your prelim year, you can:

• Read beginner-friendly books or articles on:
  • Healthcare practice management
  • Physician entrepreneurship
  • Medical billing and coding basics
• Learn basic terms:
  • Overhead, net revenue, profit margin
  • RVUs, payer mix, capitation
  • Accounts receivable, aging reports, denial management
• Ask private practice attendings:
  • “How did you decide on your location?”
  • “What surprised you most about the financial side of practice?”

When you get closer to actually starting a practice, you’ll be ready to dive deeper into:

• Creating a business plan
• Pro forma financial projections
• Financing options (bank loans, lines of credit, partners)

3. Legal Structure and Compliance (Future Planning)

Eventually you will need to:

• Choose a legal entity (LLC, PLLC, S-Corp, etc.)
• Obtain:
  • State business registration
  • Employer Identification Number (EIN)
  • Malpractice insurance
  • State medical license (if in a new state)
• Ensure compliance with:
  • HIPAA
  • Stark/Anti-kickback rules
  • OSHA and employment law

During prelim year, your objective is not to handle these directly; it is to become aware that these structures exist and ask physicians who have done it what worked and what didn’t.

---

Step-by-Step: From Training Completion to Opening Your Medical Practice

To tie everything together, here is a practical timeline that assumes:

• You’ve completed your preliminary medicine year
• You’ve gone on to finish a full residency (IM or advanced specialty)
• You’re now considering starting a private practice as you near graduation

12–24 Months Before Opening

1. Clarify Your Niche and Services
   • General internal medicine? Subspecialty clinic? Mixed?
   • Will you do:
     • Procedures (e.g., joint injections, stress tests)?
     • Chronic care programs (e.g., diabetes clinics)?
     • Preventive medicine or executive physicals?
2. Research Market and Location
   • Urban vs suburban vs rural
   • Competition: How many IM or specialists in your area?
   • Referral patterns: Are there hospital systems or PCP networks that might send patients your way?
3. Meet With Advisors
   • Healthcare attorney
   • Accountant experienced with medical practices
   • Possibly a practice consultant (if budget allows)
4. Decide: Private Practice vs Employed First
   • Some physicians deliberately take a 2–3 year employed job to:
     • Build savings and pay down loans
     • Learn operational best practices
     • Observe what to replicate or avoid in their own practice

6–12 Months Before Opening

1. Formal Business Plan

   • Project:
     • Expected patient volume and ramp-up
     • Startup costs (build-out, equipment, EHR licenses, furniture, legal fees)
     • Ongoing monthly expenses (rent, staff salaries, insurance, utilities)
     • Revenue from office visits, procedures, ancillary services

2. Secure Financing

   • Physician-specific bank loans are common
   • Some lenders are comfortable with well-structured practice plans

3. Select Location and Lease

   • Negotiate tenant improvements (TI)
   • Ensure ADA compliance, exam room design, parking

4. Technology and Infrastructure

   • Choose an EHR (consider usability, cost, integration with billing)
   • Decide on practice management and billing software
   • Set up:
     • Phone systems
     • Secure messaging
     • Website and online scheduling (if desired)

3–6 Months Before Opening

1. Credentialing and Contracting

   • Apply to:
     • Medicare
     • Medicaid (depending on your patient base)
     • Major commercial insurers
   • This can take 3–6 months or longer—start early.

2. Hire and Train Staff

   • Begin with a lean team:
     • Front desk/medical secretary
     • Medical assistant or nurse
     • Biller or billing service (in-house vs outsourced)
   • Train on:
     • Patient intake procedures
     • EHR workflows
     • Privacy and compliance

3. Develop Policies and Protocols

   • No-show and cancellation policies
   • After-hours coverage
   • Refill and results notification processes
   • Emergency protocols

1–3 Months Before Opening

1. Soft Launch Planning

   • Consider a “soft opening” with limited patients:
     • Friends/family referrals (if appropriate)
     • Local physician referrals
   • Use this time to refine clinic workflows and iron out issues.

2. Marketing and Community Presence

   • Create or refine your website and online profiles (Google Business Profile, Healthgrades, etc.)
   • Introduce yourself to:
     • Nearby PCPs and specialists
     • Local urgent care and ED physicians
   • Offer:
     • Educational talks
     • Free community seminars (e.g., hypertension management)

3. Prepare for Financial Variability

   • Maintain a cash reserve for several months of overhead
   • Expect lag in collections while claims process and credentialing finalizes with all payers

---

How to Use Your Prelim Year Wisely if You Dream of Private Practice

Bringing it back to where you are now—a preliminary medicine resident—your primary job is to become a strong, safe, and reliable physician. But you can also:

1. Adopt a “future practice owner” mindset
   • When you see inefficiency, ask: “How would I prevent this in my own clinic?”
   • When you observe excellent patient service, note what made it work.
2. Actively explore private practice vs employment
   • Ask every attending you trust about their path and whether they’d choose the same model again.
3. Gain basic financial and practice management literacy
   • Read 1–2 books or online resources per year about practice management
   • Attend any free webinars or workshops geared toward residents and fellows
4. Network strategically
   • Stay in touch with mentors in practices you admire
   • Join professional organizations that support private practice physicians (e.g., ACP, specialty societies)

You’re not expected to know how to open a practice during your prelim IM year. But if you lay the groundwork now—clinically, intellectually, and relationally—you will be far better prepared to make a thoughtful decision about starting private practice once your training is complete.

---

FAQs: Preliminary Medicine and Starting a Private Practice

1. Can I start my own internal medicine private practice after just a preliminary medicine year?
No. A preliminary medicine year alone almost never meets the requirements for unrestricted licensure or insurer credentialing in internal medicine. You typically must complete a full 3-year categorical internal medicine residency (or another full specialty training program) to practice independently and open a clinic.

---

2. If I know I want private practice, should I avoid prelim IM and only apply to categorical spots?
If private practice in internal medicine is your clear goal, then categorical IM is the more direct route because it leads to board eligibility. However, a prelim IM year can be a valuable step if:

• You’re using it to strengthen an application to categorical IM
• You’re already committed to an advanced specialty that also supports private practice (e.g., neurology, anesthesiology, PM&R)

---

3. Is private practice or employment better financially and lifestyle-wise?
It depends on your preferences and local market:

• Employment offers income stability and less administrative burden, but typically less autonomy.
• Private practice can yield higher long-term earning potential and more control, but comes with business risk, variable income, and administrative responsibility. Many physicians start in employed positions and later transition into partnership or solo practice once they understand their clinical style, financial goals, and tolerance for risk.

---

4. What can I do during prelim IM specifically to prepare for a future private practice?
During your prelim year:

• Build strong clinical fundamentals and efficiency
• Seek out mentors in private practice and ask candid questions
• Observe clinic operations and think like an owner: patient flow, scheduling, communication
• Start building basic business literacy (billing, overhead, payer mix, compliance)
• Maintain relationships with attendings and peers who may become future colleagues, referrers, or partners

By approaching your preliminary medicine year thoughtfully, you position yourself not only to match into the right next step in training, but also to be much better prepared for the eventual leap into opening medical practice on your own terms.