Starting a Private Practice in Preliminary Surgery: Your Essential Guide

Understanding the Reality: Can You Start a Private Practice After a Preliminary Surgery Year?

Residents in a preliminary surgery residency often ask whether they can go straight into starting a private practice after just one or two non-categorical years. This guide will be honest and practical:

• In the United States, you generally cannot open an independent surgical practice as an attending surgeon with only a preliminary surgery year.
• To perform surgery independently, most states, hospitals, and malpractice carriers expect:
  • Successful completion of an ACGME-accredited categorical general surgery residency
  • Eligibility or certification by the American Board of Surgery (ABS)
  • Hospital privileges for surgical procedures

Meaning: a preliminary surgery year alone is not a terminal training pathway for independent surgical practice. However, that doesn’t mean your prelim experience has no place in your future as a practice owner.

This article will walk you through:

• How a prelim surgery residency year (or years) fits into long-term plans
• When and how you can realistically consider opening medical practice as a surgeon or procedure-focused physician
• Alternative pathways if you do not match into categorical surgery
• Strategic planning to keep the option of starting a private practice alive while navigating an uncertain training trajectory

Throughout, we’ll also contrast private practice vs employment, so you can make grounded decisions—not just emotional ones—about your career.

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What a Preliminary Surgery Year Really Gives You (and What It Doesn’t)

What Is a Preliminary Surgery Year?

A preliminary surgery year is a one-year, non-categorical PGY-1 (and sometimes PGY-2) position in general surgery or surgical subspecialties. Its typical purposes:

• A “try-out” year for those hoping to transition into a categorical general surgery residency
• A required intern year for other specialties (e.g., radiology, anesthesiology, urology)
• A temporary spot for unmatched applicants to gain experience and build a stronger application

You work almost identically to categorical interns: general surgery, trauma, ICU, possibly subspecialties. But you do not have a guaranteed path to completing full surgical training at that program.

What It Doesn’t Provide: Independent Surgical Credentials

From a licensing and credentialing perspective, your prelim year does not:

• Make you board-eligible in surgery
• Qualify you for full hospital surgical privileges
• Meet typical requirements for surgical malpractice coverage as an attending

Even if you hold an MD/DO and later get a medical license (often after PGY-1), most insurers and hospitals will not allow you to perform major surgeries without residency completion and board eligibility.

What It Does Provide: Valuable Building Blocks

However, a prelim surgery residency can be a powerful asset:

• Technical fundamentals: suturing, basic procedures, OR workflow, perioperative care
• Clinical credibility: surgeons, anesthesiologists, and hospitalists recognize you as having real frontline training
• Letters of recommendation: strong surgery letters can help you pivot into:
  • Categorical general surgery
  • Other competitive specialties (anesthesia, EM, radiology, PM&R, etc.)
• Operational insights: you see how surgical services run—clinic flow, OR block use, call structure, and multi-disciplinary coordination

These elements become important later when you consider starting private practice in any specialty—surgical or non-surgical.

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Career Pathways After a Preliminary Surgery Year: Where Private Practice Fits In

Pathway 1: Transition to Categorical General Surgery, Then Private Practice

The most direct path to a future surgical private practice is:

1. Prelim surgery year(s)
2. Match into a categorical general surgery position
3. Complete 5+ years of general surgery residency
4. Obtain:
   • Independent medical license
   • ABS board eligibility/certification
   • Hospital privileges
5. Then consider starting a private surgical practice or joining an existing group.

In this pathway, your prelim year is a stepping-stone, not a terminal endpoint.

Actionable advice during your prelim year:

• Work like a future categorical:
  • Be reliable, teachable, and visible to faculty
  • Volunteer for cases, show up early, stay late when able
• Request formal feedback from program leadership:
  • Ask about your chances for a categorical spot there or elsewhere
  • Clarify whether they can support you with letters and calls
• Build a portfolio:
  • Procedure logs
  • QI or research projects
  • Strong letters for the next match cycle

Your long-term private practice goal should be clear to your mentors; they can then advise you on the training steps required to get there.

Pathway 2: Pivot to Another Specialty, Then Private Practice

If categorical general surgery doesn’t materialize, your prelim year can still be leveraged to reach a procedure-heavy specialty where private practice is common:

• Anesthesiology
• Emergency Medicine
• Interventional Radiology (with additional training)
• PM&R with interventional pain
• Critical Care (with internal medicine or anesthesiology base)
• Ob/Gyn (in some rare transitions)

In these pathways:

1. You use your prelim surgery year as a clinical and experiential foundation.
2. You apply to a new specialty—often selling your intense surgical exposure and comfort with sick inpatients.
3. You complete a full residency in the new field.
4. Then you can explore opening medical practice as a specialist in private practice or as a partner in a group.

Many anesthesiologists, pain physicians, and proceduralists have robust independent or group practices and make use of their early surgical exposure daily.

Pathway 3: Non-Surgical Clinical Roles and Private Practice

If you ultimately cannot or choose not to complete a residency, your options for traditional private clinical practice are limited in the U.S. due to:

• Licensing restrictions
• Payer credentialing requirements
• Malpractice and standard-of-care expectations

However, in some states, after an accredited PGY-1 and successful Step/COMLEX exams, you may qualify for a medical license—though you’ll be considered untrained or partially trained.

Roles might include:

• Non-procedural clinical work in underserved or under-resourced settings (often low-paid and high-risk)
• Telemedicine roles, typically under supervision or tightly protocolized
• Non-clinical medicine:
  • Medical consulting
  • Clinical research
  • Med-legal review
  • Healthcare administration

These are generally not classic private practices in the sense of being an independent, procedure-based, patient-facing surgical or specialty practice. But some physicians build consulting practices or niche services leveraging their degree and prelim experience.

Pathway 4: International or Alternative Practice Models

In rare situations, physicians with partial training move to countries with different training and licensing structures, or to systems that recognize some U.S. training differently.

• These paths are highly country-specific.
• “Private practice” in another country may require local re-training, exams, or credentialing.

Always research local regulations, immigration, and licensing before banking on this route.

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What “Starting a Private Practice” Really Involves (Once You’re Fully Trained)

Assuming you ultimately complete a full residency in a surgical or procedure-based specialty, your prelim year experience becomes a foundational memory rather than the endpoint. When you finally reach the stage of starting private practice, you’ll need to understand:

Private Practice vs Employment: Conceptual Differences

Private practice (solo or small group):

• You are a business owner or partner.
• You manage:
  • Overhead (rent, staff salaries, equipment, insurance)
  • Billing/collections
  • Marketing/referrals
• You control:
  • Your schedule
  • Clinical protocols (within standard of care)
  • Which payers you contract with
• Risk: higher financial and legal risk; income variability.
• Upside: potentially higher long-term income, greater autonomy, ability to shape culture.

Employment (hospital, academic, or large system):

• You are an employee:
  • Salary (plus bonuses/RVUs)
  • Benefits from employer
  • Less direct control over operations
• Lower business risk:
  • No rent or payroll to manage personally
  • Institutional support for compliance, HR, IT, etc.
• Less independence:
  • Schedules, call, and practice patterns often system-defined.
  • Mandatory EMR, quality metrics, and productivity requirements.

For many early-career surgeons, private practice vs employment is not an immediate choice. Most start with:

• Academic or large-group employment
• Then consider private practice after 3–10 years, once they:
  • Gain clinical confidence
  • Understand referral patterns
  • Accumulate capital and financial literacy
  • Clarify their lifestyle priorities

How Your Preliminary Surgery Experience Helps

Even though your prelim year is far from the business world, it gives you:

• Insight into:
  • OR and clinic scheduling inefficiencies
  • What frustrates patients and referring services
  • Time-management challenges in high-acuity care
• Relationships:
  • Surgeons who might later refer to you or become partners
  • Anesthesiologists, radiologists, and hospital administrators

If you’re still in a prelim year, watch for business clues:

• How do attendings talk about:
  • RVUs, collections, or payer mix?
  • Burnout and workload?
  • Autonomy vs bureaucracy?
• Which surgeons seem satisfied in private practice vs employed roles, and why?

These details inform future decisions when starting private practice becomes feasible.

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Step-by-Step Roadmap: From Preliminary Surgery to Owning a Practice

This section assumes your end goal is owning or co-owning a practice—most commonly after completing categorical general surgery or another specialty.

Step 1: Secure Your Training Path

During your preliminary surgery residency:

1. Clarify your realistic specialty path:
   • Are you competitive for categorical general surgery?
   • Do you have a backup specialty interest?
2. Create a 2–5-year training plan:
   • If surgery: reapply to the Match, explore transfers, maintain surgical CV.
   • If pivoting: meet program directors in your target specialty, get aligned mentorship.
3. Avoid long gaps:
   • Continuity in training is crucial for credentialing and licensure.
   • If you must take a gap, fill it with research or structured clinical/educational activities when possible.

Without a completed residency, your dream of starting a private practice will be very difficult to realize, especially in procedural fields.

Step 2: Learn the Business of Medicine Early

Even as a prelim or resident, you can start building business literacy:

• Take free or low-cost courses on:
  • Basic accounting and personal finance
  • Healthcare economics and reimbursement models
• Read about:
  • CPT and ICD coding basics
  • RVUs and value-based care
• Ask mentors in private practice:
  • What they wish they had learned earlier
  • How they structured their first contracts and buy-ins

You’re not just a future surgeon; you’re a potential future small-business owner.

Step 3: Clarify Your Ideal Practice Model

Once you’re in or near the end of full residency:

1. Decide what kind of “private practice” you want:
   • Solo practice (highest control, highest risk)
   • Small group partnership
   • Hybrid: partially employed, side consulting/private clinic
2. Decide your clinical scope:
   • Bread-and-butter general surgery?
   • Niche-focused (e.g., hernia, breast, colorectal) within a group?
   • Procedural practice (e.g., endoscopy) vs primarily clinic-based?
3. Decide your setting:
   • Major metro vs community hospital vs rural
   • Hospital-based vs freestanding ASC affiliation

The clearer your vision, the easier it is to evaluate job offers, partnership tracks, and community needs.

Step 4: Financial and Legal Foundations

When the time actually comes to opening medical practice (post-residency/fellowship):

• Entity formation:
  • LLC, PLLC, or professional corporation, depending on state
  • Consult a healthcare attorney and tax professional
• Contracts and compliance:
  • Payer contracts (Medicare, Medicaid, commercial)
  • Stark Law and anti-kickback statute compliance
  • Office leases and equipment contracts
• Malpractice coverage:
  • Claims-made vs occurrence policies
  • Tail coverage provisions
  • Ensure coverage fits your surgical risk profile

Your prelim surgical background helps you understand clinical risk, but legal and financial risk are new arenas. Professional guidance is non-negotiable.

Step 5: Operational Setup

Key operational elements of a surgical private practice:

• Location and facilities:
  • Office space: clinic rooms, procedure room (if applicable), reception
  • Affiliation with hospitals and/or ASCs (for OR access)
• Staffing:
  • Front-desk personnel
  • MA(s), RN(s), or surgical PAs/NPs
  • Biller/coder (in-house or outsourced)
• Technology:
  • EMR/EHR system
  • Practice management and scheduling software
  • Secure telehealth solutions (if applicable)

You’ll also need a marketing and referral strategy:

• Building relationships with:
  • Primary care physicians
  • ED physicians
  • Other specialists
• Establishing an online presence:
  • Website
  • Professional profiles
  • Patient reviews management

Step 6: Contingency Planning and Risk Management

Private surgical practice comes with significant risks:

• Variable patient volume
• Changing insurance rules
• Potential lawsuits
• Burnout from clinical and administrative load

Your risk-management plan should include:

• Adequate savings and lines of credit
• Clear policies and protocols (especially around perioperative care)
• Structured call-sharing arrangements with partners or neighboring surgeons
• Personal boundaries to preserve health and family life

Your time in prelim and residency showed you what chronic overwork looks like. Use that knowledge to design a humane practice.

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Practical Advice for Current Prelim Surgery Residents With Private Practice Dreams

If you are currently in a preliminary surgery year and imagining your name on the door of a surgical clinic someday, keep these principles front and center:

1. Accept the timeline
   You cannot safely or legally shortcut the path to independent surgical practice. Full residency training is not optional.

2. Use your prelim year strategically

   • Maximize your chance of landing categorical training in your desired field (or a good alternative).
   • Build strong professional relationships; many future referrals and partnerships originate from residency days.

3. Maintain parallel planning

   • Plan A: categorical general surgery → possible private practice
   • Plan B: another specialty with strong private practice opportunities (e.g., anesthesiology, EM, PM&R with procedures)
   • Plan C: non-procedural or non-clinical path where you can still be a practice owner or consultant

4. Track your interests honestly
   Some residents start out fixed on solo private practice vs employment, then discover they prefer academic life, systems employment, or portfolio careers (mix of clinical, teaching, and non-clinical roles). Allow your lived experience to refine your goals.

5. Invest early in financial literacy

   • Pay down high-interest debt when possible
   • Live below your means during training
   • Learn about retirement accounts, disability insurance, and basic investing

These habits will be crucial if you eventually shoulder the financial responsibilities of starting a private practice.

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FAQs: Preliminary Surgery and Private Practice

1. Can I open a private surgical practice right after a preliminary surgery year?

In the U.S., almost never. A preliminary surgery year does not provide sufficient training, board eligibility, or credentialing to perform independent surgery in private practice. You will almost certainly need to complete a full categorical residency (usually 5 years for general surgery) and become at least board-eligible before hospitals and payers will work with you as an independent surgeon.

2. Does a preliminary surgery residency help me if I later want to start a private practice in another specialty?

Yes. A prelim year gives you:

• Strong clinical experience with acutely ill patients
• OR and procedural exposure
• Valuable letters of recommendation

If you move into anesthesiology, EM, PM&R, or other specialties with robust private practice options, your prelim background can help you match and will later inform your clinical judgment and practice operations. But you still must complete a full residency in your new specialty.

3. Is private practice or employment better for early-career surgeons?

For most new attendings, employment (hospital, academic, or large group) is more common and lower risk. It provides:

• Stable income
• Institutional support
• Fewer administrative burdens

Private practice often becomes attractive after a surgeon has several years of experience, understands local referral patterns, and has the financial and emotional bandwidth to handle business ownership. Neither is universally “better”—it depends on your risk tolerance, desire for autonomy, and lifestyle goals.

4. What if I don’t match into categorical surgery after my prelim year—does that kill my chances of ever owning a practice?

Not necessarily. Failing to move into categorical general surgery does limit your chance of owning a classic surgical private practice, but:

• You may still match into another specialty with private practice options.
• You might build a niche consulting or non-clinical business (e.g., medicolegal review, healthcare consulting).
• Some countries or healthcare systems offer alternative pathways.

The key is to be flexible, proactive, and realistic—using your prelim year as a launchpad, not a dead end.

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Bottom line: A preliminary surgery year alone is not enough to support starting a private surgical practice, but it can be a valuable step on the path toward eventual practice ownership—whether in general surgery or another specialty. Your focus during and immediately after your prelim year should be securing a complete, accredited residency, while quietly building the clinical, financial, and strategic mindset you’ll need if and when you’re ready to put your name on the door of your own practice.