The Real Politics of Hospital Privileges When You Open Your Own Clinic

The polite fiction is that hospital privileges are about “quality and patient safety.” They are not. They are about power, money, and control of referral streams—dressed up in policy language and bylaws. When you open your own clinic, you run straight into that reality.

You’re not just “applying for privileges.” You’re walking into someone else’s turf war. And you’re the new potential threat.

Let me walk you through how this actually works behind closed doors—what’s said in committee meetings, how administrators think, and how your former attendings quietly decide your fate without ever saying your name out loud.

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The Real Power Structure Behind Privileges

Most new attendings think: “If I’m competent and board certified, they’ll give me privileges.” That’s the official story. The unofficial story is a lot messier.

Inside every hospital, there are three main power blocs that matter for your privileges:

1. The C-suite and their business priorities
2. The dominant private groups (or employed physician network)
3. The medical staff committees that rubber-stamp what #1 and #2 really want

They will never write this down. But this is the hierarchy.

The C-Suite: Follow the Money

Hospital administrators don’t care if you’re “starting your own clinic” in the abstract. They care about:

• Will you send cases, procedures, imaging, and labs to their hospital system?
• Or are you going to take that business across town?

To them, you are either:

• A “strategic partner” private doc they can milk for downstream revenue
• Or a future competitor aligned with another system or ASC that might siphon high-margin procedures

I’ve heard this exact line behind closed doors from a VP of Operations:
“If he’s independent but loyal, fine. If he’s independent and looking at that new surgery center, I’m not helping him grow here.”

They will not deny you purely for that. Too risky legally. But they can slow-walk your application, nitpick, or assign “provisional” status forever and make your life annoying enough that you go elsewhere.

The Dominant Group: Turf Protection

At most hospitals, one or two private groups own the sandbox. Example:

• One big cardiology group
• One anesthesia group
• One ortho group
• One GI group

These groups often:

• Control the call schedule
• Dominate key committees
• Have direct lines to the CMO or CEO

They’re not thrilled about a new, independent cardiologist or GI doc who wants privileges but doesn’t want to join their group. You are competition. You might eventually start your own ASC, or cut in on their referring PCPs.

What they actually say in committee sounds softer:

• “We’re concerned about call equity.”
• “Does he have enough volume to maintain competency?”
• “We need to review more case logs.”

Translation: We don’t want him here unless he’s under our umbrella—or at least not threatening our volume.

The Committees: Where the Politics Get Sanitized

Credentialing and Medical Executive Committees are where the politics get turned into “official” decisions.

The sequence is usually:

• Medical staff office collects your paperwork and sends it to department chair
• Department chair (often aligned with the big group or employed system) writes a recommendation
• Credentialing or MEC reads that, asks a few questions, and 95% of the time just follows it

You won’t see the real conversation:

“She’s good clinically but she’s going to that new multispecialty clinic linked to the competing hospital.”
“We really want to support our own employed group first.”

On paper? You’ll see something like:
“Recommend provisional privileges with a focused professional practice evaluation (FPPE) for 12 months, with volume and case type to be reviewed.”

That’s the sanitized version of: “We’re not super excited about her, but we can’t block her outright.”

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What Actually Happens When You Apply for Privileges

Let’s walk it like a timeline, because the chess moves start early—often before you even submit an application.

Hospital Privileges Application Flow

Step	Description
Step 1	Decide to open clinic
Step 2	Target hospital list
Step 3	Call medical staff office
Step 4	Submit application
Step 5	Department chair review
Step 6	Credentialing committee
Step 7	Medical Executive Committee
Step 8	Privileges granted or limited

The formal process looks straightforward. The informal one is about relationships and reputation.

Step 1: The Quiet Background Check

Before your file ever hits an agenda, people talk.

The medical staff office or chair will quietly ask:

• “Anyone know this doc from residency/fellowship?”
• “How was she in the OR?”
• “Any stories?”

If someone remembers you as entitled, sloppy with notes, or combative in sign-out, that sticks. I’ve seen a chair say, “Technically she’s fine, but she was a nightmare as a fellow; let’s keep her provisional for as long as possible.”

You think nobody remembers you from that one conflict as a PGY-3? They do. Especially if they were attendings then and are now in leadership.

Step 2: The Economic Profiling (Nobody Admits This)

Here’s what’s really happening when you say, “I’m opening my own clinic”:

They’re doing mental math: Are you a net inflow or outflow to their system?

If you:

• Join their employed network → green light, fast-track
• Join a friendly independent group that sends cases there → likely okay
• Open a solo clinic with no clear alignment → cautious curiosity
• Open a clinic heavily aligned with a competing system or ASC → red flags, “process” suddenly gets slow and meticulous

You’ll never see “economic competitor” in writing. But watch the patterns. Some people get privileges in 6–8 weeks. Others get “under review” purgatory for months with no clear explanation.

Approximate Time to Privileges by Alignment

Category	Value
Employed by system	8
Independent but loyal	10
Unaffiliated solo	16
Aligned with competitor	24

These numbers aren’t official. But they match what a lot of new attendings quietly report.

Step 3: The Call Schedule Trap

Even if you get privileges, the real weapon hospitals and existing groups use is call.

Control of call = control of access.

Typical games:

• “New docs must take extra call to show commitment.”
• “We can’t add you to call yet; the schedule is locked through the year.”
• “Our group covers call under an exclusive contract; we don’t have room for outside docs right now.”

I’ve seen independent surgeons get OR time only when they agree to cover brutal weekend calls while the established group cherry-picks weekday elective blocks. They use your desperation for cases against you.

And if the dominant group has an exclusive agreement, you may be technically on staff, but effectively shut out of call and certain cases. Translation: you exist on paper, but starve clinically.

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How Your Employment Choices Shape Your Privileges

Here’s the uncomfortable truth: where you work first after residency can lock in your hospital privileges options for years.

Let’s walk through the common scenarios.

Scenario 1: Employed by the Hospital System, Then Go Independent

This is the one they hate the most.

You sign on as employed, use their resources to build a panel, then leave to open your own clinic down the street once you’re established. From their perspective, you just “stole” patients they paid to acquire.

Reactions I’ve seen:

• Attempts to enforce ridiculous non-competes
• Sudden “quality concerns” when you re-apply for independent privileges
• Pressure on referring PCPs (“We recommend keeping referrals in our network”)

If you plan to eventually go solo, do not be naive about this. Once you leave their employment, your political capital in that system drops dramatically. You’re now a potential flight risk for volume.

Scenario 2: Start Independent From Day One

Riskier financially, but cleaner politically.

You approach hospitals as an independent from the start:

• No non-compete
• No sense of “betrayal” when you grow
• You can align with more than one system if you’re careful

Downside: you have little leverage, no institutional protection, and you’re asking for privileges without having “paid your dues” inside their ecosystem.

The smart ones in this path:

• Build relationships as residents and fellows with hospitals they plan to use
• Do community rotations there, scrub with key attendings, make themselves known
• Plant the seed early: “I’m thinking of staying in town and opening a clinic—what would it look like to have privileges here?”

Scenario 3: Join a Big Private Group, Then Try to Peel Off Later

This is where it gets bloody.

If you join the dominant group at a hospital, you usually enjoy:

• Automatic or smooth privileges
• Block time
• Protected presence on committees

But when you announce you’re leaving to open your own practice, that group has every incentive to:

• Cut you out of call
• Reassign your OR time
• Quietly poison the well with administration: “He’s not a team player, we’ve had some concerns…”

I’ve watched a GI group specifically warn a hospital:
“He’s leaving us and talking to the new ASC; just be careful about what privileges you give him here.”

Suddenly that doc’s colonoscopy block time evaporated, and his new cases always landed at 3 pm Friday or not at all.

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Concrete Strategies to Protect Yourself When Opening Your Clinic

You don’t have to be powerless in all this. But you do have to be strategic, not idealistic.

1. Choose Your “Home” Hospital Very Deliberately

Do not spray applications everywhere blindly.

Identify:

• Which hospital gives you the best mix of OR time / procedure support / admin openness
• Where your ideal patient population actually goes
• Which system is losing market share and desperate for new volume (they’ll be more welcoming)

Sometimes the “prestige” flagship downtown is a terrible choice if it’s dominated by a huge employed group. A smaller community hospital 15 minutes further may give you real room to breathe.

Factor	Big Flagship	Smaller Community	Competing System
Politics Intensity	High	Medium	High
Access to Committees	Low	Higher	Variable
Desire for Volume	Moderate	High	High
Dominant Group Grip	Strong	Weaker	Variable

2. Build Real Relationships Before You Need Anything

The worst time to meet the department chair is when your file hits their desk.

During residency or early attending life:

• Scrub with them
• Ask for case feedback
• Show up to M&M, tumor boards, journal clubs
• Ask: “I’m thinking long term about staying in the area; what do you think I’d need to do to be a solid member of staff here?”

People advocate for humans they know. Not CVs.

3. Control Your Reputation Ruthlessly

Every minor blow-up you had as a resident? That can haunt your privileges later.

Things that quietly follow you:

• Being “that resident” who fought over work hours constantly
• Sloppy notes prompting chart reviews
• Nursing complaints about rudeness
• Ignoring “suggestions” from attendings

I’ve seen a privileges conversation go like this about a brand-new doc:

“Technically, her record is clean.”
“Yeah, but remember how she talked to staff? I’d watch her closely.”

That’s how you end up with more FPPE conditions than your peers.

4. Negotiate Call and Block Time Explicitly

Don’t leave it as, “We’ll work it out after you’re on staff.” That’s how you get screwed.

When possible, you want some version of:

• Written understanding of your access to OR / procedure slots
• Clear inclusion on the call schedule with defined frequency
• If there’s an exclusive group, clarity on what an independent can and cannot do

You won’t always get this in a binding contract. But you can absolutely push for explicit emails or meeting notes. Paper trails matter when the story changes later.

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How Hospital Systems Quietly Punish Independent Clinics

Once your clinic is open and you’re moving patients through, the politics don’t stop. They evolve.

You’ll see a few recurring moves.

The “Quality” Weapon

If they don’t like that you’re sending some cases elsewhere, you may suddenly:

• Get more frequent peer review requests
• Get more “random” chart audits
• Have complications scrutinized differently than the big group’s

No one says, “We’re targeting you.” They say, “We’re standardizing quality.” Funny how “standardization” often starts with the independent doc who just opened their own MRI arrangement.

Your defense is boring but critical: clean documentation, appropriate indications, clear communication with hospital staff, and zero arrogance when questioned. They’re half-testing your temperament, not just your medicine.

The Referral Squeeze

Hospitals are getting more aggressive about keeping everything “within the system.”

That means:

• Employed PCPs get subtle guidance: “Use our specialists first.”
• Referral order sets are pre-populated with employed groups, making you an extra click or not listed at all.
• Discharge paperwork defaults to system-owned follow-up clinics.

If you’re a strong clinician with good outcomes, patients will still find you. But you should not count on hospital referrals to grow your clinic. That pipeline is increasingly protected.

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The Only Real Leverage You Ever Have

Let me be blunt: your only sustainable leverage is this combination:

• You take good care of patients
• You’re not a pain in the ass to work with
• You bring the hospital real, noticeable volume

Competence + collegiality + cash flow. That’s the holy trinity.

You don’t have to be a saint. But if nurses dread you, if anesthesiology hates your turnovers, if the OR manager thinks you’re entitled—leadership will listen to them long before they listen to you.

On the flip side, I’ve watched independent docs slowly become untouchable politically because:

• Their patients love them
• Referring PCPs respect them
• The hospital CFO can see their volume on monthly dashboards

When those three line up, administrators start sentences with, “We really don’t want to lose her.”

You want to be the one they’re afraid to lose. That’s your protection against the messier politics.

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FAQs: The Real Answers You Won’t Hear in Orientation

1. Should I tell the hospital I’m opening my own clinic or frame it differently?
Be honest, but strategic. Say you’re opening a community-based practice and hope to build a long-term relationship with their system—language about partnership, collaboration, and sending appropriate cases there. Don’t lead with, “I’m staying completely independent from any system” even if that’s true. That reads as potential flight risk.

2. Is it safer to get privileges first before I announce my independent clinic plans?
Sometimes. If you’re currently employed or in fellowship and applying as “future staff,” you don’t need to give a full business plan. Once you’re approved and on staff, it’s harder (though not impossible) to backtrack based on your practice model. But do not lie on any application. Omission is one thing; misrepresentation is a career-ender if discovered.

3. Can a hospital really deny my privileges just because I’m competition?
On paper, no. In reality, they can bury you in process, ask for redundant references, delay meetings, or grant such restricted privileges that it’s functionally a denial. If that happens, you can appeal, get your state medical society involved, or even bring legal counsel. But know that being “technically right” and winning politically are not the same thing.

4. Does being on committees actually help, or is it just a time suck?
It helps if you pick the right ones. Quality, credentials, and OR committees are where reputations are made and defended. If you’re in the room, people think twice before casually trashing “that independent doc.” Also, you hear the gossip in real time instead of feeling blindsided six months later. It is work, but it’s protection.

5. If one hospital plays too many games, should I just walk and use a competitor?
Sometimes that’s absolutely the right move. If a system makes it clear you’ll always be second-class to their employed group, you’re better off aligning with a hungry competitor who values your volume. Just understand there’s no perfectly clean system. You’re choosing which set of politics you can live with—and which one gives your private practice the most room to thrive.

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Key points:
Hospital privileges are not a neutral, merit-only process; they’re a reflection of economic and political interests. Your early career choices and reputation give you—or cost you—real leverage when you open your own clinic. And over time, the only lasting protection you have is to be valuable, collegial, and too beneficial to the system for them to casually squeeze out.