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by Philip Masters, MD, FACP
Director, Clinical Content Development
Whether you are an internal medicine resident completing training and not pursuing a fellowship, or if you have trained in a subspecialty and are ready to begin practice, you should consider what type of practice situation will best meet your personal preferences and career goals. Multiple practice options are available, each with certain advantages and disadvantages. Here is a summary of the most commonly available types of medical practice settings.
Solo practice is described by its name—a practice without partners or employment affiliations with other practice organizations. Although previously a common model, this type of medical practice is becoming less popular than in the past, although it is a strongly preferred by some internists.
Solo practices are usually characterized by a small staff and typically have a limited patient base. This smaller size and the autonomy of being the only physician gives the advantage of being able to design, grow, and develop the practice as you'd like relative to other practice settings. Plus, a smaller patient base provides the opportunity for you to develop close, personal relationships with your patients and staff and provide your own unique style of medical care. On the other hand, the entire burden of running the practice rests entirely on you. This includes the medical care (such as the need to manage or arrange for hospital care and weekend coverage for your patients) as well as the entire business enterprise. The work involved in developing agreements with insurers and the burden of documentation for compliance and other regulations is usually significant. Also, solo practices are often at substantial financial risk due to the costs of doing business (such as hiring staff and maintaining malpractice coverage), possible lack of referrals, the small patient base, shifting patient allegiances because of insurance issues, and lost income caused by illness or vacation. Another consideration includes the extent of your educational debt which may further increase financial risk.
The locale in which you wish to practice will sometimes determine the success of a solo practice. Suburban or rural areas are often better suited for solo practice because of significant medical need and less competition from other medical resources. Additionally, some local hospitals affiliate and support solo practices (financially or with other services, such as access to electronic medical records) to help maintain their own patient base.
Group practices are typically divided into single-specialty and multispecialty practices. The defining characteristic of single-specialty practice is the presence of two or more physicians providing patients with one specific type of care (i.e., primary care or a specific subspecialty practice), while multispecialty group practices are defined as offering various types of medical specialty care within one organization.
Some advantages of group practices are increased financial security and better control of lifestyle. Because of the larger number of physicians and increased size of the patient base, group practices are usually better able to accept and manage financial risk than solo practices. Group practices may also be able to provide more employee benefits than are feasible in a solo practice, although often less than what may be available in employed physician organizations. Group practices also usually have the resources to manage the administrative tasks associated with running a practice, relieving the individual provider from the need to do this alone. Additionally, the increased number of physicians in a group spreads the burden of covering clinical care in the hospital, at nights, and on weekends across a greater number of people, allowing more flexibility in scheduling relative to a solo practice.
Despite these advantages, autonomy and decision-making ability decrease with the size of any group, increasing the risk for conflict around significant practice issues. Larger practices may also tend to become more bureaucratic and policy driven, and this may be seen as a disadvantage.
Increasingly, physicians are being employed within one of several practice models. Some hospitals may purchase and manage existing solo or group practices, or may directly hire physicians to work in their inpatient facility or ambulatory clinics. Health care corporations may own and run clinics with employed physicians. And some physician-run groups are structured on an employment model, where a group practice is structured more like a corporation that employs clinicians instead of pursuing a more traditional partnership model.
An advantage of being an employed physician is that much of the administrative burden of running a practice is shifted to the employing entity, allowing clinicians to focus more on practicing medicine. Additionally, a baseline level of compensation is usually assured, although productivity demands and incentives may be significant. Because the organizations employing physicians tend to be larger, they usually have more resources than solo or independent group practices. Clinically, this usually means reasonable coverage for clinical responsibilities and improved control of lifestyle. This larger size and increased resources may also translate into more robust support services and opportunities for further education and training.
The downside of being an employed physician is that physician autonomy may be substantially diminished relative to other practice models. Scheduling and productivity expectations may be beyond your control, and policies and procedures may be developed by others without your input. There may be less clinical flexibility due to limitations of referrals and facilities based on the employing organization. Additionally, there may be other expectations as an employed physician, such as serving on committees or participating in other organizational activities.
Some internists work in independent contractor relationships. In this model, the practice (either solo or a group practice) remains independent, but a facility and possibly clinical coverage is shared with other physicians or physician groups. This may spread the costs of running a practice across others and may provide some flexibility in clinical scheduling. The disadvantage to independent contracting is the loss of a degree of decision making as compared to a completely independent solo or small group practice.
Locum tenens (literally "place holder") is an alternative to more permanent employment. Locum tenens positions are temporary (from a few weeks up to a year) that are offered by practices, hospitals, or healthcare organizations that have an unfilled clinical need. Not infrequently, the compensation rate is higher than what the permanent position would offer. Locum tenens offers physicians the opportunity to work in a practice or an area for a short period of time which enables you to see what a practice type or location is like without committing to long-term employment.