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how to write an effective business plan in medicine

July 26, 2023

10 min read

Practice Growth

Starting a Practice

Free template: How to create a business plan for your new practice

Your medical practice business plan is a living document that evolves as your practice grows. Here’s how to build it from scratch.

how to write an effective business plan in medicine

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At a glance.

  • A medical practice business plan is crucial for establishing direction, estimating finances, and evaluating competition.
  • Creating an effective business plan involves gathering relevant data, making conservative financial projections, seeking expert input, and planning for risks.
  • The 8 essential sections of a thorough medical practice business plan include the executive summary, business model details, market research, staffing model, 12-month budget, and more.

Medical schools and residencies prepare doctors to provide quality patient care but not to create a medical practice business plan. Yet a business plan is a key part of reaching new patients and supporting existing ones.

An effective medical practice business plan will:

  • Establish a roadmap for your practice
  • Estimate your revenue and expenses
  • Evaluate the competition

Creating a thorough business plan may feel like an onerous roadblock to moving forward. However, plotting your direction in advance will keep you on track later on, and will set you up to effectively serve your patients.

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Why you need a business plan for your medical practice

Whether you plan to start your own practice or take over someone else’s, a robust business plan is necessary. When you develop a comprehensive business plan full of intention, clear thought processes, and fine details, you demonstrate your commitment to your practice, community, and discipline.

A solid business plan effectively positions you to prevent surprises that could completely derail your practice and reputation.

“ A solid business plan effectively positions you to prevent surprises that could completely derail your practice and reputation. ”

If you plan to seek investors or business partners for your practice, a thorough business plan demonstrates that you have both a vision and the empirical data and financial goals required to back it up. It also establishes and communicates the direction you intend to take your practice.

If you do not plan to seek outside investors, your medical practice business plan is still a key tool for the most important investor: you. Working through the 8 parts of a plan will help you evaluate the landscape, establish your foundation, and move forward with your practice.

That said, writing your business plan is not the same as establishing your budget. However, you will need to create a detailed budget so you can incorporate some of that information into your comprehensive business plan.

What is involved in developing a healthcare business plan?

As you develop your medical practice business plan, think of how you approach diagnosing a patient: a systematic process. While it may vary by practitioner, you typically:

  • Get to know your patient
  • Ask about symptoms and history
  • Dig deeper into factors that are relevant to the current issue
  • Collect data from tests
  • Develop an initial diagnosis
  • Seek additional counsel when appropriate
  • Revisit the diagnosis if needed
  • Discuss the findings and prognosis with your patient
  • Schedule treatment and follow-up

The business plan creation process is similar.

Translating the process to your medical practice’s business plan

Getting to know your patient translates into defining your mission and vision. What do you want to accomplish? What is your role in your community?

Asking about symptoms and history will lead you to gather relevant documents, certifications, and professional memberships; research other local practitioners; and investigate why your practice’s focus is needed. Just as you need to know how the body’s systems fit together, you need to know how your practice will fit into the market.

Digging deeper into factors relevant to the current issue involves getting into the numbers. Evaluate:

  • Your selected location
  • Fee structure
  • Insurance company partners, if any
  • Target patient volume
  • Staffing needs
  • Services, whether legal, financial, or practice growth
  • Equipment, medical, and office
  • Maintenance and upkeep cost estimates
  • Ongoing costs, including rent or property taxes

Collecting data requires gathering facts. Avoid using more lucrative or optimistic numbers. Build your plan based on conservative estimates to set your practice up for success. Determine what benchmarks to establish and measure success.

Develop an initial diagnosis by evaluating whether you’ve made inaccurate assumptions or missed key components. Revisit areas you need to and gather new information.

Seek additional counsel in this process. Your legal and financial advisors are an important resource as you create your plan, not just as you execute it. You may also consult your staff about parts of your plan in which they have expertise. Finally, partnering practitioners should agree with the plan’s approach and direction.

“ Your legal and financial advisors are an important resource as you create your plan, not just as you execute it. ”

Revisit the diagnosis. Consider the input and adjust your assumptions, numbers, and benchmarks.

Discuss the diagnosis and prognosis with your investor(s). In this step, share your completed business plan with the individual(s) with whom you are working.

Set a follow-up plan to evaluate your progress after certain periods of time.

Patient Perspectives Report

How to build your medical practice business plan document

It’s one thing to theoretically know how to approach your medical practice business plan and another to sit down and create it. This 8-section outline will give you an idea of the crucial parts of your document.

Make a copy of this sample business plan template that you can customize and use for your practice.

1. Executive summary

In the executive summary, summarize your business model. Incorporate the information you developed while getting to know your practice.

Include an overview of information such as the practice location, services, target patient, local demographics overview, any relevant business history associated with the practice, and your mission and vision for your practice and its community impact. This is also where you will define any existing barriers to moving forward.

“ Your executive summary is an understanding and compelling argument for why the community needs your services. ”

Your executive summary is an understanding and compelling argument for why the community needs your services. It will highlight how you will fill a need that is not met in the current environment.

This is the section that will get you invited to the investor’s table, as it were. It is the bait on the hook of your argument.

Pro tip: Save the executive summary for last. Once you have the information from the other areas you will research and develop, it will quickly come together.

2. Detailed business model

Define your services and how you’ll manage prospects who fall within and outside those services. Specify your hours of operation. Define and describe your physical office space.

If you intend to offer telehealth , describe how. Define the number of staff you’ll employ, their roles, and how you plan to add staff as your practice grows. Detail the equipment you’ll use and why it’s essential.

Determine which vendors you’ll use for a variety of functions, including office cleaning; non-office hours emergency call management; office, medical, and exam equipment and furniture; office and medical supplies, software; marketing; and physical and digital security .

3. Comprehensive market research and positioning

Provide hard data on the demographics of your local geographic area and how they support your practice. For example, do enough people in your area need your services? What is the median income in the area, and how has that influenced your target fee structure?

“ Define your insurance partners, how their fee structures align with yours, and how competitive your proposed fees are. ”

Define your insurance partners , how their fee structures align with yours, and how competitive your proposed fees are.

Outline your local competition, the reasons you can be sure there is enough market availability for your new practice, and why your practice is positioned for success above your competition.

4. Detailed staffing model

Even if you plan to be the only provider in your practice, you will still need a plan to answer calls, file insurance claims, maintain files, manage billing , process payroll, and order supplies, among a host of other tasks to keep your practice running smoothly.

In this section of your medical practice business plan, list what positions you will fill and how many people you will need in each. Include compensation, along with any budgeted overtime, as well as benefits and tax considerations. Also, note when you will target hiring each throughout the year.

5. Projected 12-month income and budget

Show the math regarding how many patients you will serve for each service you will offer, your projected fee for each service, and your anticipated overhead expenses.

Your overhead will include items such as:

  • Staffing expenses based on the total number of staff and projected salaries.
  • All office-related expenses for equipment, supplies, maintenance, utilities, software, marketing, staff recruitment, and temporary services.
  • Anticipated vendor expenses such as off-hours call service, telehealth subscriptions, lab processing fees, janitorial services, etc.
  • Maintaining licensure, subscribing to professional journals, and attending conferences to stay current.

Make sure to account for one-time or short-term expenses, such as an extra administrative position to cover a known busy month, as well as for ongoing expenses.

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6. Potential risks and mitigation

What risks can you anticipate as you open your practice? This is the section where you will think of worst-case scenarios and what you would do were they to become a reality.

Consider scenarios such as:

  • A patient sues you. The United States is a very litigious society. What sort of malpractice insurance or bonds do you need to obtain?
  • A staff member gets injured at work. In addition to the mandatory worker’s comp, how else would you support them? And what does your insurance cover?
  • You get injured at work. How can you protect the longevity of your well-being and that of your practice?
  • Another global pandemic hits. How will you staff and maintain patient treatment protocols, what specialized supplies will you need to purchase, what type of insurance rate hikes could you anticipate based on the last pandemic’s model, etc.
  • A natural disaster hits. Depending on your geography, are you likely to experience a flood, fire, earthquake, tornado, hurricane, or blizzard? Are there emergency supplies you can keep on hand? Are there specific ways you can shore up your facility to make it more stable — and when would you make those changes? What specialized insurance do you need to purchase?

Talk to a seasoned physician who can provide some mentorship. Ask what they’ve faced during their years of practice and what you need to know to be prepared. Then take that information into meetings with your lawyer and insurance broker.

7. Implementation plan

In your project implementation plan, outline the steps you need to take to open your practice, what milestones you will hit, and an associated date for each major and sub-task. Whether you use formal project management software or create a project plan in a spreadsheet or other document, include that detailed information in this section.

8. Exit strategy

You’re just opening or growing your practice — why would you plan to leave it? Plans change, retirement becomes attractive, large conglomerates buy smaller practices, or a host of other scenarios could happen.

“ Just as you worked through the risks section, there is value in thinking ahead to determine your plan when you are ready for something different. ”

Just as you worked through the risks section, there is value in thinking ahead to determine your plan when you are ready for something different. Will you sell your practice? How will you transition your patients? What will happen with valuable equipment and supplies?

Identifying these items and addressing what you feel will be the best way to step away from what you are currently creating will make the process more manageable later.

How detailed is an effective business plan?

You know what process to use and the broad sections to include in your business plan, but how detailed should you get?

While you don’t want your business plan development goal to be a target length, a solid business plan typically ends up being somewhere between 30 to 40 pages. This information will include graphs and charts that demonstrate your demographic research, specific equipment needs for positive community impact, budget numbers, etc.

Your business summary and exit strategy sections should not exceed 20% of your overall business plan. Both will provide a high-level overview; neither is the section where you will get into excruciating details.

However, the other 6 sections of your business plan will get into the fine details. Each section should provide narrative information as well as specific numbers that are itemized by topic and category.

Keep your business plan alive

Even though your medical practice business plan can provide information for potential investors, partners, and financiers, it is ultimately the mirror of what you want your business to become. This should be a living document you update and change as your priorities and focus evolve.

“ As you move forward and grow your practice, set yourself up for a larger vision. ”

As you move forward and grow your practice, set yourself up for a larger vision. Adding 3- and 5-year projections to your 12-month business plan will help refine your sense of your purpose and direction.

By creating a medical practice business plan, you create confidence in not only your ability to attract patients, but also your ability to run the business that serves them long term.

Further Reading

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Karmin Gentili

Karmin Gentili has been a freelance writer and editor since 2016. She has over 25 years of experience in corporate HR and compliance consulting. She has worked to further elevate her skills by pursuing and receiving multiple certifications, including copywriting, video scriptwriting, effective content positioning, case study writing, and SEO. Her love of writing motivates her to use those skills to develop content for the medical field that ensures others can work toward achieving their goals.

Reviewed by

Lauren Wheeler, BCPA, MD

Dr. Lauren Wheeler, MD, BCPA, is a former family medicine physician who currently works as an independent healthcare advocate as well as a medical editor and writer. You can get in touch with her about anything writing or advocacy at her website www.lostcoastadvocacy.com .

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How to Write a Business Plan for Medical Practice

How to Write a Business Plan for Medical Practice

Last updated: 04 / 08 / 22

You learn a lot in medical school, but business planning isn’t a focus. However, many health care practitioners go on to run their own businesses where developing a business plan becomes essential.

If you’re planning to start your own practice, or you’re taking over someone else’s medical business and want to run it effectively, it’s a good idea to spend some time working out the details and putting together a formalised plan first. You may also want to get professional advice on your business planning, and any other aspects of running your medical practice you’re not sure about. In the meantime here are a few business planning basics to get you started.

writing business plan

Why have a business plan for your medical practice?

While it can be tempting to just dive right in and start setting up your new medical practice, a business plan can help you get prepared and make sure you stay on the right track as your practice grows.

A solid business plan is the foundation of any successful medical practice. With a business plan you can identify potential issues upfront and devise a strategy to avoid them. You can also set realistic goals for your business to help you keep moving in the right direction. If you’re looking for funding at any stage, you’ll also need to have a business plan. Most medical practices will struggle to get a business loan without a solid business plan in place.

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What to include in your medical practice business plan

Your business plan should include the following:

  • A summary of your business, including the medical services you provide, your location, and the history of the business.
  • Financial information including projected cash flow, outgoings like medical equipment, marketing and practice management software costs and projected turnover.
  • Operational factors like trading hours, fees, staffing and potential suppliers
  • Risk identification and management – details of how you will manage the biggest potential risks, e.g. malpractice insurance, other insurances, data security and your credentialing process.
  • Marketing – how you will get new patients and retain the existing ones.

As well as all the information about your medical practice and strategy, it’s also important to set goals and targets for your new venture. These should be in your business plan so you can keep track of them and make sure you’re working towards them consistently.

medical plan data

Making sure you have a solid business plan

So how do you make sure your medical practice business plan is solid? It’s very easy to have your plan in your head, but if you don’t get it out, it’s going to be hard for anyone else, especially the other providers and support staff in your practice to implement it. So the first step is to put it down on paper, or in a word document.

Once you’ve got a detailed plan on paper, don’t just put it in a drawer and leave it. Business planning should be a regular task for you and your business partners. Once you have your business plan in place, make sure you review it at least once a year, preferably more and update it as your business priorities change.

writing business plan

Writing a business plan for your medical practice might seem like a time consuming task, but it’s well worth the effort. With a strong business plan, you can grow your practice, achieve your goals and avoid many of the pitfalls that can trip up practice owners who haven’t taken the time to plan ahead.

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business plan for doctors

The ultimate business plan roadmap for doctors in private practice.

Kris Borgraeve - Co-founder Digital Practice

Kris Borgraeve

November 18, 2021

The simple checklist to start writing your business plan

A business plan for doctors with ambition.

When we help doctors communicate online and attract (more) patients to their private practice, we always include a business strategy process . The checklist partly covers general best practices to create an effective business plan for doctors, and some of the items are relevant beyond your business plan. The answers to these questions often become the DNA of the practice, and I have seen specialists and surgeons create their business success in no time, using a simple checklist like this one:

  • Your why: Taking the time to reinspect the main reason why you have chosen to create a private or independent clinic is a success factor in itself. It reconnects you with your purpose. Jot down a few bullet points to summarise why you decided to create your practice. Go back to it from time to time to reconnect with your passion.
  • Your goals: Whether this step involves closing your eyes and visualising, or sitting in front of a whiteboard with your eyes wide open. As long as you create clarity about your goals, 12 months and 3 or 5 years from today. What type of patients do you spend most of your time with? What does your team look like? How are your status and reputation?
  • Timeline: If you are starting out or upscaling your practice, create a plan with timeframes for each step. If you underestimate the time to move to the next step, it may cost you money or you may lose momentum and team members who don’t have the patience to wait until it all comes together.
  • Budget: Do some research on the various costs to run your practice. Consult with a reliable financial expert to crunch the numbers. Also research the real costs that are involved in building a brand, creating a strong profile and activating a systemised GP-referral strategy.
  • Market research: Did you know you could get access to the online traffic volumes of your competitors in any major capital city for any specialty? Check who is most visible for which type of treatment or procedure. Research the educational content that is most googled for and work with an expert who knows your local market to create realistic traffic and lead projections.
  • Avatars: Envision the type of patient you want to see in your future and ideal practice. Build your avatar with as much detail as possible, from age brackets to preferred suburbs, including income ranges, and places where your ideal patient spends time.
  • Focus treatments or services: Many specialist doctors still believe they need to communicate about every little procedure they do. Leading specialists understand the power of subspecialising. Would you rather be one of the 340 orthopaedic surgeons that do hip, elbow, knee, shoulder and wrist procedures? Or one out of 3 who is doing elbow surgery for tennis players?
  • Hospital associations: Think ahead and get informed about accreditation options for the hospitals in your catchment area. Read the fine print. Speak to colleagues in another specialty area about their experience with the hospital you are approaching.

With that checklist in mind, you will be best off if you find experts who have a clear focus on the mechanics of an independent or private health practice.

Brand, Market Research and other business planning secrets

Business plan essentials for doctors.

Your practice as a brand is a reality, no matter how big or small your efforts to turn it into a brand. Let me put this in perspective.

Even if you believe you are totally not the type of person to create a brand, you still are creating one. The following fictional scenario has often been a wake-up call in the workshops we run with specialist doctors and it will change your perspective on this concept of ‘brand creation for doctors’.

Do your research. Google your main treatments, procedures or the associated conditions and add the town or city where you work. Take a look at the top 5 specialists and ask yourself if the brand experience is building trust or not.

One of the little-known business secrets for doctors in private practice is the power of digital branding and content marketing . Doctors who have significant resources for patients who are still making up their minds are building a strategic advantage over doctors without a presence.

Business plan for doctors

Where to find help when starting out in private practice?

Business advice for doctors.

As you just start out in private practice, you will be well aware of the advantages of going private. There are many experts who can help you and a popular solution consists of one-stop-shop businesses who have a variety of experts on board, with particular expertise in the area of private practice success and growth.

What you are looking for is an integrated combination of expertise to help you with:

  • Financial setup
  • Administration and practice management
  • Credentialing and hospital accreditations
  • Real estate
  • Medical technology
  • Recruitment and HR

From experience, we know that adding marketing to the mix generally results in outsourcing back to specialist agencies such as Digital Practice. It may work well in transparent partnerships with other providers though, particularly if you have an existing business relationship with a provider in one of the above areas.

At Digital Practice, our focus is on generating income . It is the second most important layer of your business plan, right behind the clinical or surgical skills. The way we attract patient leads for your private practice is based on building online visibility, GP referral marketing and advanced market research into the information needs of your average patients. With the exponential rise of online and digital, this is rapidly becoming the first pillar of any substantial business plan for doctors, not a commodity that is added to the plan long after the above areas have been covered.

To share a remarkable story with you: Many of our top customers have actually started the process in the right order, creating an outline for their future brand first, and then adding the management, location and recruiting steps to their timeline. After all, the location, the team you hire and the management style you introduce, are all going to be part of what your patient experiences as your brand .

3 Thriving private practice business brands

Private practice business models.

The Woom is a Women’s Health brand with a unique brand and a unique business model. It offers the specialised expertise of accredited fertility specialists and gynaecologists, in conjunction with women’s health GPs, dietitians, psychologists and physiotherapists. The clear brand promise is supported by Google-optimised content per main business avenue on attractive, informative content pages. As a result, visibility is predictable and supports the business growth objectives for this ambitious and fresh expert brand in women’s health.

Advance Surgical has a boutique profile around lead surgeon Dr Jon Armstrong. The personal touch, the personability of the team and the transparency around fees and processes offer immediate guidance to the patient when they visit the Advance Surgical website. A variety of forms is available to get in touch, one of which allows patients to verify if they are a candidate for the weight loss surgery types that are offered.

Wexford Gastro has a brand positioning around the catchment area of the Wexford Building which serves as an anchor point for people in the surrounding suburbs. The brand focuses on facilitating patients who are preparing for their gastroenterology procedure, with clear information on what to expect. A fresh, simple and inviting ‘about section’ allows patients to get to know their specialist before they go and see them in a first consultation.

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The 5-minute business course for doctors

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How to Create a Successful Healthcare Business Plan for Your Medical Practice

How to Create a Successful Healthcare Business Plan for Your Medical Practice

It is a common misconception that healthcare practices do not require marketing strategies in the same way that other companies and professions do. However, healthcare should be treated as a business and cater to consumers, or in this case, patients.

A successful business plan is essential for medical practices to attract new patients, retain current patients, and maintain a positive relationship with the community.

Without a business plan, practices may find themselves disorganized, lost, and unable to adapt to any changes in business, such as decreased visits or increased appointment cancellations.

Why is a Business Plan Necessary?

Creating a business plan for your healthcare practice means laying out where you are now and where you want to be in order to fill in strategic goals and benchmarks needed to track progress. Without a finished business plan to rely on, healthcare practices will not have any insight or idea of their returns.

Additionally, the attracting and retaining of patients will not be prioritized or managed. Opportunities for improvement may get overlooked, revenue may not increase, and patient trust may be lost.

How to Create a Healthcare Business Plan

Clearly, a business plan is non-negotiable for healthcare practices. But where do you start? What should you focus on?

Most practices that put together business plans rely on these basic guidelines to get a head start. Keep in mind that any of these parts can be adjusted or changed according to what makes the most sense for your healthcare practice.

#1: Identify Your Ideal Patient

Healthcare practices are essentially promoting services to an audience, or, patients. Start identifying and defining your target audience by assessing who uses your services. Marketing plans should be developed with this target audience in mind in order to be effective.

If you have a wide range of patients varying in age, gender, etc., consider segmenting them into different, smaller groups or learn about what each patient has in common outside of traditional demographics.

#2: Define Your Vision

Solidify your goals by defining them in the largest business plan. Brainstorm and write down goals, significant milestones, and where you see the practice in 3 years, 5 years, etc. Document how you will achieve these goals and set dates for major milestones.

#3: Assemble a Team

It takes a village to run a successful healthcare practice, from the front office staff to third-party contractors. Take this time to document who will be involved with this business plan and to what degree.

Outline roles, responsibilities, and initiatives for each team member. Make sure to tie this all in with your overall vision. For example, if you envision a significant effort in social media marketing within the next year, define the role(s) that will be responsible for this.

#4: Build Patient Personas

When other businesses create their business plans, they often run an exercise to build “buyer personas.” These are essentially profiles that represent ideal customers , based on real data.

This exercise includes giving these personas creative and explanatory names, incomes, budgets, careers, and more, to help guide business and marketing decisions.

In healthcare, creating a patient persona works the same. Sit down with your team and create 1-2 profiles of your ideal patient. Give them a name, a medical condition or need, income, family status, personality attributes, etc. based on your actual patients. For example, a profile might look like this:

“Clever Cathy,” has diabetes, age 65, works in customer service, researches her conditions thoroughly/has lots of questions for doctors, makes 55k per year, has $500 to spend on care today, divorced, 3 kids out of the house.

Having these profiles on hand can help pull focus to your patient's needs during important business decisions.

#5: Perform a SWOT Analysis

Another tool to use for self-assessing your healthcare practice is a SWOT analysis . SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. Draw a 2x2 grid labeled with these terms, and start listing examples.

When assessing your healthcare practice's strengths and weaknesses, consider everything from an internal perspective and what you have control over, such as unique services (strength) and only having one provider (weakness).

Writing out your practice's weaknesses helps you to place all of your thoughts for improvement in one clean list. Keep it strictly about what you have direct control over, such as long wait times or outdated appointment booking systems.

Opportunities and threats are both meant to be viewed from an external lens and are things you do not have control over but can either leverage (opportunities) or maneuver away from (threats). Opportunities can include things like new real estate in a better location, while threats can include things like loss of staff.

#6: Finalize and Share

Once you have a full business plan solidified, finalize it and share it with all physicians, staff, board members, executives, and any other stakeholders necessary.

Once everybody is on board, you can begin the rollout, enjoying the support from every team member along the way.

#7: Check-in and Evaluate

Sometimes, a plan that we thought would surely bring in 100 new patients falls flat. That's why it is important to establish a plan to check-in with your goals, benchmarks, targets, plans, etc. to see what is working, and more importantly-- what's not.

Adjust and change your plan as needed, making sure everybody is still in the loop. By measuring and evaluating your business plan consistently, your chances of success improve.

Don't Forget “The 3 Pillars of a Successful Healthcare Practice”

While assembling your new business plan, let's not forget the 3 pillars of a successful healthcare practice : a growing patient base, a stellar online reputation, and a strong online presence.

Keeping these pillars in mind for a detailed business plan, healthcare practices can increase patient acquisition and retention. Make sure to integrate these pillars into your marketing plan!

To conclude, healthcare practices must have a business plan in order to be successful and to keep growing. These plans, as you've seen, can get large and sometimes complicated.

For busy practices, hiring a marketing agency to help handle this plan is a must. It's important to find a healthcare marketing agency that believes in your business plan. This keeps everybody aligned so your practice can see success.

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Ajay Prasad

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How to Write an Effective Business Plan in Medicine

Affiliations.

  • 1 Division of Gastroenterology (Pediatrics), Columbia University Medical Center, New York, New York.
  • 2 Division of Gastroenterology (Pediatrics), Stanford University School of Medicine, Palo Alto, California. Electronic address: [email protected].
  • PMID: 30849315
  • DOI: 10.1053/j.gastro.2019.03.003

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    The aim of this paper is to provide an easy-to-follow, standardized, and structured approach that gastroenterologists can use to facilitate writing a business plan. It consists of 5 parts: an executive summary, business concept, market analysis, business strategy, and implementation plan.

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  6. How to Write an Effective Business Plan in Medicine - PubMed

    How to Write an Effective Business Plan in Medicine. Gastroenterology. 2019 Apr;156 (5):1243-1247. doi: 10.1053/j.gastro.2019.03.003. Epub 2019 Mar 5. Authors. Amir Jazayeri 1 , K T Park 2. Affiliations. 1 Division of Gastroenterology (Pediatrics), Columbia University Medical Center, New York, New York.