Exploring entrepreneurship among general practitioners: a scoping review of education and practice.

Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMC Prim Care . 2026 Mar 6;27:134. doi: 10.1186/s12875-026-03241-5 Search in PMC Search in PubMed View in NLM Catalog Add to search Exploring entrepreneurship among general practitioners: a scoping review of education and practice Maryam Pirouzi Maryam Pirouzi 1 School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Find articles by Maryam Pirouzi 1, ✉ , Matire Harwood Matire Harwood 2 Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Find articles by Matire Harwood 2 , Shane Scahill Shane Scahill 1 School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Find articles by Shane Scahill 1, ✉ Author information Article notes Copyright and License information 1 School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand 2 Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand ✉ Corresponding author. Received 2025 Apr 3; Accepted 2026 Feb 18; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13077924  PMID: 41792619 Abstract Objective The increasing complexity of healthcare systems demands a general practice workforce equipped with entrepreneurial competencies to lead innovation, adapt to system pressures, and enhance service sustainability. Traditional medical education for general practitioners (GPs) emphasizes clinical expertise but often overlooks essential skills in business acumen, leadership, and innovation. The aim of this scoping review was to examine how entrepreneurship is conceptualized, practiced, and supported among GPs in primary care, with a particular focus on identifying the barriers, enablers, and gaps across education, practice, and policy. Methods A scoping review following the Arksey and O’Malley framework and JBI’s guidelines, to ensure methodological rigor. Literature searches were performed across SCOPUS, PubMed, and EMBASE (via Ovid), supplemented by citation searches. The strategy focused on entrepreneurship, primary healthcare, and General Practitioner. After screening and removing duplicates, relevant publications were selected through team discussion, resolving discrepancies by consensus. All included papers were coded for key themes and patterns, followed by thematic analysis to uncover key insights and trends in the field. Results Eighteen studies were included, with most (13) examining entrepreneurship in GP practice, three focusing on education, and two addressing both. Seven themes were identified: challenges in practice, areas and types of investment, medical school characteristics, contextual factors, entrepreneurial skills, behaviours and orientation, policy-level factors, and motivations. Barriers were most pronounced at the micro (individual) and meso (practice/organisational) levels, including limited business training, role conflict, operational difficulties, and lack of structural support. Macro-level constraints, such as restrictive funding and regulation, further curtailed innovation. Despite these barriers, GPs engaged in diverse entrepreneurial activity, from corporate and partnership models to social ventures, often in response to workforce pressures and growing demand for chronic care. Evidence was heavily concentrated in Western contexts, highlighting the need for more globally diverse perspectives. Conclusion The review highlights significant gaps in educational preparation and systemic support, pointing to the need for changes in curricula, policy incentives, and practice structures. Guidance from medical councils, accreditation bodies, and GP associations will be key to embedding entrepreneurship into GP training and practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-026-03241-5. Keywords: Entrepreneurship, General Practitioners, Primary care, Education, Practice Introduction Primary care systems, particularly general practice, are under escalating strain globally [ 1 , 2 ]. General practitioners (GPs) face mounting workload pressures, workforce shortages, increasing multimorbidity among patients, and rigid funding models that limit innovation and flexibility [ 3 ]. GPs need to do things differently. They need to think and act in different ways to deliver patient outcomes. According to the World Health Organization, nearly half the global population lacks access to essential primary health services [ 4 , 5 ], while the OECD reports that the number of GPs per capita is declining in many countries, particularly in rural and underserved areas [ 6 ]. These challenges are compounded by rising public expectations, growing administrative demands, and limited structural support for adapting to evolving health system needs [ 7 ]. Global health policy leaders including the World Health Organization (WHO), Organisation for Economic Co-operation and Development [ 6 ], and World Economic Forum, underscore that transforming primary care demands more than clinical reform; it requires a fundamental reimagining of service models, leadership, and delivery [ 4 , 6 , 8 ]. While WHO and OECD emphasize innovation and care integration [ 6 , 9 ], UNCTAD explicitly identifies entrepreneurship as a key driver in rebuilding resilient, equitable health systems and urges governments to adopt policies that support healthcare entrepreneurs, especially in primary care settings [ 10 ]. Furthermore, the World Economic Forum reinforces this stance, highlighting how entrepreneurial approaches in healthcare can bridge access gaps, foster community-based care models, and support inclusive health outcomes [ 11 ]. Similarly, professional organizations such as the Royal College of General Practitioners (UK) and Royal New Zealand College of General Practitioners have produced guidance and strategic documents encouraging GP involvement in service redesign, practice ownership, and business development [ 12 , 13 ]. These initiatives reflect growing momentum to position GPs as system leaders and innovators within increasingly complex health environments. In the context of primary care, these concepts- entrepreneurship, innovation and creativity- are interrelated but distinct. Creativity refers to the generation of novel ideas or approaches, such as rethinking service pathways or care interactions [ 14 ]. Innovation in healthcare typically involves the introduction of new technologies, services, or delivery models, such as telehealth or chronic care clinics [ 15 ], without necessarily altering the business model. In contrast, healthcare entrepreneurship is defined as “a dynamic, innovative, strategic, resourceful, and resilient process of starting, managing, and growing a venture that creates value for multiple stakeholders, including patients, practitioners, and health systems”[ 16 ]. This form of entrepreneurship often involves novel business models, interdisciplinary teams, and dual aims of financial sustainability and societal benefit, distinguishing it from routine innovation or clinical improvement initiatives [ 16 ]. Entrepreneurship is a relatively underexplored area due to several factors: the traditional framing of medicine as a purely clinical discipline, a lack of recognition of primary care as a site for business model experimentation, and an enduring emphasis on public service over entrepreneurial activity [ 17 – 20 ]. This scoping review addresses a knowledge gap by exploring the intersection of entrepreneurship and primary care. It synthesizes existing literature to examine how GPs engage in entrepreneurial activities, identifies systemic enablers and barriers, and discusses broader implications for healthcare systems. Specifically, this scoping review addresses the following research questions: (1) How do GPs engage in entrepreneurial activities within primary care? (2) What systemic enablers and barriers influence entrepreneurial integration in GP education and practice? (3) What are the broader implications of physician entrepreneurship for healthcare policy, innovation, and primary care service delivery? Methods A scoping review was conducted to explore entrepreneurship in primary care, using the Arksey and O’Malley framework [ 21 ], with methodological guidance from the JBI Manual for Evidence Synthesis to ensure systematic study selection, data extraction, and analysis [ 22 ]. Reporting was guided by the PRISMA-ScR checklist for transparency [ 23 ]. While the broader scoping review covered multiple areas within primary care, this manuscript focuses specifically on findings related to General Practitioners and medical doctors in practice and education. The study searched SCOPUS, EMBASE (through Ovid), and PubMed databases for literature on entrepreneurship in primary care, focusing on General Practitioners and medical doctors in practice and education. The search terms included “entrepren*”, “business innovation,” “healthcare entrepreneur*”, “primary healthcare”,“primary care services”, “community health services”, “primary health organization”, " General Practitioners” and “medical doctors” with a publication date range from 2000 to 2024 (April) and no study type limitations. After removing duplicates, titles and abstracts were screened for relevance by a single reviewer (MP), however, any studies with uncertain eligibility were discussed during weekly research team meetings to ensure accuracy and consensus. Full-text articles were reviewed by a single reviewer (MP), with uncertain cases discussed with the research team before making final inclusion decisions. A manual search of references was conducted using the reference lists of all studies that reached the full-text review stage. Studies were included if they met the predefined inclusion criteria (see Fig. 1 ). The full research search protocol has been registered on the Open Science Framework (OSF) and is available through the OSF link [ https://osf.io/mvy3e/ ], as well as in the appendix for reference. For data analysis, all papers included were imported into NVivo (version 14), a qualitative data analysis software, each document was coded by the researcher (MP) to identify key themes, concepts, and patterns within each category [ 24 ]. The analysis followed a partially inductive thematic approach, allowing themes to emerge while being categorized into predefined levels based on organisational theory: micro (individual practitioners), meso (organizational), and macro (systemic factors, such as healthcare policies and regulatory frameworks) [ 25 ]. To ensure consistency in the coding process, the first five studies were used to develop a preliminary NVivo codebook. This codebook was reviewed and refined by the research team in weekly discussions, which helped to address any coding inconsistencies and confirm alignment with the micro, meso, and macro framework. This structured yet flexible approach also allowed for the inclusion of contextual factors, such as community aspects, while minimizing assumptions to enable themes to develop naturally within the organizational theory framework guiding this review. Fig. 1. Open in a new tab PRISMA flowchart Results A total of 18 studies were included in this review, exploring the entrepreneurial activities, motivations, and challenges faced by GPs and medical doctors in primary care (see Table 1 - study characteristics). Most studies (13) focused on entrepreneurship in practice, while three examined education, and two covered both, highlighting a gap in research on how medical education prepares physicians for entrepreneurship. Geographically, research is concentrated in Western countries (UK, USA, Germany each with three studies), with fewer studies from Asia and Eastern Europe, indicating the need for more diverse perspectives on GP entrepreneurship across healthcare systems. The findings are categorized into seven themes, reflecting the multi-level influences on GP entrepreneurship. Table 1. Characteristics of included papers Authors Year of publication Country Education/Practice Method of research Main findings regarding entrepreneurship Weber 2013 Georgia Practice Qualitative This study examined the resurgence of direct-pay or cash-based models in family medicine. It highlights how physicians are moving away from insurance-based reimbursement towards direct payment models to enhance financial stability, reduce administrative burdens, and improve patient care. The study finds that cash-based practices allow for longer consultations, better doctor-patient relationships, and increased physician autonomy. However, it also raises concerns about potential patient access issues, particularly for lower-income populations [ 26 ]. WIERCIŃSKI 2019 Poland Practice Ethnographic research This research explored the entrepreneurial roles of doctors in Polish Primary Health Care (Podstawowa Opieka Zdrowotna – POZ). The researcher examines the values and practices of rural/small-town doctors and their urban counterparts by analyzing their formal and informal interactions with patients, focusing on time structures within primary care and the characteristics of symbolic exchanges in doctor–patient interactions. The research highlighted that many doctor–patient interactions transcend purely medical interventions, evolving into reciprocal exchanges characterized by mutual cooperation, attachment, and trust. This dynamic suggests that practitioners often act as social entrepreneurs, fostering deeper community ties and enhancing patient relationships [ 17 ]. Wang et al. 2019 China Practice Quantitative The study revealed that the predominant career orientation among Shanghai GPs was organizational job security/stability. This suggests a strong preference for stable and secure employment within an organization. Conversely, the entrepreneurial creativity orientation was the least favored, indicating a lower inclination towards innovative or entrepreneurial endeavors. Factors such as age, gender, education level, professional title, and years of service significantly influenced these career orientations [ 27 ]. Miller et al. 2012 England Review Practice The review reveals that active clinical engagement is crucial for effective primary care-led commissioning. Clinicians’ involvement leads to improved healthcare delivery, as they bring valuable insights from frontline practice. However, the extent of their influence varies across different commissioning models, and challenges such as balancing clinical duties with commissioning responsibilities persist [ 28 ]. Suwangto 2024 Indonesia qualitative, descriptive, cross-sectional design Education/practice The study found that basic entrepreneurship training positively influenced the entrepreneurial skills and self-perception of the participating young family doctors. Post-training assessments indicated improvements in their confidence and abilities related to entrepreneurial activities within their medical practices. This suggests that targeted training can enhance the entrepreneurial competencies of young family physicians, potentially leading to more innovative and effective healthcare delivery [ 29 ]. Yashiro et al. 2020 Japan Qualitative Education/practice Physicians’ entrepreneurial ventures are facilitated by their willingness to contribute to society, financial stability from a medical license, and self-efficacy, which boosts confidence in their abilities. However, barriers include a lack of career diversity, limiting exposure to entrepreneurial opportunities, and a rigid medical training system that does not encourage entrepreneurial thinking. While intrinsic motivation and financial security support entrepreneurship, systemic challenges within medical education and career structures may hinder such pursuits [ 18 ]. Bosa 2008 Germany Qualitative Practice The research found that GPs can drive significant changes in healthcare delivery models by leveraging their entrepreneurial skills developed within their practices. By embracing modern management tools and techniques, these physicians were able to integrate healthcare services effectively, thereby redefining their professional identities to encompass both medical and managerial competencies [ 30 ]. Zainal & Smith 2020 Singapore Qualitative Education The study identified several concerns among medical students regarding primary care careers, including limited professional opportunities, an overemphasis on lifestyle benefits over professional growth, and a lack of business training to manage a practice. Students also expressed worries about potential conflicts between business and clinical care, the perceived routine nature of primary care cases, limited continuity of care, short consultation times, and negative attitudes from specialists. However, positive aspects included entrepreneurial opportunities, portfolio careers, exposure to a broad range of clinical problems, and an optimistic future for primary care [ 31 ]. Zientek 2003 Netherlands Overview Practice The article discussed how physicians’ financial interests in healthcare facilities can lead to self-referral practices, where physicians refer patients to services in which they have a financial stake. This practice raises concerns about overutilization of services, increased healthcare costs, and potential compromises in patient care quality. The article also examines existing regulations, such as the Stark Law, designed to mitigate these conflicts, and debates their effectiveness in addressing the ethical dilemmas posed by physician self-referral [ 32 ]. Hoang and Perkmann 2023 The United Kingdom Mixed method Practice The study revealed that early-career physicians were primarily driven by a desire to improve organizational systems within the NHS. Their entrepreneurial ventures often began as internal initiatives aimed at enhancing existing processes. However, due to various constraints, these physicians transitioned their projects to external ventures, securing individual-level resources to advance their ideas. Despite engaging in entrepreneurial activities, the physicians maintained a strong commitment to the NHS, though they adjusted their career trajectories to accommodate their entrepreneurial pursuits [ 19 ]. Welsey and Greenblatt 2021 USA Quantitative Practice The findings revealed that 19.2% of these physicians had founded at least one new business, with the highest rate (33.9%) among those who graduated between 1974 and 1978. Of the 9,501 companies identified, 66.0% were related to clinical practice, real estate, or practice management; 7.4% focused on public interest areas such as advocacy, public health, and philanthropy; 5.6% were in biotechnology, healthcare IT, or medical devices; and 18.5% encompassed other business pursuits. On average, physicians took 20.2 years from medical school graduation to company founding. The study also noted disparities in entrepreneurship rates, with female physicians founding companies at lower rates than their male counterparts [ 33 ]. Preiser et al. 2021 Germany ethnographic approach Practice The study found that GPs juggle multiple roles in organizing working time, which can lead to psychological stress. Their delegation of tasks related to scheduling, vacations, and managing absences varied, influencing the psychosocial demands and resources experienced by practice assistants. The research identified both transactional and transformational leadership behaviors among GPs, each associated with specific psychosocial demands and resources [ 34 ]. Niccum et al. 2017 USA Qualitative Education The study analyzed innovation and entrepreneurship (I&E) education in U.S. allopathic medical schools, identifying 13 programs through structured searches and interviews with program directors. Most programs span all four years of medical school, require a capstone project, and involve faculty from diverse professional backgrounds. Thematic analysis identified seven key educational themes—innovation, entrepreneurship, technology, leadership, healthcare systems, business of medicine, and adaptability—alongside two teaching method themes emphasizing active learning and interdisciplinary teaching [ 35 ]. Marcianova and Pirozek 2023 Czech Republic Quantitative-Survey Practice The study found that since 2010, there has been a spontaneous movement among Czech GPs to convert their practices into limited liability companies. This shift is driven by various factors, including the desire for greater autonomy, financial benefits, and improved management efficiency. However, this entrepreneurial orientation also presents challenges, such as potential conflicts of interest and the need for business acumen among GPs [ 36 ]. Hassenteufel et al. 2020 France and Germany qualitative Practice In France, physicians’ organizations have historically maintained a strong influence over medical practice regulations and workforce distribution. However, their resistance to policy changes aimed at redistributing medical services has contributed to persistent regional disparities in healthcare access. Conversely, in Germany, physicians’ organizations have engaged more collaboratively with policymakers, participating in structured frameworks like the Federal Joint Committee, which plays a pivotal role in healthcare decision-making. This collaborative approach has facilitated more effective policy interventions to address local shortages in medical provision [ 37 ]. Cappel et al. 2006 USA conceptual or analytical review Practice The article discusses how physician entrepreneurship can lead to innovations in healthcare delivery, improved patient outcomes, and increased professional satisfaction. However, it also raises concerns about potential conflicts of interest, the commercialization of medical practice, and the impact on the traditional values of the medical profession [ 38 ]. Spence 2016 UK Thesis Practice Using a case study approach with interviews across four localities, the study found that GPs demonstrated varying levels of entrepreneurial behavior in delivering new services. Key motivations included improving patient care, financial gain, career development, and clinical expertise. Additionally, the study highlights the importance of GPs being alert to opportunities, with both formal and informal relationships with local commissioning groups playing a crucial role in facilitating entrepreneurial initiatives [ 39 ]. Duong et al. 2016 USA Education The Harvard Medical School Center for Primary Care established the Abundance Agents of Change (AoC) program in 2013 to foster interprofessional learning and innovation among medical students. The program aimed to bridge the gap between academic and community health centers in Boston by promoting collaborative projects that address primary care challenges. Through the AoC program, interprofessional student teams were provided with resources, mentorship, and funding to develop innovative solutions tailored to the needs identified by community health centers. This initiative not only enhanced the educational experience of medical students but also contributed to the improvement of primary care delivery by encouraging the application of innovative approaches in real-world settings [ 40 ]. Open in a new tab These seven themes are: (1) challenges of primary care physicians in practice, (2) areas and types of investment by general practitioners, (3) medical school characteristics and entrepreneurship, (4) contextual factors influencing GP entrepreneurship, (5) entrepreneurship skills, behaviors, and orientation of GPs, (6) policy-level factors, and (7) motivations for entrepreneurship. These themes are analyzed using a micro–meso–macro framework to capture individual, organizational, and systemic influences (see Fig. 2 ; Table 2 for details). Fig. 2. Open in a new tab Identifies themes and sub-themes Table 2. Themes and representative quotes Theme Sub theme Quotes Challenges of primary care physician in practice Micro 3 studies(9 references) • Low desire among GP to be entrepreneurship • physician negative attitude towards primary care • Prior experiences of challenges and success • Work-life balance • objection from family members Prior experiences ofchallenge and success. Similarly , physician entrepreneurs repeatedly mentioned their experiences ofchallenge and success. They thought that overcoming their past challenges could be a facilitator in launching a new business , as they gained confidence in their own abilities. One physician entrepreneur stated , “Most ofmy friends who are alumni of the Stanford Graduate School ofBusiness had backpacked in the past. I believe that those who attempted something adventurous are more likely to show interest in starting a new business” [ 18 ]. meso 8 studies (28 reference) • The Dual Role of Physicians Clinicians/Entrepreneurs • Limited consultation time • Rigid career expectations • difficulty in recruiting suitable employees • Limited interdisciplinary collaboration • High cost of running practice • organisational culture • Traditional pathways in doctors career journey Today , Polish primary care doctors must run their clinics-companies as businessmen do , and simultaneously remember about the pro-community goals of their practice. Thus , they are squeezed between distinctive forms of entrepreneurial activity. As my research has revealed , balancing the two was not easy. Therefore , I am not persuaded by research revealing an idealised picture of doctors voluntary devoting themselves to their community. Perhaps true for the other countries’ field context , however , such conclusions sharply contrast with the picture I found among Polish primary care professionals , apparently confused with the conflicting discourses , laws , and expectations shaping their work – or perhaps mission [ 17 ]. perceived that almost all medical students they knew aimed to become physicians , and if medical students and physicians chose a different career , some might consider them to be dropouts. A physician entrepreneur stated , “I believed it was part of a doctor’s job to contribute to healthcare from a business side; however , physicians around me didn’t take it that way. In contrast , they considered me like a dropout. I felt sad; however , I believe that physicians will gradually change their mindset if the number ofphysician entrepreneurs increases” [PE5] [ 18 ]. Macro • Traditional concepts of primary care model • Regulation complexity • primary care physician as a speciality becomes more competitive • Lack of GPs in primary care • Increased utilization of Services Due to Self-Referral My observations suggest that this conflicting situation is additionally exacerbated by POZ doctors’ unclear social perception. “Traditional” concepts of a free , state-provided “family medicine” , and “modern” , neoliberal settings of medical practice clash here , however , the former seems to currently be prevailing , and yet is not meeting the economic and legal frames of contemporary healthcare in Poland. These remarks find support in the doctors’ critical conclusions about patients lacking knowledge about the rules regulating the healthcare system. However , as they pointed out , there are no places where patients can educate themselves , nor there are institutions encouraging them to do so [ 17 ]. A major consequence of such regulation , … , is that the regulations are extremely complex and it is difficult for physicians clearly to understand what is or is not legitimate. Robert Saner was quoted in Medical Economics as saying “A physician who tries to understand Stark by himself is making a big mistake. He has to get outside help from a lawyer or consultant”. Another concern about the regulations in an environment in which there is a patchwork of government and private payers and a large population without insurance is the conflicting message sent to physicians. The government encourages experimentation with cost control measures such as HMOs and other risk sharing arrangements , while at the same time prohibiting a variety of other potential areas of conflict of interest [ 32 ] As has been shown above with respect to medical demography , the problem of shortages of medical supply applies mainly to primary care. This issue is increased by ageing and the development of chronic diseases needing regular and ongoing care. This is why the different health reforms mentioned above strongly targeted the reform of primary care. In this context , actors deeply involved in the development of new doctor’s associations played an important role as “medical entrepreneurs , ” promoting innovations in the primary care system as a solution to undersupply , and , more importantly , being able to find administrative and political allies to support their proposals framed in relation to the issue of local medical shortages , put at the top of the health policy agenda by other policy actors [ 37 ]. Medical school characteristics and entrepreneurship Micro Entrepreneurship knowledge competency Most of the trainees who participated (72%) did not have entrepreneurship training before and 53% of trainees did not own a business. Most trainees have heard of the pharmaceutical code , fraud guide , conflict guide. This data shows that the trainees need more familiarity about ethical codes in medical business. Almost half of trainees participating don’t know financial relations and marketing budget in the medical business. Furthermore , 54% of trainees participating don’t know self serving disclosure in medical business [ 29 ]. Meso • Lack of entrepreneurship training • Physicians are not prepared to become entrepreneurs • Model of training medical students (dual- degree Based on the results , most participants are not ready to face or to become entrepreneurs. It’s a shame because the medical business still has great opportunities. This can be seen from their business ownership and knowledge of entrepreneurial content. The finding participants had heard about entrepreneurial content but were not yet familiar with it , so this training was important to increase participants when taking part in running a health business. Based on the results , young family doctors need to learn a lot about finance and marketing budgets [ 29 ]. All faculty members highlighted that it is not only the learning environment that is important but also the personality of the students. Two members also raised the concern that owing to the demanding medical school curriculum , spending additional time for physician entrepreneurship education would require even more time for medical students to prepare and review course materials , which may result in the loss of time and opportunities to think about their future. All faculty members also pointed out that students may not take advantage of unique career experience opportunities because they are likely to have already decided on their career paths [ 18 ]. The AoC is modeled in the form of a ‘grants challenge’ , offering $20 , 000 to interprofessional student teams to develop an innovative solution that addresses a healthcare delivery need identified by CHCs. The program’s initial two years were characterized by a four-stage process which included working with CHCs and crafting a request for proposals , forming interprofessional 20 student teams comprising students from across and outside of Harvard University [ 40 ]. Macro • Councils and association standards for teaching system-based practice The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) define systems-based practice as a core David B. Duong and Erin E. Sullivan are co-first authors on this paper. Medical Education Online 2016. #2016 David B. Duong et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (X) , allowing third parties to copy and redistribute the material in any medium or format and to remix , transform , and build upon the material for any purpose , even commercially , provided the original work is properly cited and states its license [ 40 ]. Areas and types of investment by physicians 9 studies, 29 references • Types of practices (True, partial or reluctant entrepreneurs) • Physician as social entrepreneurs • rate and type of entrepreneurship among physicians (fundholders, large practice fundholders, limited liability company, quasi-market non fundholders, start-ups) GP Fundholding and entrepreneurship As noted within the introduction (sub-Sect. 1.3.2) GP fundholding was introduced by the Conservative government , and it is the primary care bi-product of the quasi-market place described in 2.8.1 , where GPs are able to become fundholders and be involved with the commissioning of healthcare services for their health economy [ 39 ]. Overall , 533 (5.6%) of startups founded by physicians are types closely associated with innovation-driven businesses , including 155 (1.6%) biotechnology , 209 (2.2%) healthcare IT , and 169 (1.8%) medical device companies. Physicians also founded 575 (6.1%) public interest startups related to advocacy , public health , and philanthropy. 1 , 759 (18.5%) of the companies are other business pursuits , including 419 (4.4%) consulting companies and both 785 (8.3%) closely related and 555 (5.8%) far afield from medicine [ 33 ]. Since 2010 , there has been a new phenomenon in which GP practices have been transferred to a new legal form , namely an entrepreneurial legal form of limited liability company as defined by the Commercial Code , based on a similar model to those used in other countries of the EU [ 36 ]. Contextual factors reshaping provision of healthcare by physicians 8 studies (20 references) • Aging population and needs for innovation • Decreasing number of medical students interested in primary care • Increasing number of medical entrepreneurs • Limited empirical research on entrepreneurship in primary care • Strengthening the role of GPs in primary care Society. Social trend. Physician entrepreneurs argued that in Japan , with the aging population and the Westernization of lifestyles , lifestyle diseases were becoming critical. They also mentioned that problems with social security would be encountered in the near future , and for this reason , the industry was paying attention to medical care to determine whether anything can be done to deal with the problem. According to physician entrepreneurs , this social trend makes it easier for physicians to start a business. One entrepreneur mentioned , “Twenty years ago , it was difficult for doctors to borrow money from banks when they proposed a business plan , but now banks consider investing in the healthcare industry as a good choice. As a result , we live in an era where banks lend a lot of capital to physicians if they have a business plan” [PE5] [ 18 ]. However , the literature review revealed that there was minimal empirical work on entrepreneurial working within the primary care NHS context [ 39 ]. Entrepreneurship behaviours, skills and orientation Mirco 7 studies, 16 references) • Age of entrepreneurship among physicians • Education and experience and entrepreneurship behaviour • Gender and entrepreneurship behaviour • Self-efficacy • Lack of entrepreneurial mindset • Misconception about financial risk • perceived high-risk of starting a business Our notion of entrepreneurship is distinct from private practice in that it involves the commercialization of products and services , often into the healthcare market , rather than exercising physicians’ specialty in a for-profit context. While autonomy in professional decision-making is a firm component of physicians’ identity , founding companies that scale beyond an individual practice is outside the mindset that tends to be instilled into medical professionals in their formation , in a similar way that academic entrepreneurship is extraneous to the conventional identity of most academics [ 19 ]. This study’s findings regarding age and disparities mirror those found in other settings. If medical school graduation is assumed to occur at age 26 years , the estimated mean age among all physician entrepreneurs would be 46 years , with an estimated mean age of 42 years among clinical practice entrepreneurs and 50 years among biotechnology company entrepreneurs. By comparison , in the general population , the mean age of founders of companies that hire at least 1 employee is 42 (12.0) years , and startups in the top 0.1% by growth have a mean founder age of 45 (10.7) years.28 Similarly , across the economy , women are approximately half as likely as men to start a business , and immigrants have overall higher rates of entrepreneurship [ 33 ]. Most medical students seemed to think that they would become doctors and never considered starting a business , as they felt they had no talent for business and no entrepreneurship experience. During the interview , a student mentioned , “I have never thought about starting a business in my future because I am supposed to be a medical doctor. Moreover , I don’t think that I am gifted in business skills.” [MS3] Some physician entrepreneurs mentioned that they had never imagined working for a company. “Before I established my business , I believed that only those who have special talent could have started a business.” [PE2] [ 18 ]. Meso 6 studies 15 references • Important factors to transfer to private practice (involving colleagues and family members, sustainability and job security, tax and cost advantages) Involvement of family members The possibility of employing other family members in the practice was also an influential factor. In our survey , this was often associated with the position of nurse or administrative support provided by a family member. Therefore , the change in legal form was also influenced by the involvement of other family members. This was an important factor for 33.85% of GPs in their decision to choose the legal form of a company , and it was very important for 13.85% [ 36 ]. Entrepreneurship and motivations Mico Five studies, 42 references) • Individual motivations (career, expertise, value creation, financial gains, societal contribution) • Interprofessional connections • Hybrid role of general practice • Economic stability as enabler • Identifying key health problems • Access to funding • Primary care as entrepreneurial space All physician entrepreneurs interviewed in this study identified key medical problems encountered during their clinical work that they really wanted to solve , and they chose business as the best way to solve them. An entrepreneur said , “I believe that the physicians’ practice for patients with symptoms suspected of influenza should be improved. Owing to the current limitation in diagnostic tools , it is sometimes difficult to diagnose influenza in its early stages” [PE2] [ 18 ]. Opportunities for entrepreneurialism and a portfolio career Some students shared that they were attracted by the opportunities for enterprise: My exposure with Family Medicine is really through my house tutors. So , my house tutor is a GP and he represents quite a few groups because he is part of a larger healthcare group. He also has his own clinic , and now as a house tutor he is also quite clinical with teaching as well. He shared many of his experiences about how his life is as a GP , the pros and cons. That was quite insightful. Previously I would think that as a GP , the community cases you see are quite run off the mill , quite a standard set , so I thought it can be a bit boring [ 31 ]. Policy level and factors Four studies, 20 references • Physician-policy interactions • Fragmentation of medical professions as a limitation in change • Capitation system discourages risk-taking and entrepreneurship • innovation requires legal supports • Insurance system problem • innovation requires legal supports Perhaps , rather than trying to control the success of the new physician entrepreneur , through additional taxes , legislation to limit their growth , and building barriers to restrict their success , efforts should be made to partner with them for mutual benefit. Providing financial incentives to new physician entrepreneurs may serve to enlist much needed intellectual capital in the quest to design a system that delivers high quality and affordable health care to the population of the United States. In developing solutions for a failing healthcare system much research will be required [ 38 ]. German physicians remain a core player of the self-administered corporatist health insurance system; they also have a major influence on policy decisions and a great capacity to orient policy through their implementation role (Rosewitz & Webber , 1990; Veith , 1988). Theses Unions are also key actors at the regional level. They are exclusively responsible for guaranteeing the provision of outpatient medical services. Regarding the international debate and the frequently applied concept of “primary care , ” the German case displays some special features , which are in part due to this historic evolution and are to date largely preserved by social law and statutory professional rights. Medical services may only be provided by (or on prescription of) a physician. Only midwifes may offer the services of their own profession (and receive a remuneration) without prior consent of a physician. As a result of this , physicians are in a key position within the German healthcare system [ 37 ]. Open in a new tab Challenges of GPs in practice Challenges faced by primary care physicians have been most frequently mentioned in the included studies [ 17 – 19 , 27 , 31 ]. Most of the challenges identified in the studies were at the meso level, followed by the macro level, reflecting the structural and systemic constraints faced by GPs in their entrepreneurial pursuits. Micro-level challenges: balancing business and patient care At the micro level (four studies, nine references) [ 17 , 18 , 27 , 31 ] several personal and career-related barriers to entrepreneurship were identified. Many GPs lacked the desire to pursue entrepreneurship as a career path, often viewing primary care as a strictly clinical profession rather than a space for innovation. This perspective was reinforced by negative attitudes towards primary care, with some physicians perceiving entrepreneurship as a deviation from their professional identity. Prior experiences of managing professional or business-related challenges influenced confidence levels in entrepreneurship. Physicians who had navigated past challenges in their careers were more confident in launching new business ventures, while those without such experiences expressed uncertainty about their ability to manage practices. Additionally,work-life balance concerns emerged as a deterrent to entrepreneurship. Many GPs found the demands of managing a business in addition to clinical duties overwhelming. The shift from a salaried position to business ownership required a fundamental mindset change, which some physicians found challenging. These challenges were vividly expressed in participant accounts, for example, one GP described the multiple roles they had to juggle: “It is just as in every other business , but , as the owner and the employer , I have certain duties. I must keep an eye on my nurses , on their social insurance , I have to follow labor laws , and besides , like every employer , I must take care of health and safety issues. In the big surgeries , there was a director and his or her deputy taking care of everything. And here , I am a director and deputy , I am the owner , stockist , hauler , literally everybody!” [ 17 ]. Meso-level challenges: structural barriers in primary care practices At the meso level (eight studies, 28 references) [ 17 – 19 , 31 , 33 ] the most frequently cited challenges were related to organizational and practice-level barriers, particularly the dual role of physicians as both clinicians and business owners. Many GPs lacked formal business training and struggled to manage the financial, operational, and legal complexities of running a private practice. Several studies highlighted the difficulty in recruiting suitable employees, particularly practice managers and support staff, who could help reduce the administrative burden on physician-entrepreneurs. Limited interdisciplinary collaboration was another significant barrier, with many GPs reporting that they lacked access to networks of business professionals or other entrepreneurial physicians who could provide mentorship or partnership opportunities. In addition, the high cost of running a primary care practice was another major barrier, particularly in rural areas where patient volumes were inconsistent, making financial sustainability more challenging. Physicians also faced pressure from colleagues and organizational culture, which often discouraged entrepreneurship. In many cases, medical professionals viewed private practice ownership as a commercial activity that conflicted with their role as healthcare providers. The traditional concepts of primary care also acted as a barrier to physician entrepreneurship. Many GPs found themselves caught between public expectations of free, state-provided healthcare and the realities of operating within a financially complex system. As one study noted: “Traditional concepts of a free, state-provided ‘family medicine’ clash with neoliberal business settings, leaving GPs uncertain about their role.” Macro-level challenges: regulatory and policy barriers At the macro level (four studies, nine references) [ 17 , 31 , 32 , 37 ], regulatory and policy constraints were frequently mentioned as obstacles to physician entrepreneurship. Many primary care physicians expressed frustration with complex bureaucratic procedures, licensing requirements, and insurance policies that limited their ability to innovate within the primary care setting. Several studies reported that state-funded healthcare models created a difficult environment for entrepreneurial GPs, as market-driven initiatives were often viewed as conflicting with public healthcare principles. In some cases, physicians felt constrained by policies that restricted private-sector involvement in primary care, preventing them from expanding their services or integrating innovative business models. The capitation-based funding model was another major limitation, as it discouraged physicians from expanding into specialized service areas, restricting financial incentives for innovation. Some GPs believed that the current funding structure failed to support entrepreneurial initiatives, leading to hesitation in pursuing private practice ventures. Areas and types of investment by general practitioners A total of eight studies [ 17 , 19 , 30 , 32 , 33 , 38 , 39 ] (38 references) explored the areas and types of investment by GPs in primary care. The findings illustrate how GPs engage in different business models, investment strategies, and social entrepreneurship initiatives, often navigating complex financial, regulatory, and operational landscapes. Types of practices and business models. The studies identified several distinct practice models adopted by entrepreneurial GPs. Fundholding practices, a prominent model in the UK and some other healthcare systems, granted GPs control over budgets for prescriptions, staffing, and diagnostic services. This fundholding practices tended to offer a wider range of services compared to non-fundholding clinics [ 28 ]. GPs operating under this model often invested in administrative personnel and technology to streamline operations, while non-fundholding practices relied more on local health authorities for service coordination. In addition to traditional GP-led practices, some physicians adopted corporate or quasi-market business models, such as limited liability companies or joint ventures with private investors. These models allowed GPs to diversify revenue streams, particularly in systems where public funding alone was insufficient to sustain independent practice. Some GPs expanded beyond traditional practice ownership, investing in freestanding laboratories, diagnostic imaging centers, minor emergency clinics, and home health services. However, these ventures were more common in urban areas, while rural communities had limited entrepreneurial activity. Gps as social entrepreneur in primary care Beyond these structural models, one study highlighted a more community-oriented, social form of entrepreneurship, in which practice ownership was closely tied to community service and non-commercial patient care initiatives [ 17 ]. These physicians often extended their role beyond primary care, filling gaps left by specialist shortages or healthcare access barriers in disadvantaged areas. One study introduced the concept of “reciprocal entrepreneurship,” where GPs engaged in informal exchanges of services with patients and community members, strengthening long-term patient relationships: “I do this for my patients. I do this for Mr. X , as he can’t go there , he has no money , he will never be admitted to a surgeon. […] I am a small-scale surgeon , a small-scale gynaecologist , a small-scale oculist , a small-scale dermatologist” [ 17 ]. These informal exchanges, ranging from extended consultation times to additional non-medical support, were most observed in rural and small-town settings, where patients relied heavily on their GP for holistic care beyond the standard primary care model. Medical school characteristics and entrepreneurship A total of nine studies [ 17 , 18 , 29 , 31 , 33 – 35 , 38 , 40 ] (20 references) explored how medical school characteristics shape entrepreneurial attitudes among GPs. The findings highlight that medical education has traditionally failed to prepare physicians for entrepreneurial roles, leaving them ill-equipped to manage private practices or launch new ventures. Additionally, institutional barriers, including rigid career pathways and a lack of structured entrepreneurship training, have limited the development of business acumen among medical graduates. Micro-level barriers: lack of entrepreneurial competency One study reported that many physicians felt inadequately prepared for entrepreneurship due to limited training in business management, and entrepreneurship, leading some to seek coaching sessions or pursue postgraduate studies in management to fill these gaps [ 17 ]. Another study found that 72% of young family doctors had never received entrepreneurship education, and over half lacked familiarity with basic financial and business concepts; those who had received business training or previously owned a business showed greater confidence in financial and operational decision-making [ 29 ]. Based on the results , most participants are not ready to face or to become entrepreneurs. It’s a shame because the medical business still has great opportunities. This can be seen from their business ownership and knowledge of entrepreneurial content. The finding participants had heard about entrepreneurial content but were not yet familiar with it , so this training was important to increase participants when taking part in running a health business. Based on the results , young family doctors need to learn a lot about finance and marketing budgets [ 29 ]. Meso-level barriers: structural gaps in entrepreneurship training At the meso level, institutional resistance within medical schools significantly hampers the integration of entrepreneurship into medical education. Despite the growing recognition of healthcare as a business sector, medical faculties often view business training as secondary to clinical competencies. A recent analysis of innovation and entrepreneurship programs in medical schools in the USA highlighted that entrepreneurship training is often introduced as an elective or specialized track, rather than a core component of medical education. The study found that while some medical schools offer structured entrepreneurship programs spanning all four years, these remain limited in reach and are not widely integrated into mainstream curricula [ 35 ]. Two other study discussed the implementation of agent of change program to improve interprofessional learning and innovation [ 40 ] or offering dual-degree like MD-MBA [ 38 ]. This limited integration of business training into the formal medical curriculum represents a significant barrier to equipping future GPs with the competencies required to navigate entrepreneurial roles in primary care. Macro-level issues: accreditation councils to integrate business training Medical councils play a pivotal role in shaping medical education and practice standards, which can significantly influence the integration of entrepreneurial skills within the medical profession. However, explicit mandates or guidelines promoting entrepreneurship education are often lacking. While bodies like the American Association of Medical Colleges (AAMC) and American Medical Association (AMA recognize the need for systems-level problem solving, entrepreneurial competencies such as financial literacy, innovation management, and business strategy are not mandated by major accreditation frameworks like the ACGME [ 35 , 40 ] . Though a few institutions offer MD-MBA or innovation programs, these remain limited and inaccessible to most students. As a result, physicians often develop business skills informally or through postgraduate training, rather than through structured curricula. Frameworks like CanMEDS acknowledge the leadership role of physicians, yet GPs are still expected to acquire entrepreneurial skills independently while managing complex, small-scale practices [ 34 ]. This regulatory gap restricts broader integration of entrepreneurship into primary care. Contextual factors Few studies have highlighted the contextual factors influencing entrepreneurship in primary care, pointing to a combination of demographic shifts [ 18 ], workforce trends [ 31 , 38 ], and technology advancement [ 32 ] and policy changes to strength the role of GPs in Primary care [ 37 ]. The aging population and increase in chronic diseases have created demand for new care models, which some GPs are addressing through innovative, community-based services. In Japan, for example, changing social needs and increased investment interest from banks have made it easier for physicians to access funding for healthcare venture [ 18 ]. Another important contextual factor within the health system is workforce trends, particularly the declining interest in primary care among medical graduates and ongoing GP shortages, especially in underserved areas. At the same time, there is a growing number of physician entrepreneurs, motivated by a desire for greater autonomy and alternative career paths beyond traditional clinical roles. These dynamics together create both gaps and incentives for entrepreneurial activity in primary care. Advances in medical technology have expanded entrepreneurial possibilities through outpatient and diagnostic services, yet these are often offset by rising operational costs and declining reimbursements, reducing financial sustainability. Entrepreneurial mindset, skills, and orientation of GPs Across the studies, entrepreneurial orientation, skills, and behaviors were often intertwined, reflecting how attitudes and competencies shape GP entrepreneurship at multiple levels [ 18 , 19 , 26 , 30 , 33 , 34 , 36 , 39 ]. At the micro level, several studies highlighted the importance of self-efficacy, opportunity recognition, and risk perception in influencing entrepreneurial engagement. self-efficacy plays a crucial role, as confidence in overcoming challenges enhances the likelihood of pursuing entrepreneurial ventures. Physicians with strong confidence in their abilities were more likely to pursue ventures, while misconceptions about financial risk and fear of irreversible debt acted as significant deterrents. Many GPs and medical students reported never considering business ownership, viewing medicine as a strictly clinical profession and entrepreneurship as incompatible with their identity. Opportunity recognition is another key skill, where identifying market gaps and financial advantages influences entrepreneurial success. Gender, education, and experience further shaped entrepreneurial behavior: male physicians generally reported stronger managerial competence, while advanced training and prior exposure to business correlated with higher autonomy and business confidence. Age also played a role, with most physicians entering entrepreneurial ventures later in their careers, although those engaged in active practice often transitioned earlier. At the meso level, the transition to a limited liability company is a critical factor in the entrepreneurial decisions of GPs [ 36 ]. Many practitioners see incorporating their practice to secure tax advantages, improve cost efficiency, and enhance sustainability. Additionally, the legal transformation facilitates business continuity, allowing practices to be transferred or inherited, ensuring long-term financial security for both the GP and their family. The ability to involve family members or bring colleagues into the business also influences decisions, providing additional financial and operational stability. Policy level factors The policy-level challenges and factors affecting physician entrepreneurship are drawn from four references [ 17 , 30 , 37 , 38 ] across multiple files, covering 20 coded references in total. At the micro level, physicians’ direct interactions with health policy have shaped both their entrepreneurial orientation and professional identity. In Poland, the 1997 reform was seen by many doctors as a shift toward market-based practice, with private ownership and economic self-management becoming central to the image of a “modern” physician [ 17 ]. In France and Germany, physicians-often through unions and professional bodies-have played a strategic role in influencing policy, either by negotiating the terms of reforms or resisting measures seen as threats to clinical and financial autonomy [ 37 ]. At the meso level, one reference (two coded excerpts), highlights the fragmentation of medical professions as a limitation to change [ 37 ]. The division of healthcare professionals into various interest groups has made policy shifts challenging. Physician organizations often struggle to unify their stance, creating resistance to systemic reforms that could facilitate entrepreneurship. At the macro level, three references explore system-wide barriers to physician entrepreneurship [ 30 , 37 , 38 ]. These include restrictive regulatory environments, physician shortages, insurance system limitations, and legal constraints on innovation. The capitation system, in particular, discourages risk-taking and entrepreneurial initiatives by tying physician compensation to patient volume rather than the value of services provided. Additionally, structural obstacles, such as the difficulty in obtaining permits for new healthcare facilities, taxation policies targeting entrepreneurial physicians, and cost-shifting mechanisms within insurance, create additional hurdles. Motivations for entrepreneurship The motivations for physician entrepreneurship are supported by five studies [ 18 , 19 , 31 , 32 , 39 ], with 26 coded excerpts categorized into micro, meso, and macro levels. At the micro level, four references emphasize personal and professional drivers [ 18 , 31 , 32 , 39 ]. Physicians are motivated by a desire to contribute to society, recognizing that business can create broader healthcare solutions beyond clinical practice. Many entrepreneurs identify key medical problems they seek to solve through innovative ventures. A wide range of interests beyond medicine, particularly in business and technology, enhances their ability to spot opportunities. Time availability also plays a role, as those with greater flexibility explore entrepreneurship. Additionally, mentorship and role models influence entrepreneurial aspirations, as physicians who see others succeed in business are more likely to consider similar paths. Some also realize that formal business education is not a prerequisite, as entrepreneurial skills can be learned through experience. At the meso level, two reference highlights the role of professional networks and economic stability in fostering entrepreneurship. Interdisciplinary connections with other industries expose physicians to new ideas and collaborations, making entrepreneurship a viable career option [ 18 , 39 ]. Financial stability within the profession allows physicians to take calculated risks, knowing they can maintain income through clinical work while exploring business opportunities [ 18 ]. At the macro level, three references illustrate how systemic factors shape entrepreneurial motivation [ 18 , 19 , 31 ]. Physicians increasingly view primary care as a space for innovation, where they can introduce new models of care and business strategies. The presence of funding opportunities further encourages entrepreneurial ventures. Many are also motivated by a strong identification with healthcare organizations and systems, believing that their business initiatives can improve patient care. Additionally, innovative ideas often align with broader health system objectives, allowing entrepreneurial physicians to gain institutional support. Discussion The review of GP entrepreneurship in primary care reveals a significant imbalance in research focus, most studies explore entrepreneurship in practice (13 studies), while relatively few examine its integration into medical education (3 studies), and two focusing on both. This suggests that entrepreneurship is often an afterthought in medical training, leaving physicians to develop business acumen informally [ 19 , 41 ]. The studies also span diverse healthcare systems, reflecting varying challenges and opportunities based on policy, regulation, and economic structures. While this diversity offers broad insights, it also highlights inconsistencies in how GP entrepreneurship is conceptualized and supported across different countries. This research reveals that the majority of challenges and barriers faced by entrepreneurial GPs are situated at the meso (organizational/practice level) and micro (individual level). This suggests that entrepreneurial limitations in primary care are more deeply embedded in day-to-day practice structures and personal career pathways rather than being purely dictated by external policy constraints. While macro-level factors (such as funding models and regulation) undoubtedly influence GP entrepreneurship, most obstacles occur within medical practice and educational institutions. For instance, the General Practice Ownership report from New Zealand highlights that many GPs felt unprepared for the responsibilities of ownership, often describing the experience as being “thrown in the deep end” due to the absence of structured support, business training, or transition pathways [ 13 ]. At the micro level, a critical limitation is the widespread lack of entrepreneurial knowledge, skills, behaviours, and mindset among general practitioners. Most GPs receive little to no formal education in business strategy, financial management, or entrepreneurship during their training. While some acquire these competencies informally through experience or postgraduate study, the majority enter private practice without the foundational capabilities needed to operate as clinician-entrepreneurs. This not only limits their confidence in pursuing business ventures but also contributes to hesitation around entrepreneurship and risk-taking. Similar findings have been observed in pharmacy [ 42 ] and nursing [ 43 – 45 ] where entrepreneurship training has only recently been recognized as essential. These findings underscore the urgent need for more intentional capacity-building at the individual level. This capacity-building requires coordinated action from medical councils, and accreditation bodies to embed entrepreneurship into medical curricula, while professional colleges and GP associations should provide ongoing support through mentorship and structured transition pathways. This lack of foundational business education exacerbates the psychological burden of managing largely due to the dual role conflict, GPs must act both as clinicians and business managers. The shift requires a fundamental change in mindset, moving to a model that also incorporates financial and operational management. Unlike corporate healthcare systems where managerial roles are distributed among administrators, GP-led practices force physicians to juggle multiple, often conflicting, responsibilities. Research on GP workload and stress has shown that even within purely clinical roles, GPs face high cognitive and emotional strain, particularly in managing conflictual consultations, prescription disputes, and administrative burdens [ 46 ]. This suggests that adding business management responsibilities without adequate support only compounds these pressures, making entrepreneurship an overwhelming prospect for many physicians. This scoping review highlights that most included studies were concentrated in Western contexts (e.g., UK, USA, Germany), while limited evidence from Asia (e.g., Japan, Indonesia, Singapore) suggests regional differences in entrepreneurial challenges and motivations. For example, Japanese physicians highlighted increased access to financing and shifting societal needs as key enablers of entrepreneurship, while Indonesian studies emphasized the lack of formal training and the need for basic business competencies among young doctors. In Singapore, primary care careers were viewed as limited in entrepreneurial opportunity due to rigid clinical roles and perceived conflicts between care and commerce. The absence of studies from Africa and Latin America limits a broader understanding of how health system maturity, financing models, and cultural expectations influence GP entrepreneurship. In addition, concepts such as jugaad in India, frugal and improvisational problem-solving, demonstrate how context-specific innovation logics can shape entrepreneurial approaches, even though no studies have yet examined its role in primary care [ 47 ]. Future research should explore these regional differences to better inform globally relevant policy and educational strategies. Implication for policy, practice and future research Current policies provide limited support for GP entrepreneurship, particularly in funding models, regulation, and education. Revising capitation-based funding structures and introducing financial incentives may encourage GPs to develop new care models and invest in practice innovations. Addressing the lack of business training in medical education through accreditation reforms could better prepare future GPs for entrepreneurial roles. One promising model is the NHS Clinical Entrepreneur Programme, which provides structured mentorship, networking, and innovation training to clinicians across the UK health system. While not specific to general practice, it offers a transferable example of how healthcare systems can retain clinical talent while enabling entrepreneurial development aligned with service improvement goals [ 48 ]. Additionally, reducing bureaucratic barriers may enable physicians to navigate private practice and innovation more effectively. Meso-level barriers, particularly practice management and workforce constraints, limit GP entrepreneurship. Shared practice models and interdisciplinary collaborations may help reduce the operational burden on GPs, allowing them to focus on patient care. Given the lack of financial and managerial expertise, practice could benefit from hiring dedicated managers or partnering with business professionals. Expanding peer mentorship and professional networks may also provide guidance and support for entrepreneurial GPs. Emerging technologies, such as AI-based tools, may also help alleviate cognitive and administrative workload, potentially enabling GPs to engage more actively in entrepreneurial activity [ 49 ]. Research on entrepreneurship in medical education remains limited, with most studies focusing on GPs already in practice. Future studies could assess the impact of business training on career trajectories and private practice sustainability. Comparative research may examine how different healthcare systems influence GP entrepreneurship, while further exploration of digital health and telemedicine could provide insights into scalable business models in underserved areas. Strengths and limitations A major strength of this research is being the first scoping review on entrepreneurship in general practice. By employing a multi-level analysis (micro-meso-macro), this study provides a comprehensive understanding of the challenges and enablers of GP-led entrepreneurial ventures, capturing individual, organizational, and policy-level factors. Additionally, the review synthesizes diverse healthcare system perspectives, offering broader insights into structural and contextual influences on GP entrepreneurship. However, some limitations should be acknowledged. The exclusion of non-English publications may have led to language bias, potentially omitting relevant perspectives from non-English-speaking healthcare systems. Additionally, the heterogeneity of included studies, particularly in methodologies and healthcare settings, may limit direct comparability of findings across different contexts. Another limitation is that title and abstract screening, as well as full-text review, were conducted by a single reviewer (MP), which may introduce selection bias. However, regular discussions with the research team helped ensure accuracy and consensus in the selection process. Conclusion This scoping review highlights the untapped potential of entrepreneurship in general practice and the systemic barriers that continue to constrain it. While examples of GP-led innovation do exist, they remain limited by structural rigidity, lack of formal training, and insufficient institutional support. This scoping review notes that entrepreneurship in primary care cannot thrive without meaningful reform-namely, integrated business education, enabling funding models, and organisational pathways that support innovation. Elevating entrepreneurship from a concept to a recognized change lever for general practice is essential for building resilient, future-oriented primary care systems. Supplementary Information Supplementary Material 1. (68.1KB, docx) Acknowledgements No additional contributions to acknowledge. All individuals involved in the scoping review are listed as authors. Authors' contributions Maryam Pirouzi: Conceptualization, Software, Data Curation, Formal analysis, investigation, Writing - Original Draft, Visualization. Matire Harwood: validation, Review & Editing.Shane Scahill: Conceptualization, validation, Resources, Writing - Review & Editing, Supervision, Project administration. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Data availability All data supporting the findings of this scoping review are included within the article and its supplementary materials. Declarations Ethics approval and consent to participate As a scoping review, this study did not involve the collection of primary data, interactions with human participants, or interventions; therefore, Institutional Review Board (IRB)approval or exemption was not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Contributor Information Maryam Pirouzi, Email: [email protected]. Shane Scahill, Email: [email protected]. References 1. Gauld R. Health sector funding and organization. In: The new health policy. McGraw-Hill Education; 2009:24. 2. Jones CH, Dolsten M. Healthcare on the brink: navigating the challenges of an aging society in the United States. NPJ Aging. 2024;10(1). 10.1038/s41514-024-00148-2. [ DOI ] [ PMC free article ] [ PubMed ] 3. Damarell RA, Morgan DD, Tieman JJ. General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research. BMC Fam Pract. 2020;21(1):131. 10.1186/s12875-020-01197-8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. WHO. Primary health care (fact-sheets). 2025. https://www.who.int/news-room/fact-sheets/detail/primary-health-care 5. Bärnreuther S. Disrupting healthcare? Entrepreneurship as an innovative financing mechanism in India’s primary care sector - PubMed. Soc Sci Med. 2023;319doi. 10.1016/j.socscimed.2022.115314. [ DOI ] [ PubMed ] 6. OECD. Realising the potential of primary health care. 2020. OECD Health Policy Studies. 7. Figueroa CA, Harrison R, Chauhan A, Meyer L. Priorities and challenges for health leadership and workforce management globally: a rapid review. BMC Health Serv Res. 2019;19(1):239. 10.1186/s12913-019-4080-7. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 8. WEF. Global health and healthcare strategic outlook: shaping the future of health and healthcare. 2023. 9. World Health Organization, UNICEF. Operational framework for primary health care: transforming vision into action. 2020. Technical series on Primary Health Care. CC BY-NC-SA 3.0 IGO. 10. UNCTAD. Entrepreneurship & innovation in the new health economy. 2022. https://unctad.org/system/files/official-document/diae2022d2_en.pdf . 11. WEF. How social innovators in Africa can be supported to build inclusive health solutions. 2022. https://www.weforum.org/stories/2022/06/how-supporting-social-entrepreneurs-can-help-combat-health-inequality/?utm_source=chatgpt.com . 12. RCGP. GP partnership principles. 2025. 13. The Royal New Zealand College of General Practitioners. General practice ownership: demystifying the business end of general practice in New Zealand. 2016. https://www.rnzcgp.org.nz/documents/37/Practiceownershipguide4web_7BmYYcH.pdf . 14. Lee YSHGR, Nembhard I, Shaller D, Schlesinger M. Leveraging patients’ creative ideas for innovation in health care. Milbank Q. 2023;102(1):233–69. 10.1111/1468-0009.12682. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 15. Kelly CJYA. Promoting innovation in healthcare. Future Healthc J. 2017;4(2):121–5. 10.7861/futurehosp.4-2-121. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. Glover WJ, Crocker A, Brush CG. Healthcare entrepreneurship: an integrative framework for future research. J Bus Venturing Insights. 2024. 10.1016/j.jbvi.2024.e00476. [ Google Scholar ] 17. Wierciński H. Are polish primary care practitioners social entrepreneurs? Ethnol Pol. 2019;40:169–86. [ Google Scholar ] 18. Yashiro D, Nawa N, Okada E, et al. Facilitators and barriers to physicians’ entrepreneurial ventures in major Japanese cities: a qualitative study - PubMed. PLoS ONE. 2021;16(10). 10.1371/journal.pone.0258957. [ DOI ] [ PMC free article ] [ PubMed ] 19. Hoang H, Perkmann M. Physician entrepreneurship: a study of early career physicians’ founding motivations and actions. Soc Sci Med. 2023;339doi. 10.1016/j.socscimed.2023.116393. [ DOI ] [ PubMed ] 20. Lokman L, Chahine T, Lokman L, Chahine T. Business models for primary health care delivery in low- and middle-income countries: a scoping study of nine social entrepreneurs. BMC Health Services Research. 2021;21(1) 10.1186/s12913-021-06225-6. [ DOI ] [ PMC free article ] [ PubMed ] 21. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1). 10.1080/1364557032000119616. 22. Peters MD, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scoping reviews (2020). In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI manual for evidence synthesis. Joanna Briggs Institute; 2024. Available from: https://synthesismanual.jbi.global . 23. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7). 10.7326/M18-0850. [ DOI ] [ PubMed ] 24. Patricia B, Jackson K. Qualitative data analysis with NVivo. 2nd ed. ed. SAGE; 2013. 25. Scahill S. Applying organisational theory in pharmacy practice research. Pharm Pract Res Methods. 2015. 10.1007/978-3-319-14672-0_8. [ Google Scholar ] 26. Weber JM. A new, but old business model for family physicians: cash - PubMed. Health Mark Q. 2013;30(3). 10.1080/07359683.2013.815001. [ DOI ] [ PubMed ] 27. Wang A, Zhao Q, Liu D, An M, Pan CW. Career orientation and its impact factors of general practitioners in Shanghai, China: a cross-sectional study. BMJ Open. 2019;9(3). 10.1136/bmjopen-2018-021980. [ DOI ] [ PMC free article ] [ PubMed ] 28. Miller R, Peckham S, Checkland K, Coleman A, McDermott I, Harrison S, Segar J. clinical engagement in primary care-led commissioning: a review of the evidence. 2012. [ DOI ] [ PMC free article ] [ PubMed ] 29. Suwangto EG. Entrepreneurial skill level and self-perception of international young family doctors: before and after basic entrepreneurship training. Bali Med J. 2024;13(1). 10.15562/bmj.v13i1.5107. 30. Bosa I. Innovative doctors in Germany: changes through communities of practice - PubMed. J Health Organ Manag. 2008;22(5). 10.1108/14777260810898697. [ DOI ] [ PubMed ] 31. Zainal H, Smith HE, Zainal H, Smith HE. Medical students’ attitudes towards careers in primary care in Singapore. BMC Med Educ. 2020;20(1) . 2020;20(1). 10.1186/s12909-020-02377-x. [ DOI ] [ PMC free article ] [ PubMed ] 32. Zientek D. Physician entrepreneurs, self-referral, and conflicts of interest: an overview . HEC Forum. 2003;15(2). 10.1023/a:1024996807586. [ DOI ] [ PubMed ] 33. Greenblatt WH. Proportion, type, and characteristics of physician entrepreneurship in Massachusetts. JAMA Netw Open. 2021;4(1). 10.1001/jamanetworkopen.2020.26938. [ DOI ] [ PMC free article ] [ PubMed ] 34. Preiser C, Tsarouha E, Weltermann B et al. Psychosocial demands and resources for working time organization in GP practices. results from a team-based ethnographic study in Germany. J Occup Med Toxicol. 2021;16(1). 10.1186/s12995-021-00336-w. [ DOI ] [ PMC free article ] [ PubMed ] 35. Niccum BA, Sarker A, Wolf SJ, Trowbridge MJ. Innovation and entrepreneurship programs in US medical education: a landscape review and thematic analysis. Med Educ Online. 2017;22(1). 10.1080/10872981.2017.1360722. [ DOI ] [ PMC free article ] [ PubMed ] 36. Marciánová P, Pirožek P. The entrepreneurial orientation of general practitioners—current theory and practice in the Czech Republic. Health Policy. 2023;131. 10.1016/j.healthpol.2023.104765. [ DOI ] [ PubMed ] 37. Hassenteufel P, Schweyer F-X, Gerlinger T, Henkel R, Lückenbach C, Reiter R. The role of professional groups in policy change: physician’s organizations and the issue of local medical provision shortages in France and Germany. Eur Policy Anal. 2020;6(1). 10.1002/epa2.1073. 38. Cappel SD, Waiker A, Tucci JE. The new physician entrepreneur-friend or foe? Entrepreneurial Exec. 2006;11:19. [ Google Scholar ] 39. Spence M. To what extent are twenty first century general practitioners entrepreneurial when delivering primary care services in new ways? The University of Manchester; 2016. 40. Duong D, Sullivan E, Minter-Jordan M, Giesen L, Ellner A. A model for training medical student innovators: the Harvard Medical School Center for Primary Care Abundance Agents of Change program - PubMed. Med Educ Online. 2016;21. 10.3402/meo.v21.30662. [ DOI ] [ PMC free article ] [ PubMed ] 41. Ju W, Xu S, Nguyen M. The need for entrepreneurship education in medical school and residency training. Dermatol Times. 2018;39(11):39. 42. Scahill S, Pirouzi M. Scoping review of entrepreneurship in community pharmacy: bringing together education and practice. Currents Pharm Teach Learn. 2025;17(5). 10.1016/j.cptl.2025.102308. [ DOI ] [ PubMed ] 43. Colichi RMB, Spiri WC, Juliani CMCM, Lima SAM. Teaching entrepreneurship in undergraduate nursing course: evaluation of an educational proposal. Revista Brasileira de Enfermagem. 2023;76doi. 10.1590/0034-7167-2021-0244. [ DOI ] [ PMC free article ] [ PubMed ] 44. Gardim L, Mendes IAC, Bernardes A, et al. Challenging the status quo through nursing entrepreneurship education: a scoping review. Nurse Educ Today. 2024;141doi. 10.1016/j.nedt.2024.106310. [ DOI ] [ PubMed ] 45. Mesquita NSd L, PNd S, MSe, et al. Challenges and perspectives of entrepreneurship in nursing. Int J Adv Eng Res Sci. 2022;9(3):54–61. 10.22161/ijaers.93.8. [ Google Scholar ] 46. Johnsen TM, Norberg BL, Krogh FH, Vonen HD, Getz LO, Austad B. The impact of clinical experience on working tasks and job-related stress: a survey among 1032 Norwegian GPs. BMC Prim Care. 2022;23(1). 10.1186/s12875-022-01810-y. [ DOI ] [ PMC free article ] [ PubMed ] 47. Prabhu J, Jain S. Innovation and entrepreneurship in India: Understanding jugaad. Asia Pac J Manage. 2015;32(4):843–68. [ Google Scholar ] 48. Holland Brown TM, Sullivan P, Sullivan P. Insights from the NHS England clinical entrepreneur programme. BMJ Innovations. 2025;11:35–40. 49. Fong L, Wynne K, Verhoeven B. Easing the cognitive load of general practitioners: AI design principles for future-ready healthcare. Technovation. 2025;142:103208. 10.1016/j.technovation.2025.103208. [ Google Scholar ] 50. Santiago S, Neal C, Caudill D, et al. Business of medicine: developing leaders in academic medicine and learning health systems. J Healthc Leadersh. 2024;16. 10.2147/JHL.S463206. [ DOI ] [ PMC free article ] [ PubMed ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1. (68.1KB, docx) Data Availability Statement All data supporting the findings of this scoping review are included within the article and its supplementary materials. Articles from BMC Primary Care are provided here courtesy of BMC ACTIONS View on publisher site PDF (1.8 MB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top