Month: April 2023

Career capital is an idea mentioned by Cal Newport in the book So Good They Can’t Ignore You, an American computer research who rights about deep work, good careers and digital disruption. Good podcast summary here. Career capital is your rocket fuel to push you to your GPwSI niche. Career capital is the experience, skills and value you bring. One of the stand out ideas to me from the book was the idea of career capital – what store of value do you have that sets you apart from other people and makes you a natural choice for that patient to choose you, that selection panel to select you or gives confidence that your new venture will succeed.

How Do I build up career capital for GPwSI?

Some is a framework created for us – schooling, university, fellowship. This basic scaffolding allows us to work in our chosen area and be trusted that we meet basic standards. If we want to stretch ourselves, or move into a new area, career capital is the rocket fuel that can push us there. Again some of this can be formal – skin cancer clinic training courses, Possums/IBCLC training, FPS training. Some may be informal – self education, conferences, shadowing. Maybe you provide value to patients via youtube videos, providing value to colleagues, becoming the go-to-person in your clinic or area for this problem. Maybe through volunteering at the local sports club you get exposure to the sport physician world.

Why do I need career capital?

To run with my rocket fuel metaphor, if there is no career capital, there is no push and you will fall short of your goals. People can’t find you, people don’t know you and your value may not be clear. We cannot just put up a shingle stating we are open for business in our niche and expect patients to roll in. We need to provide value, demonstrate safe, appropriate care and demonstrate social proof (reviews within APHRA guidelines). Of course we all have to start somewhere and just like a bank account, we start with a low stock of career capital and build over time. Like the savings account as well, frequent small additions build over time. So regular videos, patient handouts, education to colleagues, blog posts or interaction with an online community builds connection and trust allowing you to be thought of as a trusted provider.

Is career capital just marketing?

Yes in that marketing is getting people to know, like and trust you before using your service. No in that career capital is also about the knowledge or skills to complete the work required, not just a hollow sales pitch. Crucially in medicine we are offering so much more than selling some active wear or a cook book – we need to be confident our skills are safe and at expected standards, particularly if moving into a GPwSI or niche that bridges that gap between GP and specialism work. We have seen the negative aspects of this with the cosmetic surgeon problems in Australia – people with good marketing pitches but high complication rates and practices that did not meet societies or our colleagues expectations of safe practice. How do we assess our competence? having a mentor, CPD, audit, education, research, developing a craft group or joining a society in your area.

What are your next steps to develop career capital?

Is this sitting down with some paper to think about what skills you already have, what skills you might need to develop to get to your ideal niche? Is this about creating resources that patients or colleagues can use and get to understand your knowledge? Is this around finding a mentor or a volunteer position that will allow you exposure to that area that is currently walled off?

Dr Simon Wilson

Contact me via GPDU/CCIM closed facebook groups or LinkedIn

Some concerns or worries about GPwSI is that this is a drain on general practice – that consultation time is lost for true generalist work. On face yes, of course. If I am working on my GP niche, that is less time for generalist consulting. However as discussed before I feel that developing work that really excites you provides the energy to keep you at work that you may have looked to change. True generalism is very hard. There is no control on what is going to walk in the door, being spread over a generalist field inevitably means you cannot be competent in all things and these reasons may lead to us feeling overwhelmed or unfulfilled in GP work. We are already missing two of the factors that Self determination theory suggests we need to thrive

In published articles about GPwSI, there are concerns about GPs missing from the generalist workforce pool, about the financial viability of GPwSI schemes (mostly UK related) and concerns about standards and training . There are positive takes on GPwSI like this article from the AJGP– that we are not a drain on resources, consulting time or efficient specialist care

For myself, having an area that I feel confident in and allows me to offer a defined work flow for one particular patient problem (vasectomy) has led to me feeling more tolerant of some of the other stressors of GP work. I still enjoy the variety of true GP work and most of my consulting hours is spent this way. Having that 20% of work in an area where I can create autonomy and competence has been useful to me.

Working in my niche does reduce hours spent in general consultation however this is still patient care time and in an area that patients value. Patients demonstrate their appreciation with words, reviews and being willing to pay for the service, more than my general consulting patients do. In the complex pressure cooker of medicine post-pandemic this trumps any negatives workforce planners may rail against. There are many things the healthcare system could do to improve the sustainability of generalism, unfortunately few are being looked at.

Dr Simon Wilson. Also shared on Linkedin

What are the negatives to GPwSi development and niche GP? There are concepts and self view issues discuss and there some practical considerations.

Stories we tell ourselves

For some of us, we have told ourselves stories about what type of work we do, or what type of work makes up real general practice. Perhaps the story in our head is that we see all comers and have to be able to offer something for all problems. James Clear, in his book Atomic Habits talks about the fact that when we change, we might need to change the stories we tell ourselves “I’m the sort of person that _____________” to allow us to wear a new identity. Changing focus as we develop a special interest may mean less general work. Will you need to change the story you tell about yourself to develop a niche? Or will the two ideas sit side by side?

We know grief is not just about people dying. It can be about changes in identity. In this episode of the Just a GP podcast, Dr Ashlea Broomfield reflects on the changes in her mindset and grief to move from generalism to providing the type of focused practice that was important for her to provide.

Patient factors

Perhaps this means certain patients can no longer get in to see you or there are reduced appointment slots for routine or on the day medicine. For some doctors this will be a good thing, a reduced pressure to see all comers and a chance to focus on and really develop quality care in one area.

There can be frustrations from patients “I can’t get to see you anymore” “I don’t want to see the other doctors” To this I would suggest that we are not indispensable, the patients will do fine with another practitioner and we cannot forge on in generalism if it is untenable, poorly renumerated and leading to burnout.

Practical difficulties with GPwSI

Where will you offer this service? Will there be confusion between patients seeing you in your niche which may have different booking criteria like longer appointments, different gap payments compared to a regular booking? Is your current physical set up appropriate? Dr Ashlea Broomfield in the podcast mentioned above describes wanting a calm, reflective space quite different from the practical medical consulting room and so it was necessary for a room without telephones, corridor noise, hard linoleum floors and with warmth, quiet, stillness.

Do you need to inform your medical indemnity insurer? For example as your skin cancer treatments get more complex with flaps, facial blocks, you may move out of the standard non-procedural band of general practice indemnity insurance and need extra cover from your insurer. If your work focuses on a greater proportion of your income from one area, this may also trigger a review from your insurer. My insurer desires a yearly report on the proportion of vasectomy work compared to general practice.

Will your Continuing Professional Development needs and completion change? Will you keep your general registration and college post-nominals? The RACGP and AHPRA does have guidelines on what it regards as recency requirements.

If you are the only person in your practice who offers a specific therapy – prolotherapy, aesthetic injections, what is the plan if you go on leave? Other doctors can easily take your asthma or hypothyroid bread and butter patients but may not be able to to manager complications or follow up of your niche.

Now that you have special powers and a special referral network, you aren’t replaceble. Not as easy to find locums/backfill your role.

To be eligible for Medicare Australia Practice Incentive Programs, a practice must offer a full breadth of general practice. In February 2023, a skin cancer practice in Queensland lost its accreditation status for not offering a full breadth of practice and therefore lost access to Medicare funding for practice nurse support. If your work niches down significantly, will this be a concern for you?

These negatives are not a barrier

These items are not a barrier that should stop you pursuing GPwSI work if it nourishes your passion and re-ignites your interest in medicine. Developing your GP niche may also be protective against burnout. Do think deeply about these issues and let me know about others you have come across.

Dr Simon Wilson

Let’s keep talking about finding your rewarding work – that ideal patient that keeps you coming to work, that sparks interest and helps you really help a group of people.

I love to read widely – looking in books that are not just about medical clinics but podiatry, cafe ownership, dentistry. Many of these books suggest thinking about your ideal customer – that you can’t be all things to all people, but by finding your ideal person you can excel.

Can you be everything to everyone?

Tyson Franklin in his “It’s no secret there is money in Podiatry” book points out you can have a statement you treat all customers “anyone that’s breathing” however this opens you up to patients that are not your ideal fit. We can bring great focus and skills to helping one type of patient.

Dr Todd Cameron & Dr Sachin Patel in their book “The Successful General Practice” encourage you to think about the airline business. There is economy class – the basic product that gets filled up and is a reliable income, then there are the premium seats that need more focus and care but may be more rewarding to provide. They refer to the length (basic services) and the strengths (premium/interest areas) where you can offer focused services.

GPs do worry sometimes about niche work – will I lose my other skills; I joined GP to be a generalist; I feel I should have the door open to all comers; will I maintain my CPD. I would say that initially, just increasing the proportion of the work that fulfills you is very useful. If you go 100% into one thing (skin cancer clinic, counseling, coaching) then you do need to make decisions about who you see, registration and insurance however don’t let that stop you for considering some work now that will reward you.

Thinking about your ideal patient

Ben Lynch in the allied health focused “Grow your Clinic” book suggest thinking about the persona of your ideal person – who are they, where do they work, what sports do they play.

An Australian book “The 1-Page Marketing Plan” by Allan Dib has a short three questions, which Allan in turn credits to Frank Kern the PVP index Personal fulfillment – how much do you enjoy working with a particular patient type. Value to the marketplace – how much does this market segment value your work? and Profitability – how profitable is your work for this patient type. If there are very high consumable costs or insurance costs, a particular type of care might not be worth your time.

Katrina McCarters book “Marketing to Mums, how to sell more to Australia’s most powerful consumer” encourages to your think about your ideal mum(avatar). Katrina has a picture on the wall in her office to remind her of who the ideal person is and to keep going back to this avatar with all thoughts about messages, marketing, pricing, education. Katrina suggests we can really misfire if we don’t have a clear idea of our ideal mum (patient for us) and expend all our energies towards that person, rather than poorly focused scattergun efforts.

Now you think about your ideal patient for GPwSI

Do you know your ideal patient, they type you could see all day? Sit down with a drink, a note book or workbooks like the one I linked to in my last article and think about who this ideal person is.

Also published on LInkedin