Two doctors in our practice want to increase their work in skin cancer detection and prevention. I want to support them in this niche. Lets follow along as we help them develop this work.
Who do the doctors want to serve? They are for patients with a skin spot to examine, or patients with a history of skin cancer or significant sun exposure in our database who desire a focused skin examination.
The desire was to set this up, clear of usual bookings so the doctor has time, focus to be in the skin check zone.
Initially we set up a skin check clinic in our online booking system, HotDoc.
We notified people of the skin clinic via our newsletter and adding to the website. So far, we have not spent any money, just done things inhouse.
In subsequent months newsletters we have continued to mention the skin clinic and it is available on the HotDoc booking platform.
Next steps will be a custom website, for which we need a domain name and a GoogleMyBusiness entry for the skin clinic – I’ll follow with these as we develop!
I was listenging to this podcast recently and reflecting on risk taking to innovate. On the podcast they explored the need to take risks to innovate and how this may impact short term productivity as some things won’t work out. However the easy thing to do is the path laid out for you – working in your lane. Maybe that is seeing all-commer GP consulting, being flat out with this but as a trade off, not developing your interest which may lead to more satisfaction and enjoyment in work.
As 1980’s English poetic pop group TheThe sang, “the path of least resistance leads to the garbage heap of despair”
From the song “Sinking Feeling” 1983
The harder thing to do is to work on a niche or interest that will expand your reach, help new people and keep your interests alive. There will be nay-sayers and people who tell you to stay in your lane and focus on your core work. This maybe out of concern, it may be out of jealousy at seeing you follow your wishes.
It is also hard to get going with this work. It is hard to find time, focus when we are constantly hit by by demands from the day job. It can also be hard to step away from certain income in the day job to start another project which may have reduced income initially (although hopefully scalable!)
In Morgan Housel’s fantastic book “The Psychology of Money” he makes a case that we should just save – that savings given flexibility and the space needed to plan and move to the next job/career. The intangible benefits of savings gives you options and flexibility.
This podcast interview with the owner of ConvertKit was excellent – talking about the idea of a flywheel for new projects – very hard to get going with little to show initially but gathering speed and it’s own momentum over time. This is no different for myself – in writing this post, I realised I had not written since July, two months ago. Life just gets in the way. This can be called the whirlwind of regular work in some books, the stones/sand approach in other. There needs to be a way of carving out some time to focus on your new project to give it the time it needs to live and grow.
Can a GPwSI niche down too much? I don’t believe you can. In a world where single organ specialists can have super niches like just corneas, just wrists, just epilepsy and help their patient group, you can develop a super niche. Why is this? Because internet.
This company has a niche in removing possums from your house. Quite the niche – they can find their ideal customer with one specific problem and help them.
Previously the other doctors in your practice would know of your niche, local referring doctors might know of your niche but that is it. Now you can be found through google on your own or the practice website, by google maps, by patient groups sharing a good experience. Through telehealth you are not limited to just consulting with the person in your suburb but around Australia.
This company finds enough people with one need – installation of their TV. The internet can sort and filter the ideal customer for them – a new TV without the skills or time to install it themselves.
The internet is an enourmous sorting machine – in the sea of information a patient with one specific problem can find you and you can help them with this problem.
Airconditioning cleaning is a niche? Apparently – anything that is a pain-point for a person could be your niche to work in, no matter how small it seems to start with.
There is no denying that the smaller a niche is, the less people will need your service however if you can help this group they will be thankful. Mothers with breast-feeding issues with multiple births? People with ADHD and depression? Aesthetic medicine in people prone to keloids? If you can identify a groups pain point and meet them there, they will be grateful and willing to pay for a solution.
You may also need to pull from a wider area to find all the people you can help. There will not be many parents with multiple births in your suburb but if you are consulting across the state or across the whole country, the numbers in your super niche begin to grow to support your area of practice.
So don’t be worried if the work that lights you up seems too small a niche – they will be appreciative patients. There will be work to do in allowing them to find you but we can work on this!
This post is about finding my GPwSI niche. How I developed toward my niche general practice work but never in a straight line! think I have made developing your GPwSI niche sound straightforward in some prior posts. Of course life and work is never that simple! Life takes a meandering course and small twists and turns arise that looking back are important to your journey.
I have been developing a GPwSI in sexual health – PREP, MTOP and vasectomy. The vasectomy work has increased as the local tertiary hospitals have stopped offering this. This is useful, satisfying work to do, offering men and couples safe reliable contraception going forward. Obviously not everyone wants to spend 45minutes with an anxious man and his scrotum but it works for me! Providing vasectomies makes up a bit less than 20% of my work currently but still provides a niche that allows me to really develop my workflows, feel confident and autonomous in this area and provides a procedural change in pace to general consulting.
I would love to say I sat down and planned this out but the truth is bumpier than this. I came to medicine as a graduate, I was enrolled to study agricultural science on leaving high school, worked on vineyards in a gap year, started a wine making degree and ended up with a microbiology degree! I then came across to graduate medicine at Flinders university and after graduation worked around South Australia in rural GP positions.
After the children I was working in metro GP and wanted to extend myself. I had a look at simulation in GP my old website is here and the use of ultrasound in GP work as niches to develop. I explored these areas, teaching medical students ultrasound and presenting on simulation at conferences but these areas did not gel as directions to fully develop my work. The skills are rare, but not particularly valuable. However these explorations were not wasted avenues – the ultrasound I use in sexual health work for medical terminations and scrotal US. The in situ simulation training we have used in our practice for collapse after IUD insertion training. Finding your niche is not automatic, but knowledge and experience build up and you bring these skills with you to new areas. Don’t be afraid to try on new identities to see if they suit you.
There did seem to be more demand for sexual health work in Preston however and following some Business for Doctors conferences and seeing the work of George Forgan-Smith and his approach around working for your ideal patient, I started to focus more on this sexual health work.
I now work in a mix of general GP consulting and sexual health – providing Prep and MSM sexual health, Medical Termination and vasectomy. I have given away IUD placement so other doctors in our clinic can focus on this. Work in your area of excellence, other GPs have other skills and interests.
To appeal to patients and allow them to find me, I have folded in other skills – video presentations, building templates, automation’s, pro-forma letters, referral pathways for other doctors. This maintains interest, variety and keeps me keen to get into the practice on Monday morning.
This blog grew out of supporting other GPs in our practice to work on finding their GPwSI niche. I’m keen to keep talking about how I got here and how to help others get there.
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
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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
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.
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.
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.
In a prior post I talked about Dr Tait Shanafelt and their work suggesting that performing at least 20% of the work you love is a way to reduce the risk of burnout and feeling fulfilled by our medical work. How do we find that patient or problem that we love to help with and were we feel we really make a difference?
As this meme suggests, sometimes it can feel that the work we do does not align with the work that lights us up, or even the work that we are good at.
Particularly as general practitioners, the door is always open to all comers so it can feel that we don’t have a choice about who we see. Although I agree it can be harder to filter completely, a GPwSI can create an attractive space for their ideal patient and the appointment books fill up with them. Then if a few of the less ideal patients make up the other appointments our energy levels will be equal to the task as our favourite work sustains us.
I feel there are a few options here to identify your ideal patient (avatar in marketing speak).
There can simple visceral reactions – seeing a patient with a specific problem on your appointment book and smiling on the inside, knowing you can help them. You would be happy to come in of a morning and have a whole day booked up with these patients. You are not drained by these patients, you have many ways to help them and are motivated to create templates, handouts and process to help you care for that problem.
This is sometimes described as a flow state – when do you not notice time fly by? There was a good discussion about this on the Flying Solo podcast.
There can be more reflective processes. Jo Muirhead, an Australian Rehabilitation counsellor who wrote a book The Entrepreneurial Clinician provides some worksheets with the book that ask you list 150 factors about your ideal patient.
There can be external proof – do colleagues know that I have extra skills in a certain area and refer patients to me? Do patients from a particular group self-refer or come via word of mouth?
When are you most productive? This can be a tricky one as with some niche work there are great direct results to the patient in front of us (skin cancer, weight loss, abortion care) and immediate feedback that we have helped. Where as some of the harder work like long term chronic care is much harder to quantify in benefit and the achievements are spread over a very long time. I do feel my niche work is productive and efficient – I do more of it, I have better process and workflows.
There can be financial proofs – if dollars are just appreciation tokens, who is so happy with your work that you receive more appreciation tokens from?
These reflections all allow us to think about our idea person to help and then we can think about where they area, how to we find and reach them and get them to trust us so we can help them.
I recent became aware of the work of the US physician Tait Shanafelt1 and their work around workforce sustainability and longevity in medicine. In one piece of work, what really caught my eye was this statistic – if a doctor spends at least 20% of their time following their passion, the other time does not drag on ones energy and happiness. Tait refers to this as optimising meaning in your work – that finding this meaning reduces the risk of burnout and that doctors who don’t have at least that 20% are at higher risk of burnout. Specifically they found that working at least one and half days a fortnight in a desired area halved the risk of burnout.
This idea has also been take up in other business book – Marcus Buckingham used in this 20% research in his book Work + Love. This focus was on the idea of red threads, work you can get lost in, but an important feature of his work is not the find your passion and work there, but rather find your great work and learn to love it.
These findings around a portion of time engaged with a subject matter that really resonates has been replicated in other studies. In a bit of a reversal of the Shanafelt work, a study of medical educators, showed that time incongruence between desired time allocation and mandatory work (administration) by more than 20% increased the chance of burnout.
This idea of enjoying your best work, that it does not have to be a passion was also carried out in Cal Newports book “So good they can’t ignore you“, I mention him in another post around career capital. The conclusion of his book is that occupational happienss does not a require a passion. Newport also points out that control is often at the heart of visions of a dream job – and setting up systems for niche can give more control that all comer work.
For me this 20% is my small business work in running the practice and my sexual health work – PReP, MTOP and vasectomies. These factors keep me engaged and although this is still hard work at times, I am recharged by this work. I can complete a full day of general consulting and look forward to work the next days if it has a couple of vasectomies or other work that is meaningful to me booked. What would your 20% look like? Would this protect you from burnout? I’ll talk more about how to identify your work that lights you up in some more posts.
