Training/education/certification?
Training and accreditation for a GP niche – what do we need to be safe, effective without spending all the savings to complete?
We do differ from the tech bros around the MVP and fail fast models they promote – we engage with peoples health and we have legislative and medico-legal frameworks to work in. Sometimes this does need to be taken into consideration in your niche.To do the right thing by the patient you need to be safe to work in the area you aim for. Unfortunately we have seen in Australia the consequences of doctors over-reaching their skills and capacity to assess safety – particularly in the aesthetic medicine space. This has led to very negative outcomes for patients and censor and registration, cancellation or restriction for doctors. Longevity in practice is your greatest asset and something you hope niche work supports by reducing burnout risk. Don’t let it risk your career.
Depending on you niche, there may be craft groups, professional associations or educational groups that you can look to for assessment about training or certification needed.
For some niche work the focus is a deeper dive into usual GP – MHT, paediatrics, FPS and as a result self directed learning, conferences and reading widely may be perfect for developing your niche. For other work that could be a departure from regular care or seen as work encroaching on specialty care – phlebotomy, advanced skin cancer grafts and flaps, thread facelifts you may desire certification to reassure your self you have been assessed safe to work, your indemnity insurer and your patients.
We are fortunate in Australia that much of our extended care work is self-assessed. We should be wary of a UK model where anything outside of sitting down for consultation requires certification and referral and there are several layers of bureucracy involved in a good deal of care. See this screeshot below about how GP surgeries can not provide ear syringing for wax:
I am writing about what I know – supporting general practitioners who already have their fellowship with niche work. Attaining the RACGP or ACCRM fellowship really opens the door to easier private practice than only holding general registration in Australia. Speciality GP registration means access to MBS items via a provider number so the patient can have a rebate, indemnity support and ongoing CPD is smoother. There is now more flexibilty with divers CPD homes now available but membership of one of the GP colleges does give more access to resources, political might and support.
Access to specific niche MBS or medication items.
In Australia, Medicare also provides some guidance in that some Medicare rebate items or prescription privileges are only accessible by certain speciality groups or after training – S100 HIV prescribing, Opiate Substitution training, FFS psychological items, non-directive pregnancy training.
Matters can change here with time – when introduced, Medical Termination medication prescribing required a online course and registration, now it is unrestricted. In Victoria, you have have up to five patients with suboxone substitution without doing extra training.
Watch this space around access to ADHD diagnosis and initiation of stimulant medications being offered to GPs in the future – there is enough public frustration with access that I would not be surprised if this happens for adults.
Hands on training, apprenticeship models, mentoring
Like much in medicine, this niche work can be apprentice model in training. This mentor may engage you with other practitioner in this area – particularly important for small niches like phlebectomy, circumcision which has a small pool of practitioners. With large niches such as skin cancer, psychological medicine, lifestyle medicine there is a plethora of conferences and courses to complete and demonstrate competence.
In this podcast, Dr Moz describes spending a lot of time and money to access further training and education around skin cancer care, both formal courses and assisting with plastic surgery lists.
Does the patient expect or want you to have a raft of post-nominals? I think this is hard to assess. I feel more important is how you describe your work, demonstrate your communication style and relate to the patient. Of course patients expect you to be competent at the work you are offering but come at this without being able to assess this before you have helped them. This is where educational video, clear booking and appointment processes, financial consent and reviews allow the patient to know, like and trust you even before your initial meeting.
Of course a very important factor to discuss around a niche and certification or training is cost. This can be significant to complete a masters of skin cancer, some of the coaching and psychology courses. Some models can even be predatory – historically trainers for circumcision have training contracts that charged a high premium and then garnished future earnings.
There may be nudges from government or other bodies that support or provide training in areas they want more practitioners – Drug and Alcohol training is often paid for and recently the commonwealth via the RACGP has been paying $1200 extra to undertake and complete A&OD training. The Section100 HIV and Hepatitis prescriber training is funded. The Cancer Council has had programs for rural practitioners to access dermatoscopy training and be given a dermatoscope.
Money of course is not everything and some people would pursue a niche even if they did not get paid but there should be some consideration of return on investment before training. Around thinking about expected income, this becomes like a business case plan for income:
- How many patients do you expect to see?
- What is the income per niche patient?
- What is the demographic and expectation of growth of this niche
Therefore is the niche worth exploring and providing from the training costs perspective? A hard headed assessment could mean you avoid spending on a course that does not pay for itself. For other other people they are going to be happy if the new niche makes less income than their regular practice, if it meets that 20% of their golden zone that prevents burnout. Burnout is our greatest financial risk so anything that allows long term engagement with medicine is a win, even if the niche is less per hour that your existing consulting.