- Identifying and building a niche can be exciting and rewarding.
- Match your clinical strengths to gaps in your institution or community to ensure relevance and impact.
- Success depends on collaboration with administration, OR staff, colleagues, and senior partners.
- Developing a patient base, sharing results, and engaging in transparent marketing and networking are essential to sustaining growth.
I will preface this blog post with the comment that you should never pursue anything that makes you feel like you are losing your soul. Identifying and building a niche should excite you and ultimately be rewarding. Importantly, understanding growth for yourself and/or your institution is never a straight path.
A few years ago, Drs. Antonoff and Okusanya wrote a blog for the STS on a stepwise approach to building your niche within cardiothoracic surgery (https://www.sts.org/blog/finding-and-cultivating-niche). This post will hopefully update their previous work and provide some insight to pitfalls to avoid when starting to roll out your academic/clinical niche.
“Find an operation or a disease process with a high mortality and find a way to reduce the mortality even by just a bit, and you’ll have made your career.” I have heard this statement from multiple cardiothoracic surgical mentors through the year,s and I cannot attribute it to a single person, but the logic holds that if you can make a small incremental impact in a complex patient problem, you will have made a lasting contribution to surgery, no matter the specialty. The hardest part is identifying what that might be.
Whether you are a thoracic surgeon and you are going to break through the ceiling on survival for mesothelioma, an adult cardiac surgeon tackling structural valve deterioration, or a community cardiothoracic surgeon improving outcomes for ECMO patients, approach building your niche with care, passion, and an understanding that it will not go exactly as you plan, but ultimately your perseverance will be rewarded.
As you go through your training and the first few years of practice as an attending, one of the struggles of building a niche will be marrying what you may feel is a strength of your clinical base and aligning it with what is needed in your institution/community.
As an example, you’ve noticed that no one in your community is offering aortic valve repair. This care gap aligns well with your training and comfort level doing the Ross procedure, valve sparing root replacements, etc. Great! Time to get to work.
Establishing partnerships within the hospital/health system
To build a niche, you will need partnerships at multiple levels within the health system. Getting buy-in at each level is critical, as failure at any one level can prevent you from getting off the ground.
Administration: There are healthcare databases (SG2 and others) that most hospitals will have access to, which can give you diagnostic data as well as geographic information to show leadership that there may be an untapped patient population that would benefit from your expertise.
Working in collaboration with your business administrator, you can build a business plan to determine additional equipment you may need, the results of your market analysis, the budget to build your program, and a marketing strategy in the community. This step can be critical when asking for funds to get your niche off the ground or simply asking for more block time for the robot, hybrid suite, etc.
OR staff: If you are going to be starting a robotic mitral valve program and you don’t have dedicated time on the robot or have a staff that is unfamiliar with the platform, you need to be willing to take the time to train those around you before jumping into your first case. This is the team that will be doing the hard work with you. Take the time to explain why you want to do what you are building, the need for it, and the potential benefit.
Be thoughtful with the first case within this niche. If it’s a Ross procedure, make it a primary sternotomy with AI; don’t do a 3rd time redo sternotomy endocarditis. You may be ready for that challenge, but likely your team is not. Build their confidence as well as yours in the beginning.
Supporting clinicians: Don’t just ram your idea into your cardiologists, intensivists, pulmonologists, etc. Be collaborative. Take the time with each different stakeholder to sit down and discuss what you are trying to do, why you want to do it, and ultimately your end goal in creating a program or niche.
Be prepared for significant pushback. Change is hard, no matter your age or professional level. Convincing hardened cardiologists that a Ross procedure is a better option for a 40-year-old than a mechanical aortic valve will take time; don’t get frustrated if it takes multiple meetings to get your point across. Highlight your successes with each group as you start building your niche, and don’t shy away from discussing failures and how you are working to improve outcomes.
Senior partners: Don’t go rogue. Make sure you have their support for whatever you want to do. You never want to find yourself in a jam and not have help because you did something you weren’t supposed to.
Building a patient base
This is not the simple task of seeing a patient in a clinic with AI and trying to convince them of doing something other than an AVR. Building that base is more than just at the patient level, but also discussing your goal with referring cardiologists to align on new treatment approaches, ensuring imaging is adequate for what you need to give informed recommendations to your patient,s and creating a pathway for postop care to prevent early failures and returns to the OR.
If you ignore this step, you may see referrals from certain providers start to decrease. Once you have the patient in your clinic, be prepared to take longer in consult with them. If this is a paradigm shift and the patients may have already been biased towards what their treatment should be, take the time to answer their questions and explain the foundation of what you are proposing for their care.
With partnerships in place across multiple levels of the health system and a clear process for patient care from pre to post-operative you are ready to expand the patient base and pound the pavement with the public and referring providers.
Advertising to the public/referring providers
Once you have a few cases under your belt, discuss with your senior partner, division chief, department chair, etc, about marketing opportunities to get the word out about what you are doing. With approval from your leadership, meet with your internal marketing department (most institutions will have this, academic or not) to discuss what you are doing and be prepared to present your success stories.
Speak beforehand with the patients to let them know that someone from your organization might reach out for an interview. The marketing team will help build a story, post it on institutional social media, and float it to local media (print and digital) for further publication.
Before going public with anything, make sure your leaders review it, you always want their input and to ensure it aligns with their own strategic development for the partnership, division, department, etc. At the same time, work with marketing to schedule office visits to referring providers.
Be collegial, energetic, and work within their busy schedule to discuss what you’re doing and how it can impact their patients.
Getting recognized at the institutional level and building an external network
You are 6 months or a year into your niche; now is the time for a retrospective review of your results for internal review. This review process is important to demonstrate the trajectory of your program.
With objective data, meet with the different stakeholders and show the program growth, and ensure continued buy-in at multiple levels. This allows for objective feedback and identifying areas for growth. If something stands out, don’t be shy about presenting your data at a regional or national meeting.
This will create opportunities for discussion with other surgeons doing the same thing you are. They may provide insight into their own failures and what to avoid, but also present an opportunity to create a collaborative or even a multi-institutional study.
All of this will take trial and error and years to refine to grow into a well-oiled machine. Never stop, no matter the failures. Continue to improve, and if you are passionate about what you are doing, resilience will come, and you cannot possibly lose your soul carving out your niche.