Skin in the game: preventing ‘nasty’ cancers
With an average annual temperature of 16.5°C, Nottingham, United Kingdom, could not be more different from Australia’s Sunshine State.
As Dr Tarek Shalabi lived and practised medicine in Nottingham, his screensaver was set to a picture of Palm Beach on the Gold Coast.
Fate intervened and Tarek was invited to work in Australia by Gold Coast University Hospital—he made the decision to transition from a career in trauma and orthopaedics to emergency medicine.
“In the medical field, this was not the most natural transition; all my life was bones and trauma and I thought that those things were the most important things ever,” Tarek says.
“Practising medicine in Australia offers you a lot more freedom of thought, a lot more ability to follow your instinct rather than a set of restrictions or red tape.”
In Queensland, with extensive hospital-based experience, Tarek found himself considering multiple avenues and multiple different specialties.
When he heard about how general practice is conducted in Australia, he said he felt “instantly” that it would fit with him.
“You have an ability in general practice to make a contribution to your community and that is what attracted me.”
“A lot of people will put down general practice as a lifestyle choice, but the nature of practising medicine as a GP in Australia is extremely unique when compared to other parts of the world.”
Tarek advises those considering general practice to cultivate their own unique set of skills.
“Think about how you can transfer the skills that you’re learning in the hospital to general practice…because they will be unique skills that are good for your patients, practice, colleagues and in your contract negotiation.”
As most Fellowed GPs are considered sole traders, Tarek says it is important to offer unique skills.
“What you might not think is unique in the hospital is actually very unique in general practice. Take a few of these skills from your hospital experience into general practice. You will find that it is a brilliant springboard for your career.”
The ‘Skin Cancer Capital of the World’
Queensland is infamously known as the ‘Skin Cancer Capital of the World’.
With a background in trauma and orthopaedics, Tarek is carving for himself a niche market through managing skin cancer within the general practice setting.
Tarek’s foray into skin cancer medicine began by happenstance.
“There was a patient who walked into my clinic complaining of coryzal symptoms. The patient was wearing shorts.”
“My eyes leapt to a dark, oddly coloured, irregular mass on his leg. I asked the patient, ‘How long has that been there for?’.”
“The patient told me it had been there for two weeks. I asked, ‘Has it changed?’ The patient replied, ‘I’m not sure’.”
“I borrowed my supervisor’s dermatoscope and had a look underneath. I suspected that this might be a nasty melanoma.”
“I paused to ask the patient if he would be happy to spend an extra hour in my company whilst I remove that lesion to send as a biopsy, to which he replied, ‘Yes’.”
“I walked out to the waiting room, apologised and advised some of my patients that they could go and get a coffee as I’d be running a little bit late. I then removed the patient’s lesion.”
The next day, Tarek received a call from the pathology lab informing him that the melanoma was severe and needed further excision.
After discussing possible management options for the patient with his supervisor, Tarek brought the patient in the following day.
“The patient decided to have the further borders done with myself…the patient then had specialists follow up, where they looked at his lymph nodes and thankfully there has been remission.”
“Had that patient not presented to any GP or had they been wearing pants on the day, the patient would have been unlikely to have visited his doctor for another six months, at which time the management of that melanoma would be much more invasive and could have even had a fatal outcome.”
As a GP, Tarek is on the front line of preventative medicine.
“Seeing the impact of a simple excision really made me quite addicted to searching through a patient’s skin, and trying to find something that we could remove in order to avoid a nasty skin cancer.”
In the future, Tarek looks forward to working in a balanced role between general medicine and skin cancer medicine.
“I could be excising a melanoma, and in about 45 minutes I may have a patient who is in tears because of a mental health issue. The contrast in what you do is tremendous and it keeps you motivated and quite excited.”
A home-visiting doctor
Before making the jump into the GP training program, Tarek was able to taste general practice through working with an after-hours medical deputising service.
Visiting patients in their own homes “opened his eyes” to what presentations he could expect as a GP.
“I saw the impact that I could make visiting people at home simply with a doctor’s bag and a script pad. I felt that I was making an impact and that helped me make that transition to general practice,” Tarek says.
For those with the time and opportunity, Tarek recommends working with a deputising service as they provide an introduction into what it is like to see a patient outside a hospital.
Home visits, Tarek says, give doctors a huge insight into what may be impacting a patient’s health.
“When the patient walks into your clinic, you may not realise, for example, that they have got six dogs and two horses, and they have twenty stairs to get up to their bedroom.”
“When you’ve asked [a patient] to come back three times in the week, you suddenly realise just how much of a toll that might take. It opens up a role for managing the patient and doctor expectations.”
“In the rural setting, you realise that it’s actually a two-kilometre drive on a dirt road to get to their house. You realise how isolated some of them may feel. You’re able to give them a bit of companionship and a bit of reassurance and it does increase that doctor-patient bond.”
As a GP training, Tarek is able to continue doing home visits through his practice.
“Patients are generally extremely grateful…and it is an extremely rewarding method of practice.”
Succeeding in supervision
Being punctual and courteous will go a long way to creating and maintaining a good working relationship with a GP supervisor.
“Don’t expect everything to be spoon-fed to you, but generate learning opportunities yourself.”
“Take an interest in their field of interest. So if your GP supervisor loves skin, then it would be worth actually exploring that area because they’re going to be able to give you a lot of advice. Have really open communication with your GP supervisor. Find the right time to discuss a case.”
Tarek advises GP trainees to take an active role in their own learning—if something is interesting in a consult, write it down and discuss it with your supervisor at an appropriate time.
Delivering holistic care
A GP must build a relationship based on trust, Tarek says, and it is at that point that a patient will seriously consider the suggestions their GP has to make.
“When that patient develops a trust and a bond with you then you are able to take your therapeutic relationship to a higher level and be able to care for your patient holistically,” Tarek says.
The best way to deliver holistic care is by having a long-term bond with your patient, Tarek says, and it is the holistic care that empowers the patient to make decisions on their own accord for the betterment of their health and wellbeing.
The ability to plan ahead and spend time with a patient as needed is what separates general practice out from other specialties.
“You feel pressured in the hospital to be able to get things done. It is all about giving your patient medication and they will take it because it is directed on the drug chart. Then a nurse will go and deliver that medication to the patient and watch them take it.”
“Whereas in general practice, you give them a prescription. The patient might not even fill that prescription at the pharmacy if they don’t believe that it is the right thing to do.”
“That prescription is going to cost them money, so you need to use your skills as a GP to inform your patient, to meet their concerns, understand their expectations, answer their questions and give them time to digest that information.”
“If you do that, you will find that not only will the patient fill their script, but they will actively come back and ask you for their medication, because they know that is the way to look after their health.”
Communication and modesty are key, Tarek says.
“Even with my eight years of postgraduate experience before entering general practice, I have absolutely no shame in telling a patient ‘I don’t know’…when I have that open communication, the patient is actually quite happy they have a doctor who knows their boundaries.”
Tarek says to take pride in the moments of unsurety, as they can be used as an opportunity to learn—and also in the moments where things may seem simple.
“Sometimes a patient’s cold may be an excuse for them to come to their doctor to discuss something else that they’re a little bit shy about.”
“If you are as open and approachable as you can be, you’ll find that a patient may disclose that they were coming in for something else.”
“Eventually you look forward to the surprises and you embrace each surprise either with the chance to learn or with an opportunity to help.”
“In the end, [being a GP] becomes an incredibly satisfying job. You always finish your day having seen something new, having made an impact on somebody’s life.”
Portrait photography by justbphotography, Gold Coast landscape photos by Tania Richardson
