Ibrahim Azar, MD, is a hematology and medical oncology attending at IHA Hematology Oncology Consultants at Trinity Health Oakland in Michigan, a role he has held since July 2022.

Why did you decide to pursue a career in community oncology?

IA: For me, community oncology turned out to be the right choice for a variety of reasons. While as a fellow I initially focused on thoracic and gastrointestinal (GI) oncology, I learned that I enjoyed seeing a variety of different malignancies. Seeing a diverse patient population helps me keep up to date on a broad spectrum of the most current research. This prevents me from growing bored and feeling burnt out. I’m also able to collaborate with many specialists within different fields of medicine.

When deciding between the academic and community practice settings, I also took into consideration the current advantages that social media provides. One of my fears about joining community practice was the fear of not being up to date on treatment. As the MedTwitter and OncTwitter communities grew, I felt social media provided me with the ability to 1) stay current with increasingly fast updates without the need for a traditional university environment and 2) create my own audience through similar platforms (like theMednet). In my third-year fellows’ clinic, I would test this hypothesis by engaging with my preceptors about the newest research updates I had read on social media, and I felt I could keep up with the advances. I felt I didn’t need to be attached to a program or university to make my voice heard in medical oncology or to have interesting discussions about practice-changing research.

The administrative burden, slow pace of change, amount of red tape, and complicated dynamics in academia also spurred me away from that setting. Furthermore, I felt that the recent societal emphasis on access to care for underserved populations has meant an increase in subspecialist, more complex care in community settings.

Additionally, my decision to be an oncologist was heavily influenced by my mentor during residency, Dr. Syed Mehdi, an oncologist at the Albany VA. Dr. Mehdi is one of the happiest, most content physicians I have seen in my life. While he is extremely sharp, he never sought a prestigious position at a university and derived all his happiness and personal success from his interactions with his patients and mentoring residents in oncology. When choosing a career path, he played a big part in that.

Lastly, it wasn’t until I started looking for an attending job that I found out about the differences in financial remuneration between community and academic oncologists. Physicians are one of the only professions where the cost of training will outpace any gains in income. As someone who was starting their career in their mid-thirties and supports their family, I needed to be in the best financial position to do this.

I had over 10 interviews in different academic and community settings for my first attending job. One of the most memorable ones was with Dr. Shaker Dakhil and the Cancer Center of Kansas (CCK) practice in Wichita. Dr. Dakhil and his colleagues had built a very impressive and wonderful community practice where they were accomplishing things I thought could only be done at high-end universities. They had a very active NCI Community Oncology Research Program (NCORP) with hundreds of patients enrolled in clinical trials. They were able, for example, to have a community-based CAR-T program. Many oncologists in their practice were authors in high-impact journals and sat on influential committees.  This opened my eyes to the opportunities you could have in a community setting without the bureaucracy and generally reduced compensation of a university. While not every program will be as successful as CCK, it is important to see what can be done. That’s why I think fellows should interview as broadly as possible to be able to know what opportunities can be available outside of academia.

Describe your typical workday.

IA: Most of my workdays are clinical. I see patients in an outpatient clinic 4 days a week and 1 day is reserved for administrative duties. In the clinic, I see a variety of cancers as well as blood disorders. I rotate inpatient duties weekly with my colleagues. We try as much as possible to see the patients we know and have established therapeutic relationships with ourselves. My first clinic patient is scheduled at 8:20 AM and I usually try to leave by 5:30 PM with notes for the day done. We have dedicated multidisciplinary tumor boards for breast, GI, genitourinary, and thoracic cancers and a general conference that includes hematologic cancers and less frequent cancers like sarcomas, melanomas, and head and neck malignancies. I try to attend most tumor boards as well as the weekly fellows conference. We also have access to dozens of clinical trials through the Michigan Cancer Research Consortium (MCRC) NCORP.

My administrative days are usually to catch up on emails, in-basket messages, notes from prior days, and connecting with collaborating physicians. Additionally, I schedule time to work on matters related to our research department and clinical trials in our NCORP and on presentations for the residents. These are also the days I try to complete one household duty a week. Typically, this is a shorter day.

If you have to pick one aspect, what part of your job is your favorite? What part is the most challenging or frustrating? What part surprised you the most?

IA: My favorite part of my job is taking care of patients with cancer. Being able to help people in their moment of need is the best and most rewarding feeling that does not get old. By far, the most frustrating part of my job is dealing with insurance companies and prior authorizations. It is very frustrating that the patient-doctor relationship now includes a third party (an insurance company) and it is shocking that insurance companies get to practice medicine without a license. Unfortunately, there is a lot of financial profit to be made by insurance companies by denying access to care, especially to patients with cancer. This poses extra hurdles to oncologists and their practices and contributes to burnout over the long term.

I was surprised by the collegiality in community practice. Doctors are very down to earth and go out of their way to help. I was also surprised by the complexity of cases I have encountered. Having trained at an academic center, I thought I would see mostly simple cases in the community setting. However, I have seen many complicated cases that my former faculty acknowledged they had never seen or are complicated even for them. In retrospect, this is not as surprising, as over 70% of cancer cases are treated by community oncologists.

On a personal level, I also was surprised by how much I ended up liking classical/benign hematology. As someone who was interested in medical oncology all along, I didn’t realize I would like seeing benign hematologic cases as much as I did. The non-malignant cases break up what can be heavy days emotionally and it is rewarding to see a person’s life improve with something as simple as an iron infusion.

What kind of person thrives in the community oncology setting?

IA: I think enjoying taking care of patients is of utmost importance to thrive in community oncology as this is how most of the time is spent. I think it is important to be someone who likes to see a diverse array of patients. An ability to be flexible and be willing to constantly learn and invest in staying up to date on different cancers and ever-changing standards of care is also key. Being in community oncology means losing the luxury of being an expert on every case you see and an ability to adapt and enjoy the challenge is important.

What does career and professional advancement look like in your career setting?

IA: Career advancement in the day-to-day involves growing the clinic practice. This can include specializing in an area of focus on a particular organ. There are also opportunities to be involved in leadership, administration, various cancer committees, and quality improvement boards, and research opportunities within the practice. It really depends on your interests. I also have an affiliation with Wayne State University as a clinical assistant professor, so advancement to clinical professor is possible.

What makes the community setting unique compared to other career paths in oncology?

IA: I think there are three broadly separate career paths in oncology: community oncology, academic oncology, and pharmaceutical oncology. The vast majority of oncology fellows end up, like me, in community oncology, so from that standpoint it is not particularly unique. I think what makes community oncology unique is the emphasis it places on clinical care excellence. It is also the most in-demand setting in the marketplace. In my particular practice, I value the ability to offer my patients clinical trials. I also appreciate the practice model that allows me to provide good care to my patients, have a good work-life balance, and still be financially secure.