Community Breast Oncologist and Researcher Shares Her Career

Session 98

Dr. Stephanie Graff is a breast oncologist who has been out of training for 8 years. Today, she talks about her journey – what got her into the specialty, the training path, and the most and least liked things about her specialty.

Meanwhile, please be sure to check out our whole host of podcasts on Meded Media as we seek to help premed students and medical students along their path towards becoming a physician.

[01:38] Interest in Oncology

Stephanie decided on oncology in the early rotations of medical school. One of her high school teachers used to tell them that whatever they decide to do in life, they have to read about. She now finds this as true advice, especially in medicine. And she just couldn’t put down the book about oncology. When she moved to clinical rotations, everything just seemed to fit for her.

With oncology, it allows physicians to connect with patients in a longitudinal way. You’re going through something intense and emotional. Then you also get to see them into long-term survivorship.

'Whatever you decide to do in life, you have to read about.'Click To Tweet

In-patient oncology covers dying or very ill patients. But Stephanie clarifies this is just the minority of their patients. Most of her patients are working their full-time jobs on their chemo so they’re not sick. It’s not a depressing job. Of course, people die, but so do with heart failure and other kinds of diseases. That said, every field has those highs and lows.

[04:02] Going Through Oncology Training

Stephanie started doing lung cancer research, primarily because she got attached to her first mentor. But she ended up leaving her training program during the scope of her fellowship.

The next mentor she attached herself to was the breast oncologist. So for the second half of her oncology fellowship, she was mentored by the fellowship program’s breast oncologist. She found it as a good fit.

'A lot of it is just finding your niche when you start your practice. There's no breast oncology sub-boards.'Click To Tweet

For instance, sarcoma is an exceedingly rare tumor so you won’t probably be going to be a full-time community sarcoma expert. But Stephanie is part of a large group of oncologists with 15 partners in her group.

Stephanie exclusively sees breast while one of her partners does 90% GI. Two of her partners are heavily subspecialized in lungs. And one of her partners exclusively sees GU malignancies.

They have a niched subgroup specialty across her practice. They also have clinical research sites where they’re principal investigators on their disease types.

[06:55] Traits That Lead to Becoming a Breast Oncologist

'Oncology is definitely a communications-heavy field.'Click To Tweet

Stephanie thinks that the lay public’s understanding of cancer and cancer treatment is infantile in its development. So you really have to talk them away from the fear into the treatment, why the treatment, how to manage the side effects, etc. You have to do this concisely in the construct of the clinic appointment.

You have to be resilient as there’s still death and dying in oncology and you have to be optimistic by that nature.

[08:33] Types of Patients

Stephanie also runs their high-risk women’s programs. So she sees a fair number of patients identified either by their primary care, GYN, or just the breast imaging center. They usually have a striking family history or other significant risk factors. They’re being referred to her in their high-risk women’s capacity to talk about risk production and genetic testing. So she gets patients this way.

She has a great relationship with the breast surgeons, primary care, gynecologists in their study. She sees patients even before they’re diagnosed with breast cancer. She would often be called to manage even the workup of a lump. Since the fear of having breast cancer already creeps in at this time.

Breast surgeons are her number one referral source. She attends all of the breast cancer tumor boards at two different hospitals. She participates in conversations about optimal care.

Stephanie is involved in clinical research so she gets referrals from all over the country for their open trials and patients connect to them.

'The metastatic oncology patient community is very well-informed. They are very engaged and educated about their disease and their disease process.'Click To Tweet

[10:55] Running Clinical Research

Oncology is a bit different than a lot of other career tracks. In oncology, there are large academic groups and most of the research happening is sponsored by pharma. But some of them are also sponsored by the big cooperative groups like SWAG and Alliance. These are all government-funded research programs.

There’s a lot of oncology drug development happening that’s entirely funded by pharma. They want networks that can put a lot of patients on trial, do it effectively and efficiently with good, high-level expertise and experience.

'There are several nonacademic cancer research networks that are centralized cancer networks.'Click To Tweet

Pharma typically contracts with non academic research networks. Their aim is to broaden the reach of their trial and improve accessibility for patients. However, they need to maintain that academic level of experience and expertise in the actual design and delivery of the trial.

[13:30] Diagnosis vs. Treatment and Procedure Time

The vast majority of her patients come to her with the diagnosis. She estimates 15% of patients coming to her without a diagnosis. The other 85% come to her with the cancer diagnosis.

In terms of procedure, Stephanie doesn’t do breast biopsies and the breast surgeons do this. She did love procedures as a medical student and resident but this is something that she really doesn’t miss at all. She hasn’t really done one since she graduated from her internal medicine residency.

[15:05] Typical Day, Taking Calls, and Work-Life Balance

Stephanie leaves her home at 7:30 am and she’s at the hospital by 7:45 am. But her clinic doesn’t technically start until 9 am. So she uses her 8-9 spot as his add-on spots for her nurses. When somebody calls with problems, she can take care of it.

She then sees her patients in 15-minute spots. She normally sees 2-3 new patients a day while the rest are follow-ups. She keeps her lunch hour to close down her mind for a bit, follow up on emails, and eat. So she sees patients from 9 am to noon. Then resumes her clinic from 1-4 pm.

Stephanie doesn’t usually have a lot of in-patients. It’s not unusual for her to have no patients in the hospital. Her inpatient rounds are super quick at about 30 minutes. The rest of the afternoon is spent on signing charts and running clinical trial meetings. And she’d be home by 6 pm.

Being part of a large group, Stephanie is on call one week in a month. It’s usually half-day. She’s very much in control of her hours. She has three kids and family comes first. So she makes sure she sees her kid’s soccer game first before doing rounds.

Her weekend hours are normally 4-5 hours. She very rarely has any emergencies in the middle of the night. She can almost always handle everything through a phone call. All that being said, Stephanie feels like she has really good work and family balance.

'Most oncologic emergencies aren't actually medical oncology emergencies. Their either radiation oncology or surgery emergencies.'Click To Tweet

[19:20] Acting Like Primary Care

A lot of people connect with their subspecialists as a primary care physician. This is because a lot of patients need regular follow-up and monitoring because of the nature of the diseases, the long-term risks, and the side effect profile of the medication. So they’re scheduling 3 or 6-month follow-up appointments every time they leave the office.

For healthy adults, they’re not scheduling their annual follow-up or being seen every 3-6 months by their primary care doctor. So they just develop this longitudinal relationship with their subspecialists. This is one of the things she really loves about her career.

But when a patient is admitted to a hospital with a totally unrelated disease, she often gets consulted. She loves this though and she’s glad to cheer for her patients.

[21:28] The Training Path and Competitiveness

After medical school, you do an internal medicine residency. After your internal medicine residency, you do an oncology fellowship. Most fellowships are a combination of medical oncology and hematology. But there’s a handful of training programs in the country that you can just medical oncology or just hematology.

'In 2019, it's probably more employable to go through a training program for both medical oncology and hematology.'Click To Tweet

Stephanie recommends taking both oncology and hematology, especially if you’re still unsure about where your career path goes. You need to be able to see everything and help cover call for your group.

A lot of weekend calls are about hematology stuff and a lot of hospitalized medical oncology. And hematology consults are thrombocytopenia, anemia, and a lot of blood stuff. So it’s good to have that training.

In internal medicine, cardiology and GI are the top two competitive specialties. And hematology is a close third probably.

[24:00] Subspecialty Opportunities

There are true, dedicated bone marrow transplant sub-fellowships. You can graduate and have another diploma and other board certification in bone marrow transplant.

'In basically every organ system, you can subspecialize in.'Click To Tweet

You can do neuro-oncology fellowships out of neurology. You can also do gynecology oncology, although there are medical oncologists that specialize and treat gynecologic malignancies.

There are gynecologists that do gynecology oncology fellowships and manage GYN-Onc malignancies, both surgically and medically. Whereas with medical oncology, you would still need a surgeon to handle that surgical piece.

Following down the academic path, there are GI oncologists, breast oncologists, sarcoma experts, lymphoma, multiple myeloma, acute leukemia, myelodysplastic syndrome. There are also breast, lung, genitourinary, etc.

A lot of what subspecialty you choose depends on how rare the tumor is and the size of your practice.

If you join a practice of three oncologists, it’s going to be hard to be super specialized. If there’s going to be more diversity in the caseload, you’ll have to help your partners manage.

But if you join a large group, there’s a great opportunity to find a subset of patients you have a particular interest in.

'An increasing percentage of private practice oncology physicians are in large groups.'Click To Tweet

[26:35] Academic vs. Community Setting

When Stephanie started looking at opportunities, she knew she wanted to stay in Kansas City for personal and family reasons. She interviewed out of several groups and the private practice group was just a great fit for her.

Her internal medicine residency was split between two hospitals. One was a private for-profit hospital that had residents from the academic site in every single field rotating in that center. So it was an education-heavy environment in a private practice hospital.

They also had a more traditional academic site. For internal medicine residency, they had two internal medicine chiefs. One was the chief of the private practice facility and the other was the chief of the university.

Her current practice she joined felt home when she interviewed. She connected better with her now-partners. She liked the opportunities and growth developing at that time.

[28:45] Bias Against DOs

Stephanie doesn’t really see any bias against DOs. There are several DOs that are very well-respected nationally in the field of Oncology without any particular bias. There are DOs in her group.

Oncology has a really strong international medical graduate community. She doesn’t feel there’s any bias there either.

[29:40] Working with Primary Care and Other Specialties

If primary care physicians have questions about particular mutual patients but just oncology in general, Stephanie says that what they’re here for.

Other specialties they work the closest with are radiation oncologists, plastic surgery, pathology, and radiology, neurosurgeons, interventional radiology.

'I work a lot with our neurosurgeons because a lot of breast cancers metastasize to the brain or the spine.'Click To Tweet

Additionally, they have a really robust nurse navigator program. Nurse navigators help their patients move between their diagnostic imaging and their surgery as well as the systemic therapy for their cancer diagnosis and radiation oncology to help connect all the pieces.

[33:18] Plastic Surgery Side of Things

For the plastic surgery side of things, there are a lot of options for patients including breast reconstruction and mastectomy. With her mastectomy patients, they recommend that every patient talks to a plastic surgeon even if they want to stay flat.

'Information is power. It's not going to hurt to talk to a plastic surgeon and find out what's available.'Click To Tweet

They have patients that don’t think it’s for them and just come back and they’re amazed by the way science has advanced the techniques. Patients look amazing after breast reconstruction. That being said, tons of her patients work with plastic surgery.

Mastectomy and lumpectomy followed by radiation are roughly equivalent in terms of cure and survival. So very few patients need a mastectomy. Tumors that are very large sometimes are only candidates for mastectomy.

But with neoadjuvant chemo, they can oftentimes shrink a large tumor and they’re still a candidate for lumpectomy if they’re highly motivated.

They also consider mastectomy, even bilateral mastectomy in patients with genetic mutations, but this is only a minority of breast cancer patients. Only about 5-10% will have genetic mutation.

The minority of her patients need a mastectomy but nationally, statistics tell that half of them choose a mastectomy.

They try to educate patients that the outcomes are the same and that removing more breast tissue doesn’t increase their likelihood of “beating it.” However, there is just that inner voice that drives most of their patients to feel like they just really want a bilateral mastectomy.

[36:20] Special Opportunities Outside of Clinical Medicine

First, you can be an educator. At their hospital, there are lots of opportunities for education in terms of trainees. Especially in oncology, there are a lot of opportunities to educate the broader community about cancer. She does a lot of speaking events for cancer-related organizations. She does education events about what cancer looks like or what’s happening in cancer.

Second, you can do volunteering. Stephanie serves on the American Cancer Society Board for their region. She also volunteers with the American Society of Clinical Oncology, their large, national organization for medical oncology.

You can also do international mission work in oncology-related fields. You can also do clinical research. All those being said, there are a lot of opportunities to do different work within the scope of oncology.

You can do work on the governmental side for oncology. The NIH and FDA employ medical oncologists.

'There's a pretty broad spectrum of oncology-related careers you can consider.'Click To Tweet

[38:00] The Most and Least Liked Things About Being a Breast Oncologist

Stephanie feels very happy with her specialty and she wouldn’t choose anything different. As a trainee, she worried about how she was going to be a doctor and a mom. But she assures it just magically works itself.

She had worried about some sense of emotional burnout but she had never felt that. It can be saddening to have sick and dying patients. But the ability to be a part of their life and be able to play a role to help prolong their life is powerful.

'The things I was worried about have not manifested in my practice. It just really reinforces that this is the right career for me.'Click To Tweet

What she likes the most about being a breast oncologist are her patients. She loves connecting with them and hearing about their life outside of medicine. She loves helping them through their cancer experience regardless of what that looks like.

What she likes the least about her specialty is a peer-to-peer call. Sometimes, they might order stuff and insurance has to authorize them to pay for it. But the default with insurance is no.

So you have to make a peer-to-peer phone call with either a medical oncologist or sometimes a retired pediatrician. You have to explain why you want this particular test for this particular patient. But this is just a small part of what they do everyday.

[42:00] Major Changes in the Future of Breast Oncology

Immunotherapy and the way they’re treating cancer is changing a lot instead of the traditional chemotherapy drugs. They’re now using more medicines that target the patient’s immune system specifically.

They also do a ton of genomic profiling. Rather than treating lung cancer as one cancer, they’re treating it based on the genomic subset and tailoring treatment. This is going to continue to evolve. This is an exciting time to be an oncologist.

'It's going to get more complicated in terms of matching drugs with the signature of the cancer.'Click To Tweet

[43:50] Final Words of Wisdom

Don’t be shy about asking for mentors. A lot of times, your faculty in your medical school don’t know that you’re considering that career path or looking for that advice. Just reach out and send them an email. Get connected and get more advice about how you can get your foot in the door and see what opportunities arise.

Stay on top of what’s changing in your career in medicine. Make sure you’re really connecting with the science of oncology and the data of oncology is going to help you succeed in the field.