A Conversation with University Hospitals' Adonis Hijaz, MD

Female Pelvic Medicine & Surgery specialist at University Hospitals Urology Institute

UH Research & Education Update | January 2022

Who is Dr. Hijaz? 

Adonis Hijaz, MD

Adonis Hijaz, MD, was born in Liberia to immigrant parents who ran a small business but spent most of his childhood in the outskirts of Beirut, Lebanon, before moving to the capital itself. Following high school, Dr. Hijaz attended the American University of Beirut, earning his bachelor's and medical degrees and completing his residency training. He moved to North America in 2001 to start a fellowship in urology and urodynamics at the University of Toronto before coming to Cleveland, which he now considers his second home.

Dr. Hijaz credits his mother with being the most important and influential person as a child. His father passed away when Adonis was just ten years old, so his mom was everything to him and his siblings. She cared and devoted her life to her children and inspired them to achieve their dreams.

Dr. Hijaz knew when he was young that he wanted to become a physician. “Some physicians have stories or experiences in their life that shaped their career decisions, but I had more of an ongoing admiration for physicians that drew me to the field. I have always liked to help people, it’s in my nature, and I think this profession allows us to give through knowledge and experience. People come to us at the most vulnerable times in their life looking for help and hope. I’m privileged to be in this community of people who can help through healing.”

A Physician-Scientist’s Journey

Dr. Hijaz who is the Director, Female Pelvic Surgery; Vice Chairman, Department of Urology, UH Cleveland Medical Center, and Professor of Urology, Case Western Reserve University School of Medicine, is a nationally and internationally recognized physician-scientist leader in women's health and urology. He explained that his physician-scientist journey evolved through the guidance of several clinicians and research mentors who inspired him to develop the tools and skillsets to become the physician-scientist he is today. He found an interest in the specialty of urology from the excellent surgeons who trained him in Beirut. The department chair at the time was a urologist by the name of Dr. Kamal Hemady and a father figure to his residents. “He took his residents under his wing and was a good clinician and caring physician; I’d love to be just like him.” 

Dr. Hijaz knew he wanted to subspecialize. When he completed his fellowship training, female urology was in an infancy stage and just starting to develop as a subspecialty. Not much was known about the topic, and there was a significant knowledge gap, so he gravitated to learning more about this subspecialty. His first exposure to female urology was with Dr. Sender Herschorn, the Chair of Urology at the University of Toronto. It was also when he started to have a research interest. He had the privilege to work with some of the top-notch female urologists in the country who taught him how to sharpen his clinical and research skills. Dr. Hijaz credits Dr. Raymond Rackley, Dr. Sandip Vasavada, Dr. Mark Walters, and Dr. Firouz Daneshagri for clinical and research mentorship at the Cleveland Clinic. He also credits Dr. Margot Damaser at the Cleveland Clinic for her mentorship in animal models of urinary incontinence. During his fellowship, he was introduced to Dr. Marc Penn in Cardiology, whose research focused on harnessing certain chemokines' stem cell chemoattractant properties in the treatment of ischemic heart disease and heart failure. Working with his urology mentors, Dr. Hijaz started a series of experiments that mirrored the cardiology research in urinary incontinence post vaginal delivery. This fueled his interest in the research that focused on stem cell therapy for urinary incontinence.

Shortly after joining University Hospitals Cleveland Medical Center and Case Western Reserve University, he had the privilege of meeting and being mentored by an individual often referred to as the “father” of mesenchymal stem cell therapy, Dr. Arnold Caplan. Dr. Caplan was instrumental in teaching Dr. Hijaz the “logic of mesenchymal stem cell therapy” and acted as the primary mentor on his NIH-sponsored career development award.

Dr. Hijaz summarized his clinician-scientist journey. It started with clinicians who trained him, researchers who expanded his knowledge in conducting research, and was inspired by the work of cardiologists and stem cell biologists. This cross-fertilization allowed him to widen his horizon and keep an open eye for opportunities outside his immediate field of learning. Dr. Hijaz uses his journey to model his residents, fellows, and other junior faculty interested in clinician-scientist pathways. “You never know when opportunities will come your way, so keep your eyes open.” Dr. Hijaz explains there are valuable ideas and models in fields outside of urology that can be used to advance the field of urology. Dr. Hijaz’s research includes collaborators from biomedical engineering, biology, radiology, computer science, and engineering, which has led his research portfolio to grow. With time and collaboration from various departments and fields, physician-scientists can develop and expand their research. However, Dr. Hijaz also tells his trainees that perseverance is the most crucial ingredient to success. “Perseverance is needed because you'll face challenges and times of disappointment. I did on my journey, but you have to keep the fire in your belly, and sometimes you have to be strategic and change the course or focus, and you'll get it. I am far from being accomplished; I have some good successes that I am thrilled about, but obviously, there is more to be done, and I'm excited about the future.”

Empowering Physician-Scientists

Being a physician-scientist is not an easy path. It requires a lot of dedication and commitment. Yet dedication and commitment are not enough; there needs to be a culture within the work environment or institution that embraces and supports this pathway as the challenges are real and numerous. “It's just not an easy path, and it's easy to give up. But, unfortunately, I've seen it repeatedly and witnessed some of the smartest people give up on their research careers to pursue the clinical path only because of the challenges.”

The Parallel Path

We are privileged at University Hospitals and within the UH Urology Institute to have strong institutional and departmental support for the research culture and the physician-scientist track. The UH Research & Education Institute supported the Department of Urology in building a team of experts and recruiting passionate clinician-scientists. “Together with Dr. Lee Ponsky, we created an infrastructure of support which tackles many obstacles previously experienced by physician-scientist to smoothly guide young faculty through the research pathway, allowing them to focus on the ideas versus the challenges. ”The infrastructure helps investigators navigate their idea through conceptualization, proposal development, implementation, and data collection, data analysis, and management and eventual write up of the project as a paper or a grant. In addition, this infrastructure allowed us to introduce the concept of Parallel Path. The Parallel Path is a way for clinicians to advance healthcare through clinical and academic medicine. With resources committed to their success, clinicians are empowered to explore and pursue ideas they know can advance within a well-oiled machine.

Sometimes what prevents physician-scientists from taking their ideas to the next step is the anxiety of not having the skillset, time, or capability to navigate the journey from beginning to end. The Parallel Path will help physician-scientists develop their ideas into projects, implement them to get results and analyze their results to publish or submit grants. Since the program was created, the number of publications tripled, and grant submissions doubled in the Department of Urology. The team has submitted multiple large grants in the last couple of years and received two significant grant awards. “I'm excited to be part of this and happy to help develop future physician-scientists. The more we bring people into this circle of physicians and scientists, the more successful we are.”

Advancing Female Urology Care – The PREMIER Trial: University Hospitals is the lead site for this five-year study that will enroll 320 women from four academic medical centers

Inspired by his patients with uterovaginal prolapse, Dr. Hijaz recently received an R01 grant award from the National Institutes of Health (NIH) to conduct the PREMIER Trial--a multicenter randomized clinical trial to evaluate the outcome of two current standards of care surgical repairs for uterovaginal prolapse (UVP). UVP is one of the most common conditions affecting women of all ages, although more common in post-menopausal women, and significantly impacts patients’ quality of life. UVP can be managed conservatively or surgically. Among the surgical options, the first option is a vaginal hysterectomy with suspension using the native uterosacral ligaments in the pelvis. The second surgical option includes laparoscopic or robotic supracervical hysterectomy (where the cervix is maintained but the uterus is removed) followed by a mesh suspension called sacrocolpopexy. Dr. Hijaz and his team evaluated the national trends of these surgeries and found that 60% were vaginal surgeries, and 40% were the laparoscopic/robotic approach, but comparative outcome data is lacking. As a result, Dr. Hijaz and colleagues developed a study to compare and evaluate these treatment options and measure all important outcomes. University Hospitals is the lead site for this five-year study that will enroll 320 women from four academic medical centers.

Empowering Women

Dr. Hijaz will soon be actively enrolling participants from many regional sites across the University Hospitals system for a second study called the EMPOWER Study. This research is funded by an award from the Agency for Healthcare Research and Quality (AHRQ) and will reach over 5,000 women in Northeast Ohio. The EMPOWER Study will evaluate various treatment methods within a primary care setting for women with urinary incontinence. It is well known that urinary incontinence is prevalent in 50 to 70% of women. Yet, despite that high prevalence, women often do not seek help for urinary incontinence. When women do seek help, many of them are asked to manage their problems independently, or in some cases, the patient’s complaints are dismissed. Not because of a physician’s lack of interest, but probably because there are many barriers at the patient and physician level. Fortunately, significant, impactful non-surgical, affordable behavioral and physical therapies can successfully help patients. Dr. Hijaz and his collaborators developed a team science approach to identify the patient-centered and practice-centered barriers and designed a multi-level intervention to address these barriers. “We aim to empower patients and physicians by removing the barriers primary care physicians have; hence this is named the EMPOWER Study.” Dr. Hijaz has a brilliant study team and support from the primary care institute, and excellent infrastructure. “I’m really excited about it because if we can move the needle just a little, we can make a huge impact, and whatever we can find, we can most likely replicate in another system to improve on the delivery of care for women with incontinence. The goal for this three-year study is to reach more women who experience the condition, provide them with treatment and positively impact their quality of life.”

The study will recruit primary care physicians to screen patients by incorporating questions about urinary incontinence in the standard workflow. Women who screen positive will be asked if they are interested in participating in an implementation study where women will be assigned to one of the three following therapy groups: 

• Usual Care – The patient’s urinary incontinence will be managed using standard of care treatment by her primary care physician.
• Nurse Navigation – Along with the treatment described for “Usual Care,” a Nurse Navigator will work with the patients to implement behavioral changes and provide education and physical therapy options. In addition, the navigator will be available to answer the patient's questions in a timely fashion and help the patient move through the care pathway.
• Nurse Navigation and ChatBot – Along with the treatment described for “Usual Care” and “Nurse Navigation,” this option will include a ChatBot feature (mobile app) which will allow patients to directly and privately communicate with an artificial intelligence-driven ChatBot that will provide education and help them navigate the care pathway. This will, hopefully, eliminate some of the personal barriers for women, especially the issues women don’t want to personally share with others about incontinence. 

The nurse navigator/ChatBot protocols will reduce the burden for primary care providers. The study team will analyze the data at six and twelve months after the original appointment, assess adherence to therapy, and, more importantly, how the therapy impacted the outcomes the team hopes to improve. If successful, these care pathway options could be translated to other institutions and used as a model for other sensitive conditions.

“We're excited to have such an amazing team that came together from population health, biostatistics, nursing, urology, family medicine, clinical epidemiology, and primary care. It’s really a team approach. I have colleagues who have helped develop both projects, and it was great to see the collaborative effort of this team. It's really impressive, and I give credit to all of our great advisors and the people who contributed to these projects.”

Passion, Patience, & Persistence

When asked to provide advice to young physicians and scientists, Dr. Hijaz replied, “I think that the most important thing is to stay true to your passion and believe in what you want to accomplish. Learn about the environment you want to work in and make sure it is supportive. Institution and department support are tangible here at UH to help physician-scientists succeed because that's something that we strongly believe in."

Fun Facts about Dr. Hijaz

• Favorite restaurant in Cleveland is Edwins,
• Favorite Netflix series is Schitt’s Creek which he enjoys watching with his wife,
• Favorite dessert is Dulce de Leche, 
• Prefers coffee over tea, and ...
• If he could win an Olympic gold medal, it would be for soccer!