Like others who have had this honor I was quite surprised at Dr. Haas’ request that I submit something about my life in urology. Although I have been quite pleased and proud of my career in pediatric urology, I never thought it was exceptional. I certainly don’t consider myself a legend. Others have attributed other adjectives to my name, some of which are not that positive.
I have, however, had the privilege of working with some true urologic legends. These men have profoundly influenced my life and approach to medicine and deserve credit for steering me in the right direction. But the person who pushed me into medicine was my mother. I had, since I was a very young child, loved animals, and I was determined to study veterinary medicine. During my college years in my home town of Tucson, Arizona, my mother kept encouraging me to consider switching to pre med, which I finally did my junior year. In those days Arizona did not have a medical school. When applying to med school I put Northwestern University in Chicago on my list. Fortunately I was accepted, having no idea at the time how influential that decision was to be. I was leaning towards studying obstetrics gynecology, and with that in mind I thought that a urology rotation would be a good idea. I was immediately infected by the “urology bug” and quickly changed my mind as to my future plans. During that time I attended a lecture by Dr. John T. Grayhack, Kretschmer Professor of Urology and Department Chair. I was blown away by his depth of knowledge, ability to communicate and obvious honesty. I was stricken! In my senior year I worked in Grayhack’s lab with Dr. John Graham in an effort to expand my knowledge and increase my chances of being accepted into Northwestern’s residency program. In those days the process of getting a residency slot was much more personal; people were placed in programs by their professors. There was only one slot available that year at Northwestern and fortunately, primarily because my competitor had rheumatoid arthritis and Grayhack didn’t think urology was a good field for him, I was given that position….probationally, I might add.
After internship and one year of general surgery I started the urology program and spent 3 clinical years and 1 laboratory research year being molded into a different person. Dr. Grayhack demanded a high level of clinical excellence and honesty primarily by setting himself as the example. This extended to patient care and academic work. I recall giving him a manuscript I had written for possible publication that was never returned to me. On several occasions I asked him if he had had an opportunity to review it and each time he replied “not yet.” Ultimately I “got” it. The work was mediocre and non salvageable. I learned a valuable lessen about quality of work from that experience. When I gave him my next effort-- the first publication that espoused the nonsurgical management of renal vein thrombosis in the newborn--he returned it with a few suggestions and a note in the margin stating that this would be a major contribution to the literature. Dr. Grayhack was and remains a major influence in my life. Intellectual honesty is something I try to apply to both the practice of medicine and life and, some 38 years after having completed my training, I still frequently ask myself “What would Grayhack do in this situation?”
We were fortunate in the Northwestern residency program to have a separate rotation in pediatric urology at Children’s Memorial Hospital. Dr. Grayhack had recruited Lowell King from Johns Hopkins to head up the Division of Pediatric Urology. Lowell became one of the first American urologists to confine his practice to children. However, just prior to my rotation as a resident, Lowell left Children’s to head up the urology department at Presbyterian-St. Luke’s Hospital in Chicago. George Kaplan, who had finished his residency that year, took over as acting chief at Children’s and became my contact with pediatric urology. George is a gifted teacher who rapidly stimulated my interest in the field. George only stayed in Chicago that one year, moving on to San Diego where he became the first full-time pediatric urologist in that locale. Fortunately, however, Lowell King was recruited back and as one of his requirements he insisted on a second slot for a pediatric urologist. Upon completion of my residency I was offered that job. During our 6 years of working together Lowell shared with me his wealth of experience and his brilliance still influences me. He was the first urologist to place children on long term antibacterial prophylaxis for vesicoureteral reflux and was a strong advocate for the nonsurgical management of that problem. He was the second most influential person in my career and a true urologic legend. He and Panos Kelalis of the Mayo Clinic invited me to join them in editing the preeminent textbook, Clinical Pediatric Urology. I was involved in editing the four editions that were published between 1976 and 2002. It was also Lowell who stimulated my involvement in organized Pediatric Urology. Ultimately I became President of the Society for Pediatric Urology and Chair of the Section on Urology of the American Academy of Pediatrics and was awarded its Pediatric Urology Medal in 2006, my greatest honor. Unfortunately, Lowell passed away in late 2008.
In 1975 Lowell recruited F. Douglas Stephens to join our group, which at that time consisted of three physicians. Douglas was an Australian pediatric surgeon with a strong interest in embryology who had co-authored the classic text on urogenital and anal anomalies. He was (and at 95 years of age still is) a consummate scientist, applying his inquisitive nature to all problems that pertain to congenital pelvic pathology and the embryology of the genitourinary tract. He taught me how to observe, gleaning as much as possible from every anatomic and surgical detail. His was the motivating influence that taught me to observe and think about problems in detail, strongly influencing my ability to do this for clinical situations. This approach helped me to arrive at whatever original contributions I have made to pediatric urology. He certainly is another legend in both pediatric urology and surgery.
In 1976 I had the opportunity to move to Washington, DC and become head of a new Department of Pediatric Urology at the Children’s Hospital of DC, now known as Children’s National Medical Center. I was the first urologist in the DC area to practice full-time pediatric urology. Bob Jeffs had moved to Johns Hopkins, 35 miles away in Baltimore, the previous year.
In those first few years it was a battle convincing both the urologists and pediatricians that pediatric urology was different from the urology that was being practiced on adults. It took at least 5 years to get things going and in 1981 Evan Kass joined me in practice. Evan moved on to the Detroit area after 5 years and in 1987 Gil Rushton came to Washington taking over as Chief of the Division in 1996, after I had held that position for 20 years.
Since then Pediatric Urology has developed into its own urologic subspecialty with a separate section in the Journal of Urology; that section now edited by Dr. Rushton. Subsequently, the Accreditation Council for Graduate Medical Education (ACGME) recognized and certified Fellowships in the field and, as of 2008, a separate Certificate of Added Qualifications was issued by the American Board of Urology, awarded after passing the certifying exam. I am pleased that I was part of the vanguard that had, for many years, pushed for this recognition, and based on my having been such a nuisance to both the American Board of Urology and the American Urological Association, I took the examination the first year it was offered and passed. I believe I was the second oldest person taking the exam that year, surpassed only by my early mentor, George Kaplan.
In 1970 when I became one of the first 10 or so US urologists to confine his (and we were all males) practice of urology to children, I had no idea what I would have the opportunity to witness and participate in over the next 39 years: from the handful of us at that time to close to 300 men and women in the field now. Training has progressed from either becoming pediatric urologists straight out of residency or going to Europe to observe one of the experts for a few months to now spending one clinical and one research year in a certified training program and getting a certificate proving our expertise.
What a privilege it has been to be a part of this evolutionary process! I suppose if I have contributed something to the evolution of pediatric urology then the term legend may be applicable. At least in my own mind. Thanks for the honor, Gabe.
© The Canadian Journal of Urology™; 16(4); August 2009