The most moving part of the ceremony at which A. Barry Belman, MD, received the 2006 Urology Medal at the American Academy of Pediatrics meeting last October was the series of photos that accompanied it.
First came two joke photos—a funny and confident toddler in swimming goggles flexing his muscles, and a picture of Belman doppleganger Carl Switzer, the child actor who played Alfalfa in the “Our Gang” TV comedy series. Then there was the real Barry Belman as a bespectacled teenager, a newlywed, and a young professional getting a hug from mom.
Finally, he was shown as he is today, professor of urology and pediatrics at George Washington University and Chairman Emeritus in the Department of Urology at Children’s National Medical Center, both in Washington, D.C.
“They made a huge error,” said Dr. Belman when asked why he thought he’d received the prestigious award. Of course, he was just joking. “I was profoundly affected by getting this medal,” admitted Dr. Belman, 68. “Three of my children and my wife were there,” he added, referring to the ceremony that was hosted by Dr. Belman’s friend and colleague, H. Gil Rushton, MD, Chief of Urology at Children’s National Medical Center. “Dr. Belman was nominated and chosen for this award by a committee of his peers,” said Kathy Ozmeral, manager of the AAP Section on Urology. “Since 1984, we’ve always chosen someone who has made outstanding contributions to the field.”
A love of teaching
Over the past 30 years, Dr. Belman has worn many professional hats, including those of a doctor, editor, teacher, and mentor. After graduating from Northwestern University’s medical school in Chicago in 1960, he completed his urology residency there and then went on to serve as an attending pediatric urologist at Children’s Memorial Hospital in Chicago.
In 1976, he became the first full-time chair of pediatric urology at Children’s National Medical Center. Dr. Belman has also co-edited all four volumes of Clinical Pediatric Urology (1976, 1985, 1992, and 2002).
As gratifying as editing and caring for patients have been, Dr. Belman says the most enjoyable aspect of his career has been teaching. “It’s like writing music or making art,” he explains. “I’m good at it; I’m able to simplify things and make them understandable. I’m also a bit of a tease,” he adds with a laugh. “I enjoy harassing the residents and getting them to learn that way.”
Of course, instructing the next generation of pediatric urologists is also serious business. “I’m very demanding, even compulsive,” he says. “And I expect students and residents to be compulsive, too. As I said to one of my residents recently, ‘You can be bright, but that’s not enough.’ When I see a patient, I follow the same steps every time: I take a thorough history and do a good physical exam, then put everything together, to make a plan. To be a good doctor; you really have to pay attention to detail. That’s true of almost everything, of course, but doctors have a higher obligation because the consequences are greater.”
Thinking before surgery
Dr. Belman says one of the things he has tried to convey in his medical teaching is that surgery is not always the best solution. To illustrate, he points to changes in the management of vesicoureteral reflux (VUR). Children with VUR are at risk for recurrent kidney infections, which, over time, can cause damage and scarring.
“Since I began working in the 1970s, I’ve been less surgical than many others in my approach to VUR,” he says. That is because many cases resolve on their own as a child grows. “If a problem is going to go away by itself, and if it is not causing harm, it doesn’t make sense to operate. I’ve done many surgical procedures for VUR, but only when necessary.”
In recent years, Dr. Belman says, VUR management has evolved and, thanks in part to his influence, many physicians are adopting a less aggressive approach to the problem. “In fact,” he says, “the National Institutes of Health is sponsoring a study looking at whether VUR patients should even be on antibiotics.”
Dr. Belman has also spoken out against routine surgery for infants with renal vein thrombosis (RVT). “When I was in Chicago during the early part of my career, doctors were removing kidneys in patients with RVT. By the time they operated, these children were often already recovering.” Instead, he has advocated an approach that involves close monitoring and the judicious use of anti-clotting medication.
For some conditions, such as hypospadias, Dr. Belman is a strong proponent of surgery. In 1998, members of two activist groups, Hermaphrodites with Attitude (HWA) and Transsexual Menace, picketed outside the George Washington University Hospital, protesting genital surgery on infants.
“Not only are American doctors cutting into seven intersexed infants every working day,” proclaimed Cheryl Chase, founder of HWA, on the organization’s website, “but people like GWU’s Dr. Barry Belman are telling parents they have to do it for the good of the infant.”
Dr. Belman points out that having hypospadias is not the same as being an intersexual, which involves having both male and female characteristics. “Like many things, decisions about how to deal with intersex conditions are evolving, and when it comes to true intersex, we’ve made mistakes in the past,” he says.
“My problem with those groups is that they believe nobody should have genital surgery regardless of the indication—even boys with hypospadias. For an otherwise normal male with an abnormal penis, if we can normalize it in the first seven months of life, without the anxiety of having genital surgery in later on, those kids should be operated on.”
An ah ha! moment
Dr. Belman also has firm beliefs about the value of careful observation as a clinical tool. “Being a good observer is key; so is having the ability to think outside the box.”
His penchant for both enabled Dr. Belman to make an important discovery about males with varicocele—enlarged scrotal veins that can affect temperature regulation in the testes and impair male fertility. In the late 1970’s Dr. Belman saw an adolescent boy with varicocele and noticed that his left testicle was smaller than his right.
Around that same time, he happened to read a journal article by a specialist who commented that he was seeing adult males with infertility problems, and that a significant number of them had a smaller left testicle. “I said to myself, ‘Gee, I wonder if boys who have a small left testicle during adolescence are at risk of being subfertile or infertile when they’re older,’” he recalls.
Based on that intuition, Dr. Belman began recommending surgery to adolescents with varicocele. As it turned out, fully 80% of boys who underwent surgery went on to experience “catch-up” growth of the testes. “Now,” he says, “everyone is operating on varicocele.”
Just one word
When asked what he thinks the next medical watershed event will be, he recalls a famous scene from the 1967 movie, The Graduate, during which protagonist Benjamin Braddock (Dustin Hoffman) is cornered by one of his parents’ friends, Mr. McGuire (Walter Brooke). “I just want to say one word to you— just one word,” McGuire says to Ben. “Plastics. There’s a great future in plastics.”
“That’s exactly what I say about genetics,” Dr. Belman says. “Before too long, we will be manipulating physiology genetically. Hypospadias, which may be hormonally based, runs in families; and VUR is an inherited disease,” he says. “I recently saw a newborn whose mother had VUR surgery as a young child; her child has a greater than 50% chance of having reflux. Genes,” he says, “dictate how our internal chemistry works.”
In such a brave new world, Dr. Belman continues, doctors will be able to identify many diseases and conditions as inherited traits, and prevent them from occurring in the first place by manipulating a person’s genes. A hundred years from now, or less, Dr. Belman predicts, “people will laugh about the fact that we were cutting people open in 2007.”
The time has come
Although Dr. Belman doesn’t plan to retire until July 2008, he has already begun winding down. “I’m working three days a week now, and a year from July, after we find someone to add to the group, I’ll leave.”
When Dr. Belman does depart pediatric urology, the field will be in a far more robust state than when he entered it. At this point, pediatric urologists are on the verge of achieving subspecialty certification status. “The American Board of Urology has approved a certificate of added qualification in conjunction with the urology board exams,” he says. “Some people are having second thoughts, but I think it’s about time.”
To bolster his point, he notes that there are now accredited fellowships in pediatric urology; that the Journal of Urology dedicates a regular section to pediatrics; that there is a European journal devoted to the field, and two official professional organizations. “It’s all a good thing,” he says.
Building a legacy
After his official retirement, Dr. Belman will still be a part of Children’s National Medical Center. For one thing, the Urology division has established a Belman Pediatric Urology Fellowship. For another, Dr. Belman may continue to see outpatients with residents and students—as well as try out some non-medical recreational activities. “I’ve always said I wanted to sculpt and play piano,” he says.
His large and growing family—a son and three daughters, of whom he is very proud—will also keep him busy. Dr. Belman and his wife have been married for over 42 years, and she is just as active as he is. Paula Belman holds a master’s degree in school psychology, and is a court-appointed special advocate volunteer for abused and neglected children.
She has been working with the same child for several years. As the so-called “eyes and ears of the court,” she sees the child; she talks to the child’s teachers, parents, foster parents, and the court, and assesses whether everyone is doing what they’re supposed to, says Dr. Belman. “It’s a very hands-on role.”
With his impressive legacy to boast of, does Dr. Belman have any regrets as he looks back at his long career? “I’m sure I could have done more, worked harder, and been more compulsive,” he says. “But,” he concludes, “my career and my life have been far better than I could ever have hoped.”