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Steven P. Ringel, MD, F�鶹��ýӳ��
�鶹��ýӳ�� President 1997−1999

Sunday, April 23, 2017
Boston Entertainment and Convention Center
Boston, MA

Tim Streeter, �鶹��ýӳ�� staff, Interviewer

(c) 2017 by the �鶹��ýӳ��. All rights reserved. No part of this work may be reproduced or transmitted by any means, electronic or mechanical, including photocopy and recording or by any information storage and retrieval system, without permission in writing from the �鶹��ýӳ��.

TS: My name is Tim Streeter. I’m with the �鶹��ýӳ�� and I am speaking to Dr. Steven Ringel, who was president back in 1997 to 1999. Good morning, Dr. Ringel.

SR: Good morning.

TS: Thank you very much for joining me and sharing some time.

SR: Tim, it’s my pleasure.

TS: The first question is probably the easiest. When and why did you decide to become a neurologist?

SR: You know, it’s funny. I actually thought I was going to be a cardiologist. I’m old enough to have been through the—when Eisenhower had his heart attacks and everybody was pushing cardiology. I went to medical school in Ann Arbor, and actually Russell DeJong—the first editor of ����ܰ��DZ��Dz���®—was there. I loved neurology, but I thought that neurology was diagnose and adios and we couldn’t do anything. Then when I went into my residency in Chicago, I realized that a lot of medicine was chronic disease. There were some very inspiring young people, one named Harold Klawans, whom I particularly worked with. He was a movement disorder doctor. I said, “You know, I could do this. I could really be a neurologist instead,” so I started working with him during my residency in neurology. I think that’s when I switched over. Medical school stimulated me with neurology, but I had angst that it wouldn’t be the right field. I was wrong. I came to the field, then, during my residency.

TS: Did you know Dr. DeJong well?

SR: Yes. He had a very dynamic department. There were also people in neurosurgery and neuroanatomy there. Elizabeth Crosby was a famous neuroanatomist. Eddie Kahn was a neurosurgeon whom they wrote books about. Neurology and the neuro field was a big deal in Ann Arbor at the University of Michigan.

TS: Of course, he was the founder of the Neurology journal. Did any of that rub off on you, because you’ve had experience with publications in the academy?

SR: It did. He clearly was one of the people that influenced my career, and his faculty, the younger people. When I went to Chicago, it was then Presbyterian-St. Luke’s. It’s now Rush Medical College. The chair there was Maynard Cohen. He was also president of the �鶹��ýӳ��. He’s one of the old guys who’s no longer living, but back with the Four Horsemen who started the Academy, Maynard was their contemporary. He got me very involved in the �鶹��ýӳ�� relatively early in my career.

TS: Was he like a mentor, then, within the Academy?

SR: He was. He really showed me the importance of the �鶹��ýӳ��. In his department was a fellow named Floyd Davis, who was one of the earliest people in developing the education programs for the Academy, which, as you know, has been a real strength in the Academy. Those two people really directed me in a way—I don’t think purposefully, but more just because of how I saw what they were doing and how I admired that.

TS: Did you know Abe Baker?

SR: I did not know him personally. I knew who he was, but I didn’t know him personally.

TS: You joined the Academy in 1970. Is that correct?

SR:  Yes.

TS: What were your expectations at that time? What did you need as a young neurologist?

SR: I don’t know if I knew what I needed at that time. That’s funny. I joined it, again, because I was influenced by the people in my department of neurology where I was training who were very involved in the Academy. I wanted to learn more. I’m sure that I was focused on education. The Academy really was the one place where you could go and learn. The courses, the publication, the journal Neurology, so it seemed very natural to be—that was the source of information as a neurologist.

TS: Before you became president, I have a list of committees here a mile long that you participated in. Why did you get interested in these leadership positions?

SR: I’ve always thought of myself as sort of an instrument of change. I think you can’t be static and you have to grow, and the way you do that is you learn, and you see what is known in your field and what you can do to improve. I always felt that the Academy afforded me that opportunity to learn and to grow. Throughout my career, the Academy met a lot of my needs. In subsequent years, I’ve gotten very interested in health policy throughout and not just in neurology, but it was really always how it applied to neurology. It really became my way of understanding where medicine was going. Keep in mind, when I started—I went to medical school in 1964—it was a year later that Medicare and Medicaid came into being, so in my career—basically we’re talking 50 years—the change, the whole financial structure, the AMA opposed Medicare at that time. They thought of it as socialized medicine, and then the doctors quickly figured out they could make a lot of money doing that. I sort of lived through that whole period, and the Academy allowed me to understand it.

TS:  It’s interesting, because now hasn’t that kind of reversed because of Medicare setting reimbursement rates and everything? The doctors are finding that affects what the insurers will pay and that kind of depresses, in some cases, reimbursement?

SR: Yes, but I think that’s inevitable. I think if we talk about the future of medicine, it’s not sustainable where we are. The finances are going to change. Medicine has gone through—it really did start with Medicare—an entrepreneurial phase where everybody—and I’m not just talking about doctors. I’m talking about hospitals, pharmaceutical companies, durable medical equipment, everybody in our country—has taken advantage of the free enterprise system and the end result has been that we’re too expensive. The doctors may be uncomfortable with regulations to control their pay, but the reality is it’s not sustainable anymore and we’re going to see a cut. Hopefully, we will help those decisions so that they’re in the best interests of the patients, as well as our neurologists.

TS: Among the committees and task forces you’ve served on, there’s the Town Hall Forum Task Force. What was that all about?

SR: The biggest change in my career, which led to me being more and more involved in the Academy, was attributable to my wife. My wife is a public policy person who worked for the governor of Colorado, was involved in all kinds of activities related to legislative affairs. When she was a lobbyist she represented insurance companies, so I got very interested. I said, “My goodness gracious, people like my wife are controlling what’s going to happen in the medical system.” We laughed about that a lot, but she really sensitized me to the importance of the political process in all of these decisions. I was fortunate enough to be able to do a sabbatical to work in the United States Senate. I was a Robert Wood Johnson Health Policy Fellow, and that made me very knowledgeable about all of the interest groups involved and the importance of the dollar. When I came to the Academy, and before I became president of the Academy, I was in charge of their legislative process. I wanted other members to understand these issues, so that’s why we started the Town Hall Forum, because it was to talk about the political process and how that influences what we do. It was a wonderful experience. Michael Kinsley, who’s a very well-known journalist, moderated it for years. It was really a very fun experience and learning experience.

TS: Then there was another one, the Physician Workforce Task Force, in 1994.

SR: It’s interesting, because there was always a perception that there was a shortage of neurologists, so we were looking at that and trying to come up with formulas for what’s the demand and what exists. Now as you look at that it’s completely different than what we learned at that time. We were trying to figure out how many neurologists do you need per patient and how to you distribute them? What’s turned out is that, first of all, people go to communities based on what they want to do, not where the need is. As you know, rurally there’s a shortage of all kinds of doctors, including neurologists, because the medical profession and the providers don’t want to live in rural areas. The one solution that’s come up is Advanced Practice Partners.  

In my own department of neurology today, we have 14 or 16 Advanced Practice Partners. These are Nurse Practitioners and Physicians Assistants who provide wonderful care when they’re trained to understand the issues. So, this idea of a shortage of neurologists is probably going away because we’re beginning to understand that there are other people that can provide those. Interestingly, the people that figured it out first was the military.

TS: Really.

SR: They had corpsmen, who provided a lot of care, and not physicians. Those corpsmen were well trained and knew how to provide care. Admittedly, in the military you have pretty healthy people, but nevertheless, the model existed that you didn’t have to have physicians doing everything. Now what we’ve learned is that we should have everybody work to their knowledge level, so you can train people who are not neurologists, who are not physicians, who can provide many of those services, which leaves the neurologists time to do what they know how to do best.

TS: Right, and now the Academy is advocating for telemedicine, telestroke?

SR: That’s going to be an interesting challenge. I’m hopeful for that. In Colorado, where I am, we have people rurally. We ask a patient to come 250 miles to see me. They’re very disabled, and the truth is, the patient would be very happy if they could have a video screen in front of them and talk to me about their problem without having to schlep 250 miles to come to see me. It’s very conducive to care for a patient. They’re going to like that. There are a lot of issues associated with it, like adequate reimbursement for the time you put in, but the laws are changing and I think you’re going to see more of that.

TS: When you became president in 1997, was that something that you aspired to? How did you get into that position?

SR: I think it was really just sort of a natural evolution of my interest. As I alluded to, I’ve always been interested in systems and how they work.  

When I did my sabbatical in Washington and then started getting involved in the legislative process of the Academy, at the same time I was very involved in my own university in trying to figure out how to provide high quality, low cost care, and I became a vice-president of my hospital. Both of those areas were kind of helping me to understand the delivery of health care in a large health system and what all the needs of neurologists were, the solo practitioner all the way up to the big systems like the one I was in. It just sort of evolved.

TS: You had both the art, the science, and the business of neurology.

SR: It’s all part of the picture. If someone asked me today what’s the most important thing for me personally, it’s definitely the patient. I’m about to retire, and the thing I’m having the most trouble letting go of is patient care, because when it gets right down to it, that’s what we’re there for. We are there to serve these people. I’m a people person and I like working with people. I think that everything we do in health care, whether it’s neurology or any other, it has to be in the best interests of the patient. Otherwise, it’s a house of cards.

TS: When you became president, during your term, [�鶹��ýӳ�� Executive Director/CEO] Cathy Rydell told me that you’re the consummate visionary for the Academy. You were able to see the larger picture, particularly with regard to strategic planning and making sure that the Academy continued to evolve as an organization. Why was that important?

SR: You know, what works today isn’t going to work tomorrow. Things change. As we briefly talked about, the financing of health care is putting enormous challenges on neurology and on the field of neurology, all of medicine, actually, so you have to think ahead. I think the hardest lesson I’ve learned in my leadership roles is, don’t get too far ahead of your members. It takes them time to digest and understand it. One good example is when I was president of the Academy, I was pushing to have what now is the Axon Registry, but that was in 1997-98 and we started this 20 years later. It takes time to get people, and the reality was, it wasn’t until the Centers for Medicare & Medicaid Services decided that professional societies should do their registries that the Academy moved in that direction, but I was already aware of it 20 years ago. That’s my thinking. I’m always trying to think about where we need to be. It’s a tired metaphor and he’s old now, but they once asked Wayne Gretzky, the great hockey player, “How is it you’re able to score so many goals,” and he said, “I skate where the puck’s going to be.” I think we all have to skate where the puck’s going to be.

TS: In the 1997 annual report, it was noted that the strategic plan would cost nearly a million and a half dollars above what your projected revenues were going to be for the coming year. In those days the budget was only $16 million.

SR: Only $16 million.

TS: Only $16 million. That seems to be a pretty risky sort of approach to budgeting and telling the members, “We want to do this. We need to do this planning, but it’s going to cost more.”

SR: You’re right. I never lost sight of—you are serving your members and you have to have a good argument for spending their money. After all, it’s their dues that is a large part of the Academy. Actually, there are a lot of other sources of income for the Academy, publications and the advertising that comes in. Nevertheless, it’s very important that you justify it. You can’t just say, “Trust me. I want to spend X number of dollars,” and that happens to be relevant with this Axon Registry® that exists today. That’s a very expensive undertaking. The Academy wants to provide it at no charge for the members, but it’s going to cost many millions of dollars to make that work.

TS: Right. Yes. The Academy moved from its headquarters near the University of Minnesota to a leased office space in St. Paul. Had the staff outgrown its rooms there?

SR: Yes. When I was president, one of the best decisions I ever made was hiring Cathy Rydell. She’ll be there almost 20 years. The staff has grown exponentially, so we moved to St. Paul, but as you know, then we built a building. We kept getting bigger and you needed the right environment and space, and boy, the building they have now is wonderful, as you know.

TS:  It is. Yes. Was there any talk at that time about building?

SR: Yes, but it was premature. Like anything else, we were thinking ahead, but we were also, how much money do you have in your wallet? I always like going to the finest restaurant, but can I afford it?

TS: Right.

SR: I think that in the back of our mind we saw that as potential, but it was a step up to go to St. Paul. I remember it distinctly when we went there. I remember the ribbon cutting by the then Mayor of St. Paul, who I think became governor or senator.

TS: Coleman.

SR:  Yeah, Coleman. It was a big deal then.

TS: The other big change during that period of time, Jan Kolehmainen left. Had you had the chance to work with him?

SR: Yes, I had. Cathy came in, I think, ‘97, ’98, somewhere in there, during my presidency, but I was already on the board in the ‘80s, so I worked with Jan for quite a few years. He was terrific, but as the organization grew it was timely to bring in a new person with new ideas who was younger. That’s the nature of organizations; you have to. But Jan was wonderful. He really fine-tuned the whole educational part of the Academy, which was really the big [focus]. The legislative effort came much [later]. Cathy had been in the state legislature in her state in North Dakota, so she understood that process. I think that, in many respects, she expanded the whole advocacy role of the Academy. We already knew how to deliver the educational products, but that was one of the big changes that she brought.

TS: She brought in Rod Larson, who was also in the legislature in North Dakota.

SR: That’s correct. Exactly. The two of them really led that effort and understood and we ended up getting a full-time lobbying corps in Washington, DC, and put much more effort into that.

TS: Back in the ‘80s, there was discussion about maybe even moving the headquarters of the Academy to Washington. Were you part of those?

SR: Yes. That was an interesting discussion. It was because of A. B. Baker, whom you alluded to, that we had the Academy in Minnesota. In Minnesota, the Minneapolis-St. Paul area is not where most professional organizations are. Many are in Washington or somewhere in Chicago. We had such terrific staff and loyalty in the Minneapolis-St. Paul area that we ultimately decided to leave it there and then to establish a small legislative arm in Washington, and now in this electronic day and age it really doesn’t matter where you are.

TS: Right. We used a consultant for our advocacy efforts there for a long time, and then we established our own office there and staffed it.

SR: That’s right. The consultants originally were people that I knew, because when I had worked for Senator Rockefeller—I think I was there in ’91 and ’92—I got to know those people pretty well. We already had somebody and then I got to know more people and we were developing and I was involved with a lot of that.

TS: Dick Verville? [of Washington, DC, lobbyists Powers Pyles Sutter and Verville]

SR: Yeah, Dick was a wonderful person. Then we swiped another person to work with him who had been a staff for the finance committee of the Senate, so it was kind of a fun thing to do.

TS: Cathy told me that during this time there was a shift in the focus of the board away from more the day-to-day details and minutiae and allowing the executive director to work a little bit more independently while the board kind of focused on the high level strategy. How did that come about?

SR: With difficulty. Everybody likes to micro-manage. I was totally supportive of getting the board out of the weeds and up into the planning process, because Cathy is a competent individual. She could run the day-to-day operations and she didn’t need people to second guess her on a lot of that. She was accountable to the board. If the board was unhappy, they could say so, but the board needed to be strategic. It needed to think in terms of the future and what steps do we make. They didn’t need to tell her she needed to hire one more person here or there or this or that, but I think people are comfortable with little details and, you know, neurologists are pretty anal-compulsive people anyway. All physicians are, but neurologists are the worst. Maybe I shouldn’t say it that way. I should say it in a more positive way. It’s a strength. It’s a strength of neurology to follow details, but not when you’re planning. You have to get up there in the higher levels and think about where we’re going and that is not something that came easily. We had to keep pushing that to make that happen.

TS: So, board develops a strategy and let the executive director and staff develop the tactics, carry them out.

SR: That’s correct. Absolutely.

TS: Now this sounds pretty quaint here in 2017, but the Academy launched its first website in 1997 and began to accept abstracts on floppy disks and then eventually, a year later, submissions directly to the website. That must have been pretty revolutionary at that time.

SR: I know. I just read a book by Tom Friedman, the New York Times columnist, called “Thank You for Being Late.” He talks about how with the electronic age and with computers, what has happened is that things accelerate much more quickly. When I was in Washington, DC, in 1992, I was just learning to use a computer. The BlackBerry was only used by a few of the people in Congress. They were the ones who started using it. Now every one of us has one of these phones sitting in our pocket and I read in Friedman’s book that the amount of computer capability that you have in your iPhone is the same as when we put somebody on the moon. The acceleration, the rate of change that is going on now is almost mind boggling. Medicine changes literally year to year, whereas in the early years of my career it was decades. Slow change in the Jan Kolehmainen era. Now it’s a much faster rate of change.

TS: Do you think that with all these communications from the Academy, it’s difficult for a busy neurologist to kind of keep up with what’s going on and what their benefits are?

SR:  Yes, totally. I just came from a meeting of Neurology Today®, which I’ve been the editor of and am stepping down, and we’re trying to decide always how are we getting to our members, what information are we providing them, how do we provide it conveniently, and yet accurately? We don’t want to get things out fast if they’re not accurate. As you know, since there’s been a lot of interest lately in alternative news, we have to be very careful to make sure that we never lose our brand, and our brand is quality. We bring the right information to you.

TS: I talked to Christy Phelps [Christine E. Phelps, Deputy Executive Director of the �鶹��ýӳ�� Institute] in my research for these interviews and there was a new logo that was created. Christy told me that, first of all, you were very supportive of the staff and the creativity in bringing new things to how we communicate with members, how we put on the meetings and things. She also mentioned that you were part of a unique video that was shown at the annual meeting to promote the new logo.

SR: It’s true. People won’t even remember this anymore, but we had a little reflex hammer and a tuning fork crossed like this and it looked like a tomahawk and a tuning fork. It’s a metaphor for how hard it is to get people to change. People get comfortable with doing things a certain way and they don’t want to change. We really wanted to change it. In the video you referred to, when I gave my presidential address, Christy got me to dress as a hobo and we made a video somewhere in the Minneapolis-St. Paul area in the railroad tracks. My back was to the camera and I was spray painting on the wall the new logo, so when I was introduced as president they showed that video and then I turned around and it was me, which was a little unique for a presidential address, but it was fun. I always like to have a good time. My view is that you have to inspire people, and laughing is a good way to do it.

TS: Since you were president, the membership has doubled now to 32,000. Staff has more than doubled from 79 to 175 approximately. Budget from $16 million to $54 million. What accounts for that growth, in your eyes?

SR: Most of the growth has been in international members, because we have always had almost all of the neurologists in the United States and Canada. The number of neurologists has grown, but not at that rate, so where we have picked up members are people from throughout the world. We really are from an educational standpoint number one in the world in neurology, and everybody looks to us. Many of the large societies, like the European Neurologic Society, have modeled themselves after what we have done. That’s where really a good part of the growth has been, which is interesting, because with all of these legislative issues today they’re focused on American neurology and financing, but in many respects, they’re similar to issues that people have in other countries. Hopefully, they get something out of it. I think they’re attracted here for the education, but I think those issues are going to be universal.

TS: We’ve also created categories for advanced practice providers, for business administrators—

SR: And that’s going to grow a lot.

TS: Yeah. We’re casting a wider net.

SR: Yes, exactly, and I think you’re going to see many more advanced practice providers in the Academy in the future. In my own department we have a huge number of those individuals.

TS: Speaking of practice, the Academy separated its advocacy activities from the practice activities within the staffing area and established the Center for Outcomes Research. I think, at that time, wasn’t there a stroke registry that was developed?

SR: Yes. That’s kind of the early feature of what eventually has become like an Axon Registry. We were sort of putting our toe in the water and learning how to do that. It takes a lot of work and time to do that. I’ve been involved with registries for a lot of years. I was involved in an amyotrophic lateral sclerosis registry that was funded by a pharmaceutical company, but I learned a lot about how you collect data on a national level. What we were trying was—that one on stroke—was another example. Now, as it turns out, the federal government collects a lot of stroke information, but they learn from us. In what we started doing, now there’s a big national registry for stroke which is required by the federal government. It’s interesting how these things have evolved.

TS: You are a champion of evidence-based medicine?

SR: Yeah, I am. We had to move out of what we referred to as eminence-based medicine—it must be right because His Eminence said so. I am the first to admit that data doesn’t tell the whole story. There’s more to it than that. Human interaction is complex and you can’t always get it down to an algorithm, but you can’t use that as an excuse. You have to demonstrate value. It’s demanded of us today and it’s a legitimate demand. If we’re going to have to rein things in because things are too expensive, we have to use data to understand where we’re getting the most value and where we’re not.

TS: Is this when the Academy started publishing practice guidelines?

SR: Those came out, yes, but I think when we first started doing guidelines the goal was to standardize care more, but the biggest problem was, we would publish the guidelines, but we didn’t know how to implement them. The registries give you an opportunity to implement them because you feed back data to someone saying, “You’re not meeting the guidelines. We set up the guidelines and here’s your data, and you’re still only doing it 20 percent of the time when you should be doing it 100 percent of the time.” That’s why it’s so expensive, because you have to have feedback to somebody in real time to change behavior. That takes quite an operation to be able to accumulate the data, feed it back to the individual, and the hopefully the individual will change behavior based on—everybody wants to regress to the mean. Nobody likes to be outside.

TS: The Brain Matters Stroke Initiative, was that the registry, or was that something different?

SR: No. Some of that was advocacy and making people aware of the importance of neurologic disease. Stroke got a lot of attention because we were developing thrombolytic therapy which could change the outcome immediately. Everybody knows when you have a heart attack you have to move very quickly, but we needed a huge educational effort to make people aware that stroke attack, brain attack—that took years to implement, and we were using some data to show the advantages of that, but now everybody understands that. What are the symptoms of a stroke? You have to call a doctor right away. We’re really pushing the envelope today. We have ambulances equipped with CT scans that you go right to the patient when they’re having the stroke and you send information back electronically and administer the thrombolytic agent in the field. To get from when we started to that was a major undertaking. It took years.

TS: And now we seem to be kind of in that same public information spike with concussions.

SR: That’s right. It’s true. Our big beneficiary for all of this has been the National Football League because this chronic traumatic encephalopathy has made people aware of these football players who are getting brain damaged. We’ve always known that there was sort of a punch-drunk syndrome. I think Muhammad Ali is a good example of that. Somebody who was battered and who developed a Parkinsonian-like picture, undoubtedly from all that punishment he took to his brain. Now it’s soccer moms that are worried about it, so we have really emphasized the importance of protecting the brain.

TS: We were talking about big data, but even in 1997 you were trying to pull data to make your case to CMS, or HICFA, as it was known back then.

SR: That’s right.

TS: Was that kind of the beginning of, “Prove to us that your outcomes are successful. We’re not just going to take your word for it.”

SR: Yes, it was. Like anything, the early part of that was laborious and difficult. We’ve learned a lot since then. The outcome of all this is that CMS has decided that they can’t do all of this, so they’ve turned it back to the professional societies and they’ve said, “You come up with the guidelines. We can’t do it. And you come up with the measurement and show the outcomes.” We were very good at developing guidelines, but we weren’t good at collecting data to demonstrate that we were successful, so that’s Axon Registry. But you’re right. That was ’97, 20 years, which gives you an idea of what it takes to turn a freighter that’s moving. To turn the freighter takes time.

TS: And now we’re developing the quality measures and isn’t it really the neurologist, the medical community, that should be developing the measures, rather than the bureaucrats?

SR: Yes. It makes a lot of sense. An interesting thing that the Academy has to get involved in, which they’re starting to do more, is that it isn’t just the neurologist. It’s also the patient that has to get involved. It has to be patient centered care. You have to have care that the patient agrees that this is a good outcome. You may think it’s a good outcome, but the patient may not. Ultimately what matters is how they perceive the outcome. What is the quality of life for them? I think you’re going to see more and more of these measures input from the patients we serve.

TS: You alluded to your fellowship in Washington, DC. In your advocacy and meetings with the lawmakers and their staff, how difficult was it to get across the message of the value of the neurologist in patient access?

SR: You could get the message across, but keep in mind that a lot of other people were sending messages to them, too. It’s a fascinating world, the political world. It really is all about money and access. People are bombarded, so every ten minutes they’re getting something else from somebody. Much of the work you do is with their staff, because you make their staff aware of these issues. All politics is local. I’m trying to remember the congressman from Massachusetts—

TS: Tip O’Neill.

SR: Yes, Tip O’Neill. He said, “All politics is local.” It’s true, and I think the Academy has understood that. No matter what’s going on in Washington, we need our members to work on their congressmen in their district because that person is going to vote and you have to do that. The legislative effort isn’t just when you’re in Washington. It really is back home, as well.

TS: The Academy started to talk about creating a political action committee during this period of time. What were the pros and cons of that debate?

SR: The pro was that we definitely felt that we could have more influence if we could also provide funds to the person’s campaign, because that has an influence. It does. I can remember distinctly sitting—while I was having a conversation with Senator Rockefeller, he was going through a stack of checks he received and he would say, “Oh, gee. That guy gave that much?” It would register in his mind. They will never say that they’re influenced by the money, but they’re influenced by the money. That’s the reality. The disadvantage of it is that neurologists give a relatively small amount of money, so how much impact can you have? That was what we were weighing all along. We just didn’t have the dollars, and even now it’s hard to raise the dollars to have a great impact, but it’s better than nothing. It works.

TS: Was that Jay Rockefeller?

SR: Yes. That’s who I worked for. There was a program, the Robert Wood Johnson Foundation, in the Institute of Medicine. I guess it still does exist. They choose six people a year to work in Washington. I was fortunate enough to do that.

TS: For some time, the Academy had worked with, I think it was, CNS [Child Neurology Society] and ANA [American Neurological Association] in—

SR: I started that [the Neurology Public Policy Fellowship, which supported a neurologist to be on a congressional or executive branch staff for a year].

TS: You started that.

SR: Yeah. Because of my time in Washington, I decided that we needed more people, and it wasn’t just me. Ira Shoulson, who had done a Kennedy Fellowship, was involved in making this decision. We knew that we needed a critical mass of people who were more sophisticated in understanding the legislature and how you work with Congress in doing these things, so we started that program where we would train people and get them in Washington, not just with Kennedy or with Robert Wood Johnson, but with our own program.

TS: And then the Palatucci Advocacy Leadership Forum was, I suspect, inspired by that?

SR: Yes. It’s just an evolution of involvement of what are the ways we can get to—and the Academy got increasingly involved in state societies, because you had a group of neurologists who originally got together for educational programs in every state practically, like in my own state, the Colorado Neurologic Society, so we started to try to get the Academy to feed into that more the importance of legislative approach.

TS: The Academy has held Annual Meetings in Minneapolis, its home city, in 1963 and the 50^th anniversary in 1998.

SR: I was there.

TS: You were there. Why is it that—

SR: So, I hope it doesn’t offend Minnesotans, but it’s a second-tier city, and you want the most people to come. People want to come to the coasts. That’s just the reality. There are all kinds of considerations. For example, New York City is so expensive it’s very hard to hold a meeting there. Boston is extremely popular. Washington, DC, is a good one. San Diego, San Francisco, big popular places. We try to bring the meetings—we had one in Denver, which is not a second-tier city, although we’re rapidly becoming a first-tier city. That’s my political push here. A lot of it has to do with access, airports, hotels, and keep in mind, we have a lot of international people coming, so you really want to make it easy for them. I think it’s going to be interesting to see what happens to these meetings in the future. The young generation are picking everything up electronically. I don’t know that the appeal is going to be for them to come to a meeting. I think the Academy has to be very cognizant of getting the people other than the Annual Meeting.

TS: And we’ve got various regional meetings. We’ve got a Sports Concussion meeting, Breakthroughs in Neurology, the Fall Conference, which is usually someplace warm, Las Vegas, and then we’re going to have the Winter Conference again.

SR: Right. And I think that’s what you’re going to see. There are so many meetings today, and this convention center that we’re in didn’t exist a few years ago. These are big money makers for the cities, so they’re counting on them still having these big meetings. I think in the terms of professional societies you have to think of other ways to get to your members, not just an annual meeting. Annual meeting is because you like seeing people. You want to be with your friends.

TS: Network.

SR: Yeah, it’s networking. That’s exactly right.

TS: The 1999 meeting was in Toronto. That was the first meeting outside the US borders. Was that a risk?

SR:  A small one. It’s funny. That’s where I gave my presidential address the last year. My mother came to that meeting. She was taken into a room by Immigration and they searched her, so we were worried about things like that that happened to my mother. I’ll never forget that. But it wasn’t a big risk, because Toronto is really North America. People are pretty comfortable moving around all of North America. I actually think the bigger risk was Hawaii, because that’s a long way and getting members to go out there—I can’t remember the numbers—I think that was a big risk to go that far. You really have to make it into a vacation almost, because you’re traveling so far, whereas Toronto is no different than going to Chicago. It’s close.

TS: Vancouver last year.

SR: Yes, exactly, and that’s a beautiful city.

TS: Was there anything special that you remember about the 50^th anniversary meeting?

SR: I felt honored to be able to be the president at that time, because we made a big deal out of it. It was 50 years, so it was fun. There were more festivities than usual. That’s what I remember most. It was just more hoopla.

TS: Frank Forster was the only surviving member of the Four Horsemen.

SR: Yes, exactly.

TS: Did you know him?

SR: Yes. It was really an honor to be able to sit down with him. You know, it’s funny. There have been several people, famous neurologists, that I had the opportunity to meet when I was president. The one I remember the most was Roger Bannister. The first four-minute mile. It was Sir Roger. Sitting down next to him was just a thrill for me, because I could remember 1954, when I was 11 years old, and he ran the four-minute mile. It was a neurologist that did it. We’re not as nerdy as everybody thinks we are.

TS: Oliver Sacks.

SR: There’s another one. I loved that guy, and boy, was he candid in his books. I’ve read everything he’s written. He’s probably the most famous neurologist by far, and just a very creative, unusual mind. There are so many people that—we have Nobel Laureates. It really is wonderful to get to know all these people and understand their perspectives.

TS: The 1999 meeting was the first Neurobowl® and foundation Silent Auction. Was it a challenge to keep the meeting fresh each year?

SR: I think you had to be creative. You find the right people. Tom Swift is one of the most talented, entertaining people you will ever meet. He was president of the Academy, too, but today he’s still doing that Neurobowl. He struck a chord with neurologists. They love making diagnoses of rare things. There isn’t a neurologist alive that doesn’t get excited when they pick up some rare disease. I call them neurology skin flicks. There’s something about them, so you’ll see. It’s tonight, and the room will be filled. They’re all second guessing what it is, and Tom is so entertaining and he and Kapil Sethi work very hard to bring fresh material every year. It’s probably the most popular event we have.

TS: Do you think there should be more of those more lighthearted events?

SR: I do. I think humor and entertainment lets the bitter pill go down more easily. I think there are a lot of challenges in medicine in the future. You know, there’s been big focus on burn-out among neurologists. I think you have to also inspire them and entertain them and make them feel good about themselves. You can’t batter them all the time with all the difficulties. You also have to make them feel good. That kind of thing, I think, is important.

TS: As far as research goes, 1999 was the end of the Decade of the Brain. What did that accomplish for the Academy?

SR: We were trying to put neurology in the front page and make everybody aware of it. I can remember they teased me a lot. Senator Rockefeller used to tease me a lot about it. He said, “Most people have a day, some have a week. You guys want a decade.” But it worked. It really did work. It became the catchword, and you know, it’s interesting.

Stroke and dementia and traumatic brain injury are on the front burner. People are aware of it. Everybody’s afraid that they’re going to get demented or their kid’s going to get a traumatic brain injury or they’re going to have a stroke, so it accomplished what we wanted. We moved heart attack over and cancer and said, “What about the brain?” and it worked.

TS: It also galvanized research.

SR: Yes, totally, and we could get more funding because we had people who were advocating for neurologic research, so it worked.

TS: Publications. I was surprised when I learned that the Academy did not own the Neurology journal until 1996. It had been owned by several different publishing companies, correct?

SR: Yes. I was involved in those kinds of negotiations and that was the beginning of our awareness that we needed to expand our publications. We founded �鶹��ýӳ�� Enterprises, which really was more than anything focused on publications. We looked at other opportunities, but we started Neurology Now® [now Brain and Life™] for patients, Neurology Today® for a newspaper, and we started ����ܰ��DZ��Dz���® Clinical Practice, and now there’s a whole—we call it Neurology, and there are spokes going out to other journals, because we really expanded all of our publications. You’re right. For a long time, we were just Neurology and it was owned by a publisher and then we began to realize that there were many more opportunities and we needed to take more control of it.

TS: You mentioned Neurology Today. You and Bud Rowland worked to launch that.

SR: Yes. When I was chairing �鶹��ýӳ�� Enterprises, or involved in �鶹��ýӳ�� Enterprises, I really felt that the newspapers which were gaining prominence in the neurology newspapers weren’t doing a great job in the sense that they would have a reporter go out and report something, but they weren’t interviewing people to say, “Is this good stuff or not good stuff?” I felt we could really do a better job. Bud Rowland was a star. He was admired by everyone. He had been editor of Neurology, had been president of the �鶹��ýӳ��, had been president of the American Neurological Association, and on and on and on. Twenty-five years as chair at Columbia. He trained most of the many, many famous academic neurologists, so it was an easy choice picking him to edit this. I was his associate editor. The happy triad with Fay Ellis, who as it turned out was a wonderful journalist who came at that time from I think it was Lippincott before it was Wolters Kluwer. It turned out to be a very happy marriage for the three of us and the newspaper has just grown over the years. Really, Bud brought it credibility. He was a tireless editor. He loved making sure that things were accurate. He really made sure the quality was outstanding.

TS: He had a red pen, didn’t he?

SR: Yeah, he had a big red pen. That was what he was known for. When I started, my first paper submitted to Neurology, I got it back from Bud. We didn’t have track changes and computers, and Bud had redlined everything, but that was because he really was a journalist and understood, say it clearly, don’t use all these words, get rid of all this excess language. He was wonderful.

TS: And now you’re stepping down from the editorship.

SR: Yes. It’s true. Joe Safdieh is now going to be the editor and hopefully the newspaper will continue to flourish. I’m sure it will. He’s a smart fellow. I’ve been involved with him for 17 years, when we first got the idea, and I think it’s been published for 16 years. I’ve been editor since Bud retired and I’m proud of it. It’s been wonderful for me because it’s kept me up to date with everything that’s going on in the field. I hope it does for the readers, as well. We have two wonderful things, Neurology Today, two advantages over other publications like the journal Neurology. One, we don’t have to wait for submissions. We can take anything from anywhere and write about it, which gives us a tremendous advantage of material, because some of the very best stuff goes in prestigious places like New England Journal of Medicine, Journal American Medical Association, Neuron Science. The second thing is, and I kind of tease my colleagues about this, journalists write. Journalists do a good job, and they meet deadlines. Neurologists never meet deadlines and their language is more cumbersome, so it’s such a thrill to have good writers, smart people, who get it to you on time.

TS: Right. I’ve just got a couple more minutes here. Looking back on your presidency, what was the best part of it?

SR: The people. There’s no question. Being able to work with very smart people was the best part of my—I met so many interesting people. There’s so much talent out there. My job was trying to get as many of these talented people to do things for the Academy of Neurology. The Academy is very lucky. They get a lot of smart people that help them. It’s a member-driven organization and it’s mostly volunteer. If you can get those people to give of their time, it’s wonderful. That was by far and away the best part of it.

TS: What would you say to a young neurologist who wants to get more involved?

SR: Do it. Do it. You will grow. I have grown and learned throughout my career and the Academy was a big part of that for me. I have no reason to think that wouldn’t be for someone else. I think the Academy is always going to be on the leading edge, sometimes the bleeding edge, but I think that if you want to be at the forefront of change, you should be involved in the �鶹��ýӳ��.

TS: Thank you, Dr. Ringel. It’s been a pleasure to have you here and sharing your experiences.