Interview with Nelson G. Richards, MD, FAAN

June 29, 2017

Tim Streeter, AAN staff, Interviewer

This interview was conducted via email between Nelson G. Richards, MD, FAAN, (NR) and AANnews® editor Tim Streeter (TS). Richards, who joined the AAN in 1957, was the first practicing neurologist to be elected AAN president. He is retired and living in Virginia.

TS: When and why did you decide to become a neurologist?

NR: During my residency rotation through the various specialties in internal medicine, neurology was selected as a further residency program. The next two years in neurology residency increased my interest. The next year at NINDB, I completed my neurology residency. I decided on neurology as my subspecialty. While there I got an offer to join the Cleveland Clinic Department of Neurology. Both of my mentors, Dr. Harold G. Wolff at the New York Hospital and G. Milton Shy at NIH, had advised me to go into private practice and make a difference. We went to Cleveland in 1958.

TS: What were your expectations of the Academy when you joined in 1957? What did you need as a new member?

NR: I wanted to get more involved in neurological organizations and practice. The AAN invited all neurologists to join. The AAN had continuing education courses and a scientific program. I was just finishing my residency in 1957 and needed further activity in neurology.

TS: What motivated you to get involved in AAN leadership activities?

NR: I had joined the American College of Physicians (ACP) and the practice management-oriented side of the American Society of Internal Medicine (ASIM). The Academy included both academic and practice management in one organization. The AAN was inviting participation. I started working with staff at the 1964 Annual Meeting in Denver and then became the local Annual Meeting chairman in Cleveland in 1965. I continued as chairman of this committee for a few years. The Practice Committee was being developed and I joined Drs. Rosenbaum and Segerson in that committee with their other activities (such as CPT).

Dr. Foley, during his presidency in 1964, had talked with Dr. Herb Rosenbaum, from St. Louis, of the need for office-based neurologists at the AAN. Herb, with Dr. John Segerson of the Menninger Clinic, started organizing the Practice Committee. It was developed for the “grass-roots neurologist,” as Dr. Foley had suggested. I joined the committee. Education courses were developed for the Annual Meeting, including the Coding for Procedures (CPT) and diagnosis codes (ICD-9-CM) for the the insurance companies and government Medicare/Medicaid “third party” carrier programs. I borrowed experienced staff from the American Society of Internal Medicine to aid us in organizing and recording efficient committee meetings and the structure of the board.

TS: Did you have any mentors who helped show you the ropes and encouraged your involvement in the Academy?

NR: Herb Rosenbaum, at the Academy, was organizing the Practice Committee and was a mentor and stimulator. My observations and activity at the ACP and ASIM were also a support in understanding their organizations, meetings, and staffing. This was helpful in developing my thoughts about the potential for the Academy. We borrowed some of the ASIM staff for organizing the activities and actions of the Practice Committee. I basically used the examples of the ASIM for the Academy.

TS: You were the secretary-treasurer in 1969. What were some of the financial concerns at that time?

NR: I was there mainly there to assist Bob Baker, the secretary-treasurer, in his development of financial stability for the Academy. He was very well positioned for that job and brought on Stan Nelson. I needed, also, to learn the organizational structure and activities of the Academy.

TS: In the mid-1960s, some Academy members in practice felt the AAN was dominated by the academic neurologists. Was that a widespread feeling? Did you share that view?

NR: Yes, I did. In 1948, when the Academy was formed, this was one of the main objectives to have an organization for all neurologists. This was the initial leadership concern of the “Four Horsemen” who started the Academy: Drs. A.B. Baker, A. Sahs, F. Foster, and R. DeJong. Abe Baker was the driving force. I did share this view. The Academy has become stronger and larger over the years. All neurologists, national and international, all are now represented and active.

TS: Were you involved with any of the separate practice societies that started to form?

NR: I was involved in many societies and their committees including the AMA, American College of Physicians, American Society of Internal Medicine, and helped form state and local neurological societies. Following my internal medicine residency, I joined the ACP, becoming a Fellow there in 1961. I joined the ASIM, where I got my orientation experience in practice management. I was exposed to their activity and became active in their committees. I carried this experience to the Academy organization during my presidency. Advice from their membership, staff, and executive director was very supportive in my understandings of medical organizations and committees. Advice came along during difficult times at the Academy. The relationship of the ASIM with the more academic ACP was very similar to the Academy, where academics and practice are in our one organization. Indeed, the ACP and ASIM have joined each other. I used my observations at ASIM for the structure of the Academy.

TS: Dr. John Conomy said that you “brought the community of practicing neurologists into the mainstream of the organization and eventually into the leadership and conscience of the AAN.” What were the obstacles you faced? Who were some of the leaders who held differing views?

NR: I did not feel any obstacles and found much support in changes I suggested. Academic neurologists were helpful in the understanding of our objectives not to replace but complement academic and private practice’s relationships. Some of the eastern neurologists did express some reservation in the need of an additional society in the middle of America. I asked five of the recent presidents to be available to give me suggestions and advice when needed. Maynard Cohen, the immediate past president, was very helpful and became a good friend.

TS: What were the challenges of being a practicing neurologist in those days?

NR: There were few referrals for the office-based neurologist. Neurological consultations were felt to be “diagnose and adios.” Detailed neurological examination was needed and the formulation of the problem, but few neurodiagnostic procedures were available. Previous neurological education had usually been minimal for most doctors.

TS: Were you involved with the Practice Committee when it began?

NR: Yes, after Herb Rosenbaum and Jack Segerson began forming the committee, I joined them. The courses were developed. Many courses were from the committee members as the committee enlarged.

TS: Was it a challenge to get the first practice management course into the Annual Meeting in1981?

NR: There was some resistance to include practice management within the Annual Meeting. Documentation of practice was related to the proper coding numbers for the patient’s insurance. Medicare/Medicaid were the “third-party payers.” The need of coding by ICD-9 and CPT were poorly understood in many practices. Efficient office management was needed, usually with the additional employment of personnel. The challenge was there. Budgets were tight with additional help being needed.

TS: You were the first practicing neurologist to become AAN president in 1983. How did that come about?

NR: The Academy was for all neurologists, including those in office-based practice. The courses in practice were popular. An office-based neurologist was needed. The activity of the Practice Committee may have been a source for a practicing neurologist.

TS: Was it difficult to get the Executive Board to adjust the schedule of the Annual Meeting to better accommodate practitioners?

NR: No, I had great support from the previous presidents and chairmen of the Education Committee. When we placed the courses at both ends of the scientific papers presentation it was based on the desire that all partners at home should get access to the meeting. This was developed to make it possible for those members who came to the meeting to return home and allow their associates, who were at home in their active practice, to come to meetings.

TS: Can you talk about the Academy’s relationship with the American Medical Association? What was the value of that relationship to the AAN during the 1970s and 1980s?

NR: We have a very positive relationship with the AMA which was developed by our delegation. Our main objective was to be more active and available to the AMA in the regulation of medicine. The AMA appointed us to many important committees. These included those that regulated coding reimbursement levels, definition of procedures, scientific questions, and ethics and other councils on practice problems. The AMA was originally formed to regulate medical school education. We were able to develop relationships with other medical organizations at the House of Delegates meetings. During the ‘70s and ‘80s, they supported our resolution on banning boxing as a risk of damage to the nervous system. We were active on debates at the Councils with final voting.

I was surprised how much of the education, research, and delivery of medicine influenced the responsibility of the AMA. Dr. Ken Viste, president from 1995 to 1997 and President Francis Kittredge, Jr., were very active, along with other AAN members at the reference committees and delegation interaction. These are very important for recognition of the AAN and interaction with other medical and political organizations.

TS: Why was it important for the AAN to get a seat on the RUC?

NR: This is the committee of the AMA that establishes the levels for reimbursement in relationship to other specialties’ imbursements. Our members, Drs. Marc Nuwer, Neil Busis, and Bruce Sigsbee, were very active and successful at the RUC for the AAN, adjusting our fees of imbursements for EEGs, EMGs/NCVs, consultations, and follow-up. They were all members of the Practice Committee.

TS: You extracted all the neurology-specific ICD-9-CM codes for our first book for members. How long did that take you?

NR: It took about a weekend to survey all the codes in the ICD-9-CM, Fourth Edition DHHS and extract them for our booklet. Dr. Laura Powers, from the Practice Committee, subsequently assisted me and became my replacement as editor.

TS: Can you talk about Stanley Nelson when he was executive director? What was his style and his contributions to the success of the AAN?

NR: He was working with a very small staff and had little contact with the membership for doing a difficult job. The AAN was growing in membership and organizational activities. He, and his small staff, organized and set up the conventions. He was always pleasant with the various problems. He needed help. He was basically a CPA.

TS: How was Jan Kolehmainen selected to be the successor to Stan Nelson? What qualities did he bring to the AAN?

NR: He brought his “Finnish” patience and organization abilities to the enlarging staff. He had new skills in management that he brought from previous positions. I don’t recall how he was selected but believe he was brought from a similar organization. Stan Nelson had died.

TS: There were only a dozen or so employees on staff when you were president. Did that impede the Academy’s efforts to serve its members, or was that a “simpler time” back then?

NR: It was a simpler time. I had a new basic change in the Academy to one similar to the ASIM in function and activity. Staff and members worked together with almost no resistance. With the two-year president’s appointment, the first year was involved with structure and committee selection, and the second year, there was the application of the action the appointed committee. It was really a great time.

TS: Was there any discussion of moving the Academy offices during those years?

NR: Yes, there was as we were growing out of our original small office. The opportunity occurred to buy into a building and have larger office space with progressive enlargement potential.

TS: What was your proudest accomplishment during your years in the AAN, and what do you wish you had more time to address?

NR: All neurologists had a place for membership. This was the primary objective of the “Four Horsemen,” Drs. A.B. Baker, Russell DeJong, Adolph Sahs, and Francis Forster, with others, who envisioned the Academy as a place for all neurologists. I am very happy and proud of what we accomplished. The Academy has continued flourish with our CEO Cathy Rydell’s leadership.

TS: Through the years, you worked closely with a number of AAN presidents and executive directors. Are there any memories or impressions you would care to share?

NR: A.B. Baker was a dynamo for the Academy. He and Maynard Cohen provided slides for a course in neuropathology, which was the beginning of the Special Courses at the Annual Meeting. Maynard preceded me as president with his strong ideas of education being our primary objective. We had many discussions about the courses. We had a very good relationship, him in academics and me in practice. We became great friends. Roger Rosenberg came to the nominating committee with a hand-out of what was needed to be done for development of the Academy. Maynard advised me that Steve Ringel should have a great future at the Academy. Ted Munsat did a great job with the courses, making them available worldwide. Francis Kittredge, with his legal and financial orientation, continued working toward a Foundation. Bruce Sigsbee, with his organizational and CPA orientation, was very active with the RUC in fees development. Many others were intense in their committee work and accomplishments. Cathy Rydell, with her hard work and new ideas, has made the AAN well recognized in organized medicine and with our membership. We are recognized.

TS: What was the best part of your presidency from a personal standpoint?

NR: I enjoyed the opportunity to develop a vision I had along with the advice, help, and assistance of many members of the Academy. The continued fantastic accomplishments of the Academy in developing the “Proactive Neurology for the Present and Future” have been wonderful as others continue the progress. [See Richards NG. Proactive Neurology for the Present and Future. Presidential Address. American Academy of Neurology, 1985.Neurology, Vol.36, No. 7, pp. 978-983, July 1986.]

TS: What advice would you give to AAN members who want to play a role in shaping the future of neurology?

NR: Get involved with new progressive ideas for neurological research, education, and practice. The Academy has truly been a great organization with a future, so be a part of it.