Interview with Thomas R. Swift, MD, FAAN: AAN President 2005−2007

Thomas R. Swift, MD, FAAN
AAN President 2005−2007

Saturday, April 22, 2017
Boston Entertainment and Convention Center
Boston, MA
 
Interviewer: Tim Streeter, AAN Senior Writer

(c) 2017 by the American Academy of Neurology. 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 American Academy of Neurology.
 
TS: Hello. My name is Tim Streeter [TS]. I’m with the American Academy of Neurology. This afternoon, I have the good fortune of being with Dr. Thomas Swift, who was the president of the Academy from 2005 to 2007, and he is going to share his experiences as one of the leaders of the Academy of Neurology. Hello, Dr. Swift [TRS].

TRS: How do you do, Tim Streeter?

TS: I’m fine. My first question, the obvious one, when and why did you decide to become a neurologist?

TRS: When I was a medical student at Cornel in 1962, before you were born, I took a neuroanatomy course, which every student has to take, and one of the neurology residents had dropped out for a year to teach neuroanatomy. He was so excited about the nervous system. We were doing gross and microscopic anatomy and looking at all the pathways. I said, “I want to be just like him, and I want to do that.” He and I later became very good friends. That was Alec Reeves, who was chairman at Dartmouth for a while.

TS: So, it was as simple as that.

TRS: It was that simple. He was my role model, and I got focused on neurology in my first year in medical school, and I never changed after that.

TS: You joined the Academy in 1975? Is that correct?

TRS: That’s correct.

TS: What were your expectations then? What did you need as a young neurologist?

TRS: Well, to a certain extent, I can’t answer that question, because I didn’t know why I joined. Everybody seemed to be joining. There was a lot of encouragement for Dr. Plum, who was my mentor, and everybody seemed to be members of the Academy, and I liked going to the Annual Meeting. I just got kind of sucked into it. I really liked it.

TS: Was that Dr. Fred Plum?

TRS: Fred Plum. Yes.

TS: He was involved a lot with Academy activities, wasn’t he?

TRS: Academy. He was very involved in the Academy and ANA [American Neurological Association], both.

TS: What motivated you to get involved in leadership activities? Do you recall what your first committee assignment was?

TRS: My first committee assignment was, I think around 1980, and it was when Dave Pleasure was chair of the Science Committee. I went on the Science Committee. I was encouraged to do that by Dan Feldman, who is a well-known researcher in neuromuscular disease, who was active in the Academy. He put my name up, and I got on, and I found it fascinating. I really enjoyed it, so I stayed a long time on the Science Committee, and went through several chairs of the Science Committee.

TS: Why did you gravitate to the Science Committee?

TRS: When I was a medical student, I’d done a lot of research on neuroanatomy and neurophysiology. The Science Committee was a natural for me to do that. I was very interested in that. I was doing a lot of science at the time. I had NIH grants, and I was studying peripheral nerve and muscle. There was a lot of resonance with the Science Committee with that.

TS: Did the Science Committee have responsibilities, then, for the science programming at the Annual Meeting?

TRS: It was interesting. Back in those days, the two big things that happened at our meeting—our meeting has become much more complex and far ranging. But at the time, it was pretty much education and science. To find time in the program, you were always having the chair of the Science Committee and the chair of the Education Committee battling for time in the agenda. What happened was, after a while, they figured out they needed a Meeting Management Committee to help adjudicate disputes.

TS: Referee?

TRS: To try to figure out what we really wanted to do with our Annual Meeting. If the president at the time happened to be friends with the chair of the Education Committee, education got more time. If he or she happened to be friends with the head of the Science Committee, science got more time. It wasn’t done on a rational basis. I think it was I who suggested having a Meeting Management Committee, because I had previously been very active in the AAEE, which has now changed its name several times, but we had a Meeting Management Committee there and it worked very well. So, we instituted it here, and it became very important.

TS: What were some of the committees you enjoyed the most, other than the science committee?

TRS: I would say the committee meeting I enjoyed the most was the Meeting Management Committee. I also enjoyed being on the Board, and being with my colleagues in the executive function of the Academy. I really enjoyed interacting with staff, which we were blessed to have a wonderful staff. 

But I would say Meeting Management Committee was the most interesting committee. Not only because of the issue we had to handle, because we had a global view, not just of the Annual Meeting, but other meetings, too. But also, the importance of how to put the Annual Meeting together, because that’s our showcase for the Academy. 

I really enjoyed that work. I also enjoyed the after-hours poker games with the late, great Susan Spencer and Lisa DeAngelis, and a bunch of other people. Especially, I’ve always loved the women in the Academy. We haven’t had enough. We need more. But I really enjoyed those poker games after the, you know, late at night.

TS: You were the first delegate to the AMA [American Medical Association] from electrodiagnostic medicine, is that correct?

TRS: Correct.

TS: Can you talk about the relationship between the Academy and the AMA over the years?

TRS: The Academy and the AMA—first, you have to look at what’s happened to the AMA. The AMA was started, and had the majority of physicians in the United States were members of the AMA. The AMA then brought in specialties. So, you had the people in practice against the specialists, and it became almost like a jousting contest.

And with time went by, the specialty societies got more influence in the AMA, and the practitioners went down in importance. They were mostly in private practice at the time. Many of them in single practice. I saw their power base eroding for a lot of things that were going on in medicine at the time.

Meanwhile, the specialties were getting increased. When I was in the AMA, it was kind of the last of the power brokers from the clinical side, from the clinicians and the doctors. Before their membership started going down, so a minority of physicians are now members of the AMA, but the specialties have gotten much larger.

Now they’re jousting with each other for power. When we were there, we first had to convince the AMA that electrodiagnosis was a specialty area of medicine and dealt with specific diseases of nerve and muscle, and that we were involved in everything from diagnosis to treatment, and everything. Once we fought that battle, they accepted us, and I was the first delegate.

I didn’t realize how much of a political arena I was getting into, and that was quite interesting. They had these big cocktail parties. Another thing I found out was that a lot of people at that time, this will show you how old I am, was a lot of people were smoking. A lot of doctors were smoking.

There were people up on the Board of Directors who sat up at the head of this gigantic hall. Most of them were overweight and most of them were smoking, and there were ashtrays all over the place. Now that would never happen today. That’ll show you how old I am and how long ago that was.

Excuse me, one other meeting. We had the vice president of the United States address the House of Delegates, Dan Quayle. There were AIDS activists outside, and they threw human blood on us as we were leaving the auditorium one day. That was kind of one of the more exciting things that happened then.

TS: Did he try to spell potato at all?

TRS: I couldn’t figure out why they asked him to speak, and I couldn’t figure out actually what he had to say. I mean, it was sort of a generalized platitude.

TS: You have had a very strong concern about workforce issues over the years. I wonder if you could talk about the challenges that practicing neurologists face, what the profession faces as far as making sure there are enough neurologists to treat a growing population of people with chronic disorders.

TRS: Yes. This has been a big interest of mine, because neurologists provide very unique abilities toward our patient population. If you go back to our patients, and start with our patients and the things that they’re facing, they’re facing challenges like dementia, Parkinson’s disease, as they age. And as you know, the population’s getting older. A lot of baby boomers are getting all these terrible diseases now.

But the way the structure is set up for reimbursement for neurologists, it’s very hard for neurologists to stay in business taking care of these patients, because the reimbursement is not there. So, inequalities in reimbursement is a big problem for neurologists. So, the system has driven neurologists into doing procedures. Procedures are fine. Very often, they’re necessary. But they’re very often not in the best interests of our patients.

Our patients really need face time with a neurologist. They need to explain their symptoms. They have to feel as though the neurologist is trying to understand their symptoms, and come up with a diagnosis and a prognosis in how they’re going to be managed. That all takes a lot of time, but if you look at the reimbursement for that, the reimbursement is not there. There are various trivial procedures that are done in medicine that have higher reimbursement.

Let’s say for example, for me seeing a new Alzheimer’s patient. That may take an hour and a half. I see the patient. I examine the patient. I talk to everybody in the family. I look through all their records. I review all their imaging. That takes a lot of time, and I talk to them various treatment options. But the reimbursement is not there to do that. So, neurologists, when they’re planning out their work schedule, they can’t plan to do that. They’ve got to plan to do things that are going to generate some income so they can run their offices. It’s also true in the other specialties that are not really procedure oriented, such as pediatrics, family medicine, general internal medicine, and psychiatry. In psychiatry, what’s happened is, when I trained, psychiatrists would spend time talking to patients, figuring out what their dynamics were and what their diagnosis was, and now psychiatrists basically write prescriptions.

When you see a psychiatrist now, you’re not likely to have a firm diagnosis, because that takes time. So, they have stopped using diagnoses like schizophrenia and a lot of other things, and now they are basically treating them all with the same group of medications, and most of these medications were invented by neurologists. But psychiatrists use them by the ton. But we’re the ones that came up with them.

That’s been a big problem, and I think that is the problem that fuels a lot of the dissatisfaction with practice that a lot of neurologists are running into, because what we really enjoy doing is talking with patients, spending time with patients, examining patients. Everything else we do is work.

That’s the fun part, and that’s the part the patients need. I worry when a patient comes into a neurologist’s office for a visit and doesn’t see a neurologist. He sees somebody else. Because I don’t think these are simple diseases we’re dealing with, and require a lot of sophistication and experience.

TS: When you talked about procedures, was that what led to Botox? Our training sessions and Botox?

TRS: Botox, EMG, EEG, evoked potentials, various other procedures neurologists are doing now. Injection therapist and things. Those are fine, and those have their place, and those are sometimes necessary to confirm diagnoses. Most diagnoses in neurology are clinical diagnoses. You rarely learn something unexpected from a test. A test is used primarily to confirm things that you suspect clinically, and they’re important. But the most important thing is for a neurologist to do neurology.

TS: Now your term as president ended just before Obama was elected and Obamacare came about. That’s created a lot of consternation on the part of physicians with the extra paperwork that they’ve had to deal with.

The Academy did not take a stand on Obamacare, and recently it did not take a stand on the American Health Care Act from the Trump administration. We instead came out with a set of health care reform principles that we’ve said would guide our decisions. Is there a point where the Academy should take a stand on legislation of that large of a nature, and say, “This is not good for the American people”? We do it certainly with Congress, with things like SGR. But these larger bills that tend to have supporters on both sides of the political spectrum, we don’t seem to wish to alienate them.

TRS: Yeah. Some of this is frittering around the edges of what’s really important. If you look at most industrialized, such as England, Germany, Japan, they have single-payer systems. I’m afraid if we had a single-payer in the United States, it would be the government. I think that would be a big mistake. In England, the system is run by the National Health Service, which is basically physician-run.

Physicians actually have experience taking care of patients. What I would like to see in the United States is a single-payer system, but not the government. The government, through its work at the VA, has proven that it can’t take care of patients. This should be set up like a National Health Service in England. There are scientifically done surveys of how much Britons like their health care, and they spend one-fourth per capita what we spend. All their health outcomes are better.

One of the problems is, we’re one of the few countries that doesn’t try to control drug prices. The reason we don’t is because of lobbying efforts in Washington. So, Democrats and Republicans are never going to be in favor of having physicians in the United Sates import drugs from Canada, or from other countries where they’re much cheaper. They’re the same drug made in the same factory, and they cost 10 percent of what they cost here.

Also, we have to look at insurance companies. Insurance companies are getting paid, and they’re getting paid a lot. They’re not doctors. They’re not hospitals. They don’t take care of anybody. Why are they being paid? They’re being paid—they make money on people’s misery. They shuffle papers and they shuffle money, and in this process, make themselves wealthy.

Now, both the Democrats and Republicans look on that as a viable industry. I don’t. If you talk about fundamental reform, when Obamacare came in, I was very sorry to see that they didn’t set up a system where they had a physician-run, single-payer system. They wanted to use insurance companies, and also, they didn’t want to control drug prices. They didn’t want to do malpractice reform.

Those are all things that we desperately need for our system to be running well. So, I have a lot of problems wondering about the niceties of little things that just kind of peck around the edges, and don’t really change the fundamental thrust of it. I think the finances are going to force us into a single-payer system, and I have a fear that it’s going to be the government. I think that’s a big mistake.

TS: The government runs Medicare/Medicaid. Is that any consolation that they can do something of that magnitude?

TRS: The government also runs the Veterans Administration health care system, which is a terrible system. Probably shouldn’t even exist. Veterans should be given vouchers to be taken care of in private hospitals. There’s no reason for the government buying all the expensive technology, and never really being able to keep up. But the government doesn’t really run Medicare and Medicaid.

Medicare and Medicaid treatment is done by physicians, and physicians labor under their rules and regulations, which make them very unhappy. I think this drive toward this excessive documentation, any physician will tell you that they don’t like it. I don’t think it helps patient care. It takes up a lot of their time. It also forces them away from looking at the patient. The patient’s telling you about their symptoms. They’re giving you facial expressions and body language, but you’re not looking at the patient. You’re looking into a computer, and you’re writing all this down. So, especially in a training situation, I examine a patient. I’m showing a neurological sign. The resident is looking into the computer, trying to decide what test he should get. Well, there’s too much testing. There’s too many MRI scans done. There’s too much technology use, and it drives the cost of our system up. If you just look at the costs, the costs are going to force us into a single payer. Right now, Alzheimer’s disease by itself is breaking the bank. But you look at all the other diseases of aging that are coming down the road at us. It’s going to be terrible.

We’re going to end up with a single-payer system. There’s no doubt in my mind. I just hope it’ll be doctors that run the system. I do think we need malpractice reform, too. That’s a big thing, too.

TS: That causes a lot of those extraneous tests, basically.

TRS: Absolutely, and also documentation. I do some expert witness testimony, and they send me a paper file sometimes. Now, more and more, it’s on disc, but when they used to send me, the paper file would be this thick. Useful information, this thick. I mean, it’s all stuff. It’s not really helping anybody.

TS: One of the major things that happened during your tenure or just before, Medical Economics Management was elevated from a subcommittee to a committee, and there was a new Payment Policy Subcommittee established. What was the impetus behind these changes?

TRS: The real fundamental impetus behind that was the fact that the insurance companies and their decisions about how to pay people follows the Medicare fee schedule, which is done by a committee called a RUC [RVS Update Committee]. The RUC meets about every four years, and the various specialties in medicine sit around the table, and talk about each procedure and what the RVU [relative value unit, a measure of value used in the reimbursement formula for physician services] is for it, and how much you’re going to get paid for it.

Well, this table, you look at the people around the table, it’s heavily weighted towards the proceduralists. They have the most money, and they have the most lobbyists, and they have the most influence. So, the five that I mentioned, neurology, psychology, pediatrics, family medicine, and general internal medicine always get the short shrift in that RUC process. But once that RUC process sets those RVU values in the payment schedule, all the insurance companies fall in line behind that.

So, that is a key thing where we wanted to be sure that we got our voice heard at that RUC meeting. For that reason, we needed a major push from the Academy, and that’s why I was so strongly supportive of that. I think it’s helped us some, although it’s like a glacier coming at you. I mean, it’s difficult.

TS: The Academy published its 100^th guideline in 2006. You were initially not a big fan of guidelines, as I understand.

TRS: I very much was opposed to guidelines, and I have to tell you that I was both vindicated and not vindicated by the guidelines. I didn’t realize that the guidelines would be so popular. They’re very, very popular. But I think the guidelines tend to produce cookbook medicine, and one size fits all. Now there are some places where guidelines are helpful. A lot of the guidelines, to me, are counterproductive.

One place where they’re helpful is in the Academy’s position on concussion, especially in teenage sports. I’ve had the experience of going to a soccer game, and seeing my friend’s daughter play, and I would wince every time they head the ball. I didn’t like seeing that. But one of the girls got a concussion, and they took her out, and they whipped out the Academy guidelines right there on the field. The person in charge of that, the athletic director, administered the guidelines right there, and I thought that was good. I was glad to see that. But I think the guidelines tend to over-simplify what are really complicated things, and guidelines can be applied inappropriately.

But I have to say that they’ve been very, very successful in terms of the usage that society likes things like that. They like things that are clear cut and say it like it is. It’s also given us some notoriety. So, I have to say, my initial opposition to them, I’m a little bit tempered about it now. I still have my concerns about it, but I think they have been a valuable thing for the Academy.

TS: It seems the Academy’s guidelines are very highly esteemed within the medical community.

TRS: I think the reason for that is that the AAN is a highly esteemed institution. I think the Academy is extremely well run. It’s based on solid values. It’s got the best people in the field working for it, giving their volunteer time to just work for this organization and make it the best we possibly can. I think, really, the Academy is a model for how a medical society ought to be run.

TS: One of the things that happened during this period was opening the Washington, DC, office. Now you may know that back in the ‘80s, there was discussion about moving the whole organization to Washington. The headquarters. Do you think in looking back, do you think that the Academy would have been better served to have moved to Washington, or do you think that the eventual creation of the Washington office with Mike Amery and a few more staff added to it has done what we’ve needed to have it do?

TRS: I think the right thing happened. I think the Academy stayed where it was, and actually went into bigger quarters, and we have a Washington office to work for us. I think, while we’ve definitely made some gains by having the Washington office, I think the fundamental structure of how decisions are made about health care spending is massive. We are—you look at medical students, two-and-a-half percent of a medical school class becomes neurologists.

So, we’re a small specialty. How much clout, no matter how good we are, no matter how hard we work, and how many staff we have, how much clout are we going to have? Our biggest clout comes from the fact that these diseases—when I was president, we took patients to Washington, DC, and we had senators meet with them. I met with the head of Medicare, and I said, “Because of your payment schedule, this patient can’t get an appointment with a neurologist. She has to wait six months for an appointment with a neurologist. Because the neurologist doesn’t want to go out of business, so he can only schedule so many new Alzheimer’s patients in a week. Whereas, there’s a greater need for that.” So, I think what we do, I don’t think we get valued for what we do, and I think everything falls away from that. People don’t understand very often.

It used to be said, it’s not so true anymore, that your next-door neighbor thought you were a brain surgeon. You probably heard that a million times, but that’s what they thought. But we’ve got a much bigger profile now. But I think having the Academy meeting where it is—I mean, excuse me, the office where it is—and having our Washington office is the right way to break it down.

We have to keep being a player, but I think no matter how hard we fight, we’re always going to be fighting the fact that we aren’t as large or as wealthy as some of the other specialties. I think for that reason, some of the alliances we form with these other non-procedural specialties has been very, very important.

TS: What are your thoughts on BrainPAC?

TRS: I give money to the BrainPAC. I think the BrainPAC is a good thing, simply because everything is a PAC now. If you want to gain access, and you want to support candidates that look at your position, it’s inevitable you have to—that’s how our system works.

Now, [Ralph] Nader said, “The only difference between a Democrat and a Republican is the speed with which their knees hit the ground when a lobbyist shows up.” So, we have to be a player. There’s no doubt about it. That’s just the American way.

TS: It’s a necessary evil, isn’t it?

TRS: It’s the American way.

TS: The Academy published some position statements on coverage for anti-epileptic drugs for epilepsy patients, driving and seizure disorders, and neurologists and imaging. What is the value of these position statements?

TRS: I think the position statements really help practicing neurologists. One position statement, which the Academy changed, which I was opposed to, when Nelson Richards was president, he published a simultaneous editorial. I think it was published simultaneously in Neurology, JAMA, and New England Journal, and the position was “ban boxing.”

I think that the American Academy of Neurology should support a complete ban on boxing. In boxing, the purpose of boxing is to give the other person a concussion, and it doesn’t help to have a neurologist at ring side. It doesn’t help to do MRI scans. The patient’s already had a concussion. The other boxer. The boxer’s already got brain damage. So, they watered down our position.

I’m in favor of an outright ban on boxing. Now, I think probably society would never permit an outright ban on boxing. But I think it’s true that that should be our position, because we care about the brain. A lot of the other position papers we had have been very helpful to practicing neurologists. We have to keep reviewing our position papers.

TS: Do they help explain to lawmakers our position on various issues?

TRS: I think they do. I think when they see it written and they come from our prestigious organization, I think it does. I think it makes a big difference.

TS: There were some key advocacy victories in the area of fair reimbursement and some increases in E&M coding. How have you seen the Academy’s relationship with CMS over the years?

TRS: I think we’ve had a relationship. I don’t know how fruitful the relationship has been. I think we have to carry our own water. We have to press forward. We have to have collaborations, especially when it comes for the RUC. I think for the RUC, we have to speak with a bigger voice.

TS: The Academy also successfully lobbied Congress to authorize the Parkinson’s disease and two MS Centers of Excellence in the VA. Why was this an important victory?

TRS: I think those chronic diseases—if you look at Parkinson’s disease, 10 percent of people over age 65 have a movement disorder. If you look at people age 85, 50 percent are demented. Those are things we don’t like to think about, because people want to live to be 85 years old. But the Parkinson’s Disease Center of Excellence is such an important thing, because you get the best people, the best researchers, the most patients.

You can carry out the clinical research we need to find better ways of treating it. When I see an Alzheimer’s patient now, the treatments we have that are FDA-approved aren’t very effective. They’re expensive, but they’re not very effective. When I see a new Alzheimer’s patient, I get them enrolled in a clinical trial. I think it should be true of every ALS patient, and many patients with movement disorders.

I think that’s something that the Academy could do a better job of promoting to people in the field. When you see a new Alzheimer’s patient, or Parkinson’s patient, or an ALS patient, get them enrolled in a clinical trial. There’s a very good website, clinicaltrials.gov, which has all the clinical trials on the planet. Disease specific. So, you can find somebody close to home that’s doing research. I’ve been sending patients for that.

TS: Do you think this was a situation where working with the VA was fruitful?

TRS: I think it was fruitful. I’ve been a consultant for the VA for many, many years. I finally stopped being a consultant because the VA would not take care of one of my patients who was a veteran. What happened to him, I think this is illustrative of what happens. This man was in Vietnam. He was walking with his friend. His friend stepped on a landmine. This veteran then, the shrapnel went through his lower jaw, took out most of his teeth, and some of the teeth in his upper jaw. But because of a regulation, he’s not eligible for dental care at the VA. He told me that. He came to see me for an unrelated problem, and I said, “I’m going to send you to the dental clinic to see about those teeth.” He said, “Oh, no. They won’t see me down there.” I said, “What?” I called down to the dental clinic. I said, “You’re not going to take care of this guy? This guy is a hero.” They said, “No, we can’t, because when he was signed out, he wasn’t service-connected for that. Anything could have happened to make him lose—.”

So, I went to the director of the VA hospital, and I said, “You have to take care of this man in dental clinic.” He said, “We can’t.” So, I took off my VA badge and put it on his desk and said, “I’m out of here. And I’ve been a consultant for 30 years, and I’m out of here.”

TS: The Academy established the State Society Leaders Roundtable when you were president. What was the need for that?

TRS: I think theoretically, it would increase participation by people in a given state if they had strong leadership in that state. A few states have done that. It also gets more people involved with the Academy. So, every way we can, we want to get more people involved in the Academy.

The state societies on the whole have been a little bit disappointing. I think the reason for that is they’re very often run by people in practice. They don’t have a lot of time. They don’t have any support staff to look after them. I just missed the Georgia Neurological Society meeting, and I live there, because of a conflict. But I don’t think it’s paid off the way we were hoping. I still think we should do it, because we do get something from it, but overall, I’d have to say it’s been a disappointment.

It’s been very state-specific, and within a state, it’s been very leadership-specific. So, if you have a good leader who is in charge of it for a few years, things run well, and they increase their enrollment. But then things can peter out and somebody else can come in. I think it’s just the nature of the beast.

TS: Has there ever been any discussion about taking the state societies and making them into, or inviting them to become, chapters of the Academy? So, the Academy would have chapters in 50 states.

TRS: I think if the chapter involved giving them some logistical support, that would pay off. I’m not sure if that would be cost effective, though. I have my doubts about that.

TS: We have given them some support with setting up websites and things like that.

TRS: I think they almost need, to really powerhouse this thing, they need to have an employee that could spend time contacting the members. Contacting all the neurologists in the state, and keep on them, and keep getting them to come to their state meeting, and keep getting them to come to the Academy meeting, and talking about issues that concern neurologists. If they had that, it would make a big difference. It would be very expensive.

TS: Let’s go to the topic of education. Maintenance of certification, which was mandated by the ABPN [American Board of Psychiatry and Neurology]. That became a big issue during your term. What did it do to the Academy as far as looking at what education services it provides to members, and how it could help them with Continuing Certification (CC)?

TRS: I think this is a very interesting issue, because there’s very few studies that show that CC does any good. Now, maybe it does. Theoretically, it does. But when I got board-certified, we didn’t ever have to do any maintenance of certification or recertification or anything like that. I think some of the best clinical neurologists are the older guys that don’t do maintenance of certification. 

But we trained in a different era, when you had to be a better neurologist, because you didn’t have a lot of these new gadgets. You know, imaging and tests and things we have now. I’m a little bit worried about the bureaucracy intruding on the practicing neurologist. Recertification, maintenance of certification—these things take time.

In maintenance of certification, I think they’re going to learn something. But is it actually going to make a difference when they’re one-on-one with a patient? I just wonder about that. I’d like to see some studies that show that it actually does, because we get involved with things. We put more burdens on practicing neurologists, but is there a payoff? Is there a payoff from, and again, I’m looking at our patients—are patients better off because of this?

Medicare has a whole bunch of these things. You’re going to get paid more if you do X, Y, and Z, but does that really result in improved patient outcomes? I think that’s what we were really about. For a lot of these neurological exams, the degenerative diseases that people are getting—not neurological exams, neurological diseases—you have to be able to show a benefit. Well, for many of them, we don’t have treatments for them.

TS: Science and education programming during your term received a six-year accreditation with accommodation from the ACCME. Do you recall what’s required in that process?

TRS: I don’t really know. These are accrediting agencies, and they look at everything. I think a lot of these accrediting organizations at one time were extremely necessary. When hospital care in the United States was very regular, practicing guidelines were nonexistent. I think that there needed to be some form of accreditation. I think what’s happened now, it’s almost overkill with a lot of these things.

I know at our hospital, we have to get ready for our accreditation visit. They hire people fulltime to do nothing but work on that. They enroll the faculty and the staff and the practicing physicians into doing various behaviors that are necessary, and I think what’s happened now is they really have all the information they need. It’s all on computer. They can find out anything they want about you. So, I have kind of a mixed feeling about it. I think they probably were very necessary at one time, and obviously they would have to exist, because you couldn’t have hospitals with substandard care, but I don’t think that’s really happening that much.

TS: The Academy created a couple education research grants, and you talk about looking back and seeing if it was worth it. These were established to improve neurology education and promote career development of neurology educators. Were there any tangible results that you saw from that?

TRS: I’m not sure that’s really paid off in a big way. I think what happens, there are some people that just want to be educators, and they’re good at it. There are teachers that are good at it. The question is, can you make a good educator out of somebody that really, that’s not his or her interest, or can you make a good teacher? I’ve always wondered about that. That also pertains to leadership development. 

I think we’re doing all we can to make sure that we have a good group of young leaders. I think youth is an extremely important thing. For years, the Academy was run by white-haired, white guys like me. I think what we’ve got now—when I was president, we put medical students and residents on some of the committees, and I’ll tell you, it was like a breath of fresh air having these people. Having their viewpoint. I forget what your original question was.

TS: As far as the grants that were used to promote education research in neurology, was there any substance that came out of those?

TRS: You see, I really would rather, my own personal feelings, I would rather have seen that gone into clinical research grants. Not that it’s not important. I just don’t know what the payoff is going to be for that.

If you look at neurologists in residencies across the United States, there was a conference about five or six years ago at NIH looking at what happens to neurology residents. Those that, if you look at all the neurology residents in the United States, those that go on to independent funding, which would be an objective evidence of whether they become scientists, for example, and live in an academic life, it’s disappointingly low. I mean, it’s like one in a thousand neurology residents ends up getting funded. Maybe it’s not that low. Maybe it’s one in 500, but it’s still very low, and most of those people come from the prestigious programs.

I think that we have to find better ways to produce, especially clinical researchers, because they face obstacles that basic researchers don’t face. I think we have to do everything that we can to support that. That’s why the educational research grants, I would rather have seen gone into supporting people with clinical research trials. I voted against those educational research grants.

TS: Going back to the Annual Meeting, and the Meeting Management Committee, how challenging is it to keep the Annual Meeting fresh each year?

TRS: Well, fortunately we have a wonderful staff. I think if you look at the meeting and how it’s evolved over the years, it’s been nothing but fresh. It’s fresh every year. This meeting is terrific. I went to a session today. It was overfilled. It said, we have another room. You can watch it down the hall. That was overfilled. They started out in the hall, and that was overfilled. They had chairs out in the hall watching the big screen, and that was overfilled. So, I think in terms of acceptance by our members, not just national members, but international members, it’s been terrific. And every year, the meeting’s changed and gotten better. This is the most advanced meeting we’ve ever had right now, and there’s so many good things about this meeting.

TS: Before we leave the topic of the Annual Meeting, I have to ask about Neurobowl^®. You started Neurobowl?

TRS: Yeah. I started Neurobowl, and I forget what year we started it, but I think this is our 20th year, maybe. I’m not sure. But I had the idea for years, and the Academy wouldn’t let me do it. They said, “That’s ridiculous, and it’ll never work.”

But the reason I did it was, when I was an examiner for the boards, at that time, the candidate had to examine a live patient. I walked into the room, and the patient was sitting on the bed, and I walked in with a candidate, and I looked at this young girl, and I knew she had Huntington’s disease. She hadn’t moved, hadn’t talked, and I said to myself, “How did I know that?” And I realized I didn’t know how I knew that. She did have Huntington’s disease. But then I began to realize that many of the diagnoses I was making, I had no idea how I was doing it.

So, I said, “Well, I’m kind of a quirky guy, so maybe other people do know how they’re doing it.” So, I started talking to people. They had no idea how they were doing it. But they were doing it. And sometimes doing it in a split second. So, I started Neurobowl to try to get people up on the stage to make diagnoses, and then ask them how they made the diagnosis. Well, they invariably say they don’t know how they did it.

The first year, it was a course. The first year, 250 people showed up, and I learned something from that. Our meeting has a lot to do with genetic tests and neurology and various technologies and imaging. But what people are really hungry for that come to this meeting is clinical neurology. Because when they go to their offices, they’re faced with live patients.

They have to come up with the diagnosis and some kind of treatment options, and some kind of testing, and this kind of thing. So, we put on Neurobowl, and it just grew like Topsy. It got bigger and bigger and bigger, and now it’s completely out of control. But it led to our publication of our book, Instant Neurological Diagnosis.

There’s a book for laypeople called Blink. Maybe you’re familiar with it, written by Malcolm Gladwell. But his book came out after Neurobowl started, about 10 years after Neurobowl started. I’ve tried to get him to come to this meeting, because what he’s talking about in that book is exactly what happens when a doctor’s making a diagnosis. You don’t know where it comes from. It comes from something deep in your brain, but it’s also true in your everyday life.

When you see somebody, and you meet somebody, you have an affinity for them. You like them. You don’t know why you like them or you don’t like them. And you’re usually right. Malcolm Gladwell uses the experience of the World Series of Poker. So, 10,000 people start playing. It’s in Las Vegas every year, and the winner wins $10 million or something. You familiar with that?

TS: Yeah.

TRS: So, everyone’s getting the same cards, but every year it comes down to the final eight people, and they’re more or less the same people every year. He says the reason for that is that they make good decisions. So, what happens when you’re confronted with something, you have a feeling about it. This is good for me. This is not good for me. I like this. I don’t like this.

You don’t know where that comes from, but then your frontal lobes kick in and say, “Wait a second. Let’s analyze this.” And there may be some red flags or things like that. When those things come together, you make good decisions. And these people playing the World Series of Poker, if you see them, they’ve got hoods over their face. They’ve got dark glasses. They have facial hair. Just the men.

And they don’t want—all this has to do with how you make a decision, and the things that influence you are so subtle, you don’t know what they are. You never will know what they are, really. But this is what Neurobowl embodies, and that is, it really celebrates this very human function of our brains. That we’re able to do this. I put up a slide one time. José Biller got it in a tenth of a second. A tenth of a second, he made the diagnosis.

That wasn’t unusual for him. To me, it’s a miracle of how the brain works, and how it’s so much better than any artificial intelligence you would ever have, because it takes so many things into account. Never so much as it does as when you’re making a diagnosis on a patient.

TS: Interesting. We’ve just got time for a couple more questions here very quickly. What was the best part of our presidency from a personal standpoint?

TRS: I guess the best part of my presidency was working with neurologists, and with our staff. The neurologists that work for the Academy, in all its various committees and sections, and this, that, and the other, are the top people in the world. They’re from academic institutions, they’re from the NIH, they are people out in practice in the middle of nowhere.

We should be so proud of those people, and the fact that they give up their time. I mean, I’ve been working for the Academy since around 1980, and I still love it. Because you’re with the best people. Our staff are so wonderful, and they can’t do enough for you. Christine Phelps, who’s a really dear friend of mine, I’ve known for a long time, has done so much for me.

She’s the one that—I originally thought Neurobowl should be a course, and she’s the one that suggested it be an entertainment, really is what it is. Because, and that was her idea, and how to build it, and how to build on it. So, it’s the people involved in our organization who are so fortunate. I have a theory that when you have a big organization, if people at the top are friends, good things happen.

When people at the top are not friends, it filters down through the organization and it’s not a success. We have a successful organization here. All the pieces have fit into place like a Rubik’s cube. It just worked out perfectly.

TS: What advice would you give to a young neurologist who would like to aspire to a leadership role?

TRS: What I tell them to do in terms of workaday things is write a letter to the president, and say, “This is what I’m interested in. Put me on a committee.” A president would never turn that down if he or she had any brains. But in terms of doing it, I always tell people that they should speak up. Because they have opinions about things, and being young, their opinions are probably better than people like me, that have been around for a long time.

The way our young physicians access information is completely different than the way I did. Theirs is better. I find myself as someone, if I’m having a conversation with somebody, I go to my phone and look it up. So, the way they access information, and we’ve adapted to that in the Academy, because we’ve built social media. This [AAN Annual Meeting] app we have—I don’t know if you’ve been on the app yet. You probably have. It’s fantastic. It’s got everything you could ever want.

So, what I would say to a young physician is, and this comes from mentor Fred Plum—he says the worst thing that could happen to you is to wake up one morning and realize you’re bored with your specialty. He says, don’t ever let that happen to you. And the surest way not to let that happen is to stay in academics. I’ve been in academics all my life, and I have to say that when I was chairman of the neurology department at the medical college, I used to sit in my office and say, “I can’t believe they’re paying me to do this. This is so much fun.”

Seeing our young students learning, seeing our residents learning, our colleagues getting research grants, seeing patients—we had an epilepsy surgery unit. I’ll just give you one example. We had a woman that had—and we have an epilepsy surgery reunion every year where all the people that had epilepsy surgery for epilepsy would come in and sit in the cafeteria and talk about their experience.

Here’s a woman who was having about 10 seizures a day. She had to wear a football helmet. She fell on her face, and her face was all terribly scarred. She was on so many anticonvulsant drugs that she could hardly think of talk. She had epilepsy surgery to take out a little piece of her temporal lobe that was causing the seizures. She never had another seizure. She got off all these terrible medications. Her mentation got completely back to normal. She was bright and alert. She had plastic surgery on her face, and all the scars are gone. She’s a beautiful woman. Every day, she climbs a 200-foot ladder to watch for forest fires. She’s an employee of the National Park Service. She’s a productive member of society. Now, to me, that’s very uplifting. I mean, just that one person alone, and there are thousands, but just that one person alone, I was so glad to be part of that. That makes my day, every day, seeing that.

TS: That’s a good way to end the conversation here. Thank you so much for your service to the Academy, and to humanity.

TRS: Thank you, sir.

TS: Thank you.
 

Thomas R. Swift, MD, FAAN, during the “Hall of Presidents” session at the 2017 Annual Meeting in Boston.