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Guy McKhann, M.D.
June 2000
The Neurology Department at Johns Hopkins was formed in January 1969. To put things in proper prospective it is worth spending a few moments discussing the state of Neurology in the 1960's. Prior to that, in the United States, there were two types of Neurology Departments: one was a larger department with a research base, much as we have developed over the years. Chief among these were Boston City Hospital, headed up by Derek Denny-Brown, the Massachusetts General Hospital, headed up by Raymond Adams, and The New York Neurological Institute, headed up by Houston Merritt. The other form was a much smaller unit, such as those at UCSF, Cornell, Michigan, or Washington University. Often these departments had only three or four faculty members, with no research facilities other than those for clinically based research. A more common administrative arrangement was for Neurology to be a division of Internal Medicine, or rarely, a component of Psychiatry.
In
the latter part of the 1960's, a number of other medical schools considered
the possibility of forming a separate Department of Neurology. This activity
was brought about, at least in part, by the realization that there was more
to Neurology than just an extension of the clinical problems of Internal
Medicine. There were burgeoning fields of research in the Neurosciences,
and the clinical applications of these research advances would be not only
in Psychiatry and Neurosurgery, but also in Neurology. In addition, one
should not down-play the influence of the NINDS, which mandated that Neurology
training programs should have identified beds and out?patient facilities.My generation of academic Neurologists was just coming into being at that time. Immediately ahead of us were people like Fred Plum (Cornell), Milton Shy (NINDS, Penn and Columbia), Bob Fishman (UCSF), Bud Rowland (Penn and Columbia), and Bob Joynt (Rochester). All had or were setting up their own units. We were the next wave. My colleagues, such as Dick Johnson, Art Asbury, Barry Arnason, and I criss-crossed the country looking at the same jobs and then comparing notes.
Others will have to comment on why and how Hopkins came up with me. I do know that the driving forces behind starting a Neurology Department were the people with strong bases in Neuroscience: Vernon Mountcastle in Physiology, David Bodian in Anatomy, and Earle Walker in Neurosurgery. I think my name was brought forward by Bob Cooke, then Professor of Pediatrics, with whom I had worked as a medical student at Yale. I had also spent a year as a resident in his Department of Pediatrics the first year he came to Hopkins.
I was quite surprised when I received a call from Vernon Mountcastle telling me that Hopkins had selected me to lead the department. I thought that it was very unlikely that they would take someone out of Pediatric Neurology to do this. At the time, I was very happy at Stanford. My research was going very well. I was developing a first rate Pediatric Neurology Service and Palo Alto was a very pleasant place to live. I also had the opportunity to have attracted first rate people to work with me who later had great influence on the Neurology Department at Johns Hopkins. John Freeman and I ran a Pediatric Neurology service together, Gary Goldstein had just come out to be a pediatric neurology fellow, Bob Herndon was a fellow faculty member, Jack and Diane Griffin and Larry Davis were medical students.
On the other hand, Hopkins was a first-rate medical school where Neurology was not nearly as strong as it should be. At times like that, I often turned to my father for advice. I remember his remarks quite well "You won't get an opportunity like this very often, and if you can't build a decent program at Johns Hopkins, there is no hope for you!" Needless to say, I paid attention to his advice, took out my flute, played the role of the Pied Piper, and attracted the above-mentioned team to Baltimore. Our early success was directly related to the strong support of Deans Tommy Turner and Dave Rogers. Tommy Turner was just finishing his time as Dean. Tommy was not only very active in my recruitment, he has continued to be very supportive of Neurology. His successor, Dave Rogers, took over about the time we started the new department. Dave was a continuing source of advice and support.
Baltimore on the other hand was, at that time, a bit of a dump. The Inner Harbor did not exist. There was a waterfront consisting of broken down factories. There was almost no reason to visit downtown in Baltimore at night or on the weekends. Having come from sunny California, I was concerned whether I would be able to recruit anybody. However, in a few years no one seemed to want to leave.
My ideas about how the Neurology Department should be organized were influenced by three models with which I had personal contact. The first was the Neurology Service at the Massachusetts General Hospital. The MGH Unit was directed by Dr. Raymond Adams and included people such as Maurice Victor, E.P. Richardson, Miller Fisher and Phil Dodge. It had a very strong neuropathological orientation, but there were other areas of research. Neurochemistry was just starting with Hugo Moser and electron microscopy with Dr. Harry Webster. As residents we spent a full year in neuropathology, which among other things gave us time to think about the diseases we were studying, even if some of us didn't become particularly adept neuropathologists. Out of this department came a number of leaders of Neurology, Dick Johnson and Don Price at our Institution as well as Arthur Asbury, Dick Baringer, Barry Arnason and Joe Volpe in Pediatric Neurology.
The second influence was my time at NIH. During the Korean war many of us spent time in the service. I was lucky enough to go to the NIH in the Public Health Service. There I learned Neurochemisry for three years with Don Tower, but I was particularly influenced by Milton Shy. Milton brought science to Neurology in ways other people did not. He considered the brain as an organ that had its own unique biochemistry, physiology and a psychology, that all could be influenced by disease.
The third influence was the extraordinarily stimulating environment at Stanford University in the 1960's. Part of that atmosphere was the strong interface with people in the basic sciences such as Eric Shooter, Joshua Lederburg, Arthur Kornberg and in the clinical area David Hamburg in Psychiatry and Norman Kretchner, my boss in Pediatrics. Even though they were senior to me, they were very supportive and paid a lot of attention to a young, struggling pediatric neurologist.
There had been a division of Neurology in the Department of Internal Medicine with Jack Magladery, Bob Teasdal, and Tom Preziosi, but there was really no research activity at that time, and the clinical service was solely a consulting one. In contrast Neurosurgery under Earle Walker was quite strong and EEG, under Ernst Niedermeyer, was actually in neurosurgery.
The first residents that we recruited all went on to be Professors of Pediatric Neurology: Gary Goldstein, Mark Molliver, Ruth Mary Deyel, and Al Percy. We never did tell the rather arrogant Osler housestaff that there was a bunch of Pediatricians running around, telling them how to manage their patients. The next wave was a little more legitimate and included people like Jack Griffin, Larry Davis, Dave Zee Gihan Tennekoon, and shortly thereafter, Mahlon Delong.
The first faculty recruits became the core of the Neurology Department.
We started with a series of research groups. Dick Johnson headed Neurovirology,
Dan Drachman Neuromuscuilar Diseases, John Freeman Pediatric Neurology,
and a little later, Oscar Marin Behavior Neurology. That period of the first five to seven years was an extraordinarily exciting time. We were all building something from scratch. Each person developed his own area of research and clinical expertise. The grants rolled in, excellent fellows and junior faculty joined us. We were on our way!
This pattern of specialization continued with the epilepsy monitoring unit directed by Ron Lessor and Bob Fisher, the Neurology - Neurosurgery Intensive Care Unit with Dan Hanley, the vestibular unit with Dave Zee, movememt disorders with Mahlon DeLong and of course, peripheral nerve diseases with Jack Griffin, Dave Cornblath and Jeff Rothstein. Don Price came as the only neuropathologist, but look what has happend to that world-known unit. Neuropathology has had its own star-studded prodigy such as Arthur Clark, Allan Levey, Jon Glass, Linda Cork, and Sam Sodia.
There was never any master plan, the department grew around clinical and research opportunities, but most of all people. Thanks to the funding mechanisms of the NIH, particularly the CIDA award (now called a K-08), a person at the completion of training could obtain salary and some research support for 5 years. The department was built by that funding mechanisms. The recipients almost all went on to develop funded research programs either here or elsewhere.
We gradually outgrew the primary base at Johns Hopkins Hospital, and greatly expanded the program at what was then Baltimore City Hospital under the succeeding direction of Oscar Marin, Mahlon DeLong, Margot Bleeker and Peter Kaplan. We also developed a much smaller, but clinically excellent program at Sinai, with Al Krumholz, Barny Stern and Brian Litt, Bob Wityk.
The strongest affiliate, however, became the Kennedy Institute (now the Kennedy Krieger Institute). The neurological orientation started under Bob Haslem, greatly expanded, particularly in research, under Hugo Moser, and has become the premier place in the country under the direction of Gary Goldstein, with strong research programs directed by leaders such as Mike Johnston and Martha Denckla. Although administratively separate, these investigators have their academic home in Neurology.
We started out with Brady 2 Ward, for which we personally paid for the air conditioning. It was really a crummy place. Gradually we expanded and we moved a number of times before the Meyer Building was finally built. The idea of the Meyer Building, that is combining the clinical services and research laboratories of Neurosurgery, Neurology and Psychology in one building came in part, from a casual remark by Bob Heyssel (then Director of the hospital) to me when I was chairing a committee on building new facilities He suggested combining the facilitator for the three programs. Bob was very supportive as we developed this new facility , which not only centralized our clinical and research activities but also made a remarkable difference in inter-relations between people in these three departments.
One measure of our success has been the number of neurologists fulfilling outstanding career at other institutions. Some were Hopkins medical students, others residents, fellows, and faculty. We consider them all part of our neurology family. Besides academia, some are making their mark in industry or even law. I haven't space to mention them all, but can single out a few luminaries such as Anne Young and Jack Penny at MGH, Les Weiner at USC, Howard Lipton at Northwestern, Mike Graves at UCLA, Eva Feldman at Michigan, Mahlon DeLong, Allen Levey, and at least eight others from Hopkins at Emory, Lynn Raymond at Vancouver, Ian Butler and Gerry Wolinski at Texas, and Bill Mobley at Stanford.
I have often felt that if you do not get your kicks out of recruiting bright people and watching them develop their own independent expertise and careers, then find a different job.
We have been extremely fortunate over the years to have had tremendous support from nursing. This started with Ms. Shipley, when we were on Brady 2, who was wise enough to recruit Shirley Sohmer. Shirley was the first head nurse in Neurology and then the head nurse in Neurology and Neurosurgery. She finished her career as the nursing supervisor for all 3 services - Neurology, Neurosurgery and Psychiatry. Shirley was an extraordinary colleague and friend and always supportive of people within the department. She attracted some very good people, Judy Rhode, her successor, Ski Lauer who set up and still runs the intensive care unit and Mary Rose one of the stars of the Neurology/Neurosurgery floors. We established a new model of nursing in which nurses were no longer hourly paid employees, but are paid annual salaries and have set up a level of professionalism that became a model for other units in the Hospital. While speaking of nurses I must go onto mentioned my colleague in the studies of CABG (Coronary Artery Bypass Surgery), Maura Goldsborough, a nurse investigator, without whom we could not do any of these studies that we are now running.
I am often asked if there was an underlying philosophy to the Neurology department. I think there was, more unspoken than spoken. Basically, it evolved around the presumption that a neurologist could be both a good clinician and a good scientist. That does not necessarily mean only bench science but also includes clinical science. Another way of putting this is to say that "good clinical care is expected but not enough - we must ask how to do it better. If we, at Hopkins, do not ask how to do it better, then who will." Recruiting the right kind of people - medical students, residents, junior faculty and senior faculty - was essential. It also required the right environment so that individuals could have the time, the support, and intellectual milieu to develop their fields of endeavor. I have never been a believer in the idea that there is only one way to do Neurology. I never thought that Hopkins should have a book about how to examine the nervous system, how to do it and what to write down. Perhaps this comes from my background as a Pediatric Neurologist. In that area, you have to obtain the information that you need, when you could, by watching a child, listening to a child and putting that information into the framework you needed to know. I have never been smart enough to be able to tell a bright person what is the best area of research for him or her. I can support that person, and did? often through false starts. But people really have to evolve what is best for them.
People who come to visit the Neurology Department at Hopkins often comment to me afterwards what a super time they had, and what a marvelous esprit de corps there is. I think this is true and I think there are reasons for it. First of all there are actions and interactions between the basic scientists and the clinicians. There is none of the backbiting or jealousy that I have seen at other institutions. Hopkins has a long tradition of great strength in the basic neurosciences going back to Phil Bard, Vernon Mountcastle, as well as David Bodian and the development of the Neuroscience Department by Sol Snyder and the Hughes Investigators, such as Rick Huganir.
We have the pattern of interchange of people coming out of M.D./Ph.D. programs into Neurology, and people going, after their Neurology training, back to basic research laboratories for further training. Some, like Mark Molliver, Paul Worley or Gabrielle Ronnett remain in the basic sciences, others, after staying in basic neurosicences for periods of time, like Richard O'Brien and Ted Dawson, then join the Department.
There also have been excellent interaction between clinical departments. As I mentioned earlier Earle Walker was extremely supportive of our early endeavors. Don Long has worked very closely with me and Dick Johnson bringing the neurosurgery and neurology departments close together. We have functioned almost as a single department, and are all the better for it.
We have similar close relationships with Paul McHugh's Psychiatry Department. People in that Department such as Bob Robinson, Ray DiPaulo, Jason Brandt, Joe Coyle and Marshall and Susan Folstein have all worked very closely with us in the development of joint programs. Over the years, many colleagues in Radiology, Orthopedics, Ophthalmology, Medicine and Pediatrics have all been of enormous support and help. There is another aspect of Hopkins which I think sets the tone and that is the demeanor of those who are our superstars. People like Victor McKusick , Vernon Mountcastle, Dan Nathans, Sol Snyder, and Paul Talalay have been extraordinarily supportive of the institution, way beyond just their own research interests or the interests of their departments. This behavior has set a tone for the rest of us which I think is really an essential part of the Hopkins environment.
When I became a department chairman in 1969 the entire department could meet in a small office with room to spare. It has since grown considerably. At that time the chairman could still participate in clinical activities, research activities and handle the administrative aspects. Somehow, over time, the job of chairman has now become exceedingly complex. But I still think that it is an important job for first rate people to take on. But a person needs a much better administrative infrastructure then we are used to having. There are too many meetings where administrators are talking to administrators and the clinician scientist are essentially on the sidelines. I was very fortunate to have available to me as Deputy Director of the Department, Hamilton (Chip) Moses who functioned as my administrative alter ego. Chip handled things on the clinical side and, probably most importantly, was the person who helped us adapt to the changing patterns of medical care. He paid attention to HMOs, 3rd party payors, and reimbursement? areas that are clearly not my strength!
I think this is an extremely exciting time in Neurology. All these years of basic neuroscience research are really starting to pay off in terms of understanding the mechanisms of neurological disease, developing models of neurological disease, and the initiation of new interventional and therapeutic approaches. The introduction of newer forms of imaging the nervous system allows us to ask questions we could never ask before? questions about basic processing of information by the brain as well as ways in which the brain is disrupted by illness. Most importantly imaging gives us parameters of patterns of recovery of the brain and indications of whether we can or are affecting that recovery.
It is about ten years since I ran the department (or the department ran me). In the intervening ten years Dick Johnson gave it extraordinary leadership, and maintained it at the forefront of the departments in the United States. Now Jack Griffin is putting his stamp on the department as he expands it in other areas. Over this intervening 30 years, we have gone from patchy islands of excellence in Neurosurgery and Psychiatry to an integrated brain research team that is among the best in the world. I am happy to take some credit for this evolution, but only a little. There have been many excellent people who have been and are doing things very very well. There is no indication that this momentum will stop, nor should it.
There will be, over the next few years, a whole new wave of leadership in the Clinical Neurosciences at Johns Hopkins . Neurosurgery has blossomed under the leadership of Don Long and will continue to do so under Henry Brem its next leader. Psychiatry has been at the forefront of Psychiatry departments in the country. Paul McHugh is getting ready to hand its direction over to his successor.
Very few people are lucky enough to be given the opportunity that I was and I am deeply grateful to the people who were on that search committee. To the many people in Neurology - medical students, residents, faculty at Johns Hopkins, and faculty at other institutions, we are proud to have influenced you and recognize that you influenced us in return. I thank all of you for your achievements. Probably the highest honor I can receive is the success of other people. My father gave me another bit of advice "Find the brightest people you can and then get the hell out of their way". I am glad I got out of people's way, because they have done very well indeed.
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