June, 2000 (from Dr. David C. Anderson)

Several months ago, Milt Ettinger gave me a folder containing his collected reflections on the history of the department of neurology, Hennepin County Medical Center. The history was reported in installments with entries from 1965, 1972, 1975, 1980, and 1986. The reports detail the growth of the department and the professional trials and triumphs of its members. There have been no entries since 1986. I will write installments for 1990 and 1995 checking with Milt about accuracy and perspective. I will also update the account at this point (2000) and promise to continue the history as long as I am Chief.

August 1966 (Milton G. Ettinger)

HISTORY OF DEVELOPMENT OF NEUROLOGY DEPARTMENT AT HENNEPINCOUNTY GENERAL HOSPITAL

(Formerly Minneapolis General Hospital)

In early 1953, the Medical Director of the Hospital, Dr. Thomas Lowry, approached Dr. Harold Noran, who was a practicing neurologist in Minneapolis, regarding the establishment of a neurological unit at Minneapolis General Hospital. Prior to that time, neurologic problems had been referred to downtown consultants who, for many years, had volunteered their time to provide the hospital with adequate neurologic consultation but no teaching program in neurology had been developed for the interns or residents. After discussion with Dr. A.B. Baker, Professor and Director of Neurology at the University of Minnesota Hospitals, a neurology program was initiated at the Minneapolis General Hospital in July, 1953.

The first neurology patients were admitted principally on the Medical Service, but at times they were placed in available beds throughout the hospital, often on the Urology and ENT Services. Approximately 15 beds were designated as belonging to Neurology. Two rotating interns and one resident from the Medical Service were assigned to care for these patients on Neurology, and their instruction was received from Dr. Noran who made daily ward rounds on the Service.

This situation continued for approximately one and a half years when, late in 1954, again in collaboration with Drs. Noran and Baker, a geographically independent Neurology Unit was established on Station 7 of the Annex Building (where it still resides.) At that time 28 beds were assigned to Neurology, and Dr. Baker appointed the first full-time instructor from the University of Minnesota Hospital to supervise the teaching program in Neurology. Dr. John Logothetis held this position from 1954through 1956. In addition, Dr. Noran continued as Chief of the Department, making frequent ward rounds and supervising the administrative problems of the Department. Also, in 1954, the first University of Minnesota neurology resident was assigned to the General Hospital on a three-to six-month rotation basis. In addition, the Medical Service continued to assign a resident to Neurology for a three-month period.

In 1957, a three-year training grant in Neurology was obtained from the United States Public Health Service through the efforts of Dr. Noran and Dr. Baker. This training grant established some salary items for a full-time instructor as well as support for residents and an EEG technician. Throughout this period of time, Dr. David Mendelson was assigned from the University as a full-time Neurology instructor and Dr. Noran continued as Chief of Service. The residency coverage was maintained by a resident from the University Neurology Department and a resident from the Minneapolis General Hospital Medical Department assigned on a three-to six-month rotating basis. By this time, interns were rotating in groups of three, and at any onetime three interns were assigned to the Neurology Department for a one-mouth period. In 1960 Dr. Milton G. Ettinger was appointed as full-time instructor. The training grant from the Public Health Service had lapsed by that time, and support for the neurology program was contributed principally by the University of Minnesota with a minimal contribution from the Minneapolis General Hospital. Seventy percent of Dr. Ettinger's salary and the principal share of the salary of the residents assigned to Neurology from the University were obligations honored by Dr. Baker at a time when the General Hospital was contributing very little financial support to the program. In addition, Dr. Baker increased the number of residents in Neurology rotating to the General Hospital (from one to two), so that at all times the Neurology Service had three residents and three interns in attendance to care for the patients. In 1962, Dr. Ettinger was certified as a specialist in Neurology by the American Board of Psychiatry and Neurology, and in January, 1963, Dr. Noran relinquished his position as Chief of Service and Dr. Ettinger van appointed to that position. (Noran continues in an active consulting role to this time.)

In 1963 arrangements were made with the Psychiatry Department, University of Minnesota, for rotation of psychiatry residents through the Neurology Service at the Minneapolis General Hospital to meet their requirement for three months training in Neurology. In addition, a number of third-year neurology residents from the University began to return to the General Hospital to act as senior residents. From 1963 to the present time, we have had from four to five residents on service at all times, one or two first-year neurology residents from the University, a resident from Medicine, one from Psychiatry, and a senior resident in Neurology from the University. We continue to have three interns assigned in rotations of approximately 25 days each. In 1961, Dr. Anna Ellington joined Dr. Ettinger as the second full-time neurologist in the hospital. Her salary was obtained from research grants Dr.Ettinger had secured from the Public Health Service. The General Hospital contributed nothing toward her support.

In 1964, Dr. Ellington accepted a position with the University Neurology staff and Dr. William Riley was appointed the second full-time neurologist at the General Hospital. By this time, the hospital had been transferred from the city to the county administration and Dr. Ettinger's and Dr. Riley's salaries were considered to be a reasonable obligation of the county hospital. In addition, three full-time resident stipends, ranging from $4500 to $5500, were included in the hospitals contribution to the neurology program. At the present time, the Neurology Service staff and teaching program are strongly supported by active consultants and attending physicians from both the downtown area and the University of Minnesota neurology program. (Appendix 1)

In anticipation of eventually requesting Public Health Service support for a neurology training program at this institution, certain requirements for such programs are currently being met. In addition to full-time clinical instructors, we currently have available special training for neurology trainees in Pediatric Neurology, Neuropathology, and electroencephalography.

The latest development in the growth of the neurology training program was the decision made by Dr. Baker in September, 1964 that the training had now approached the point where he could with confidence; assign medical students from the University Medical School for their neurology training to the Hennepin County General Hospital. Since that time, we have included in our complement of personnel, 8 to 10 medical students on full-time duty for a ten-week period as indicated above. (Appendix II)

Appendix II illustrates the growth of the Department with respect to inpatients, outpatients, EEG and consultations during the past twelve years of operation of the Neurology Department in this institution. As will be evident from examination of the statistics, with the present size operation and the present number of personnel, the Department is working at maximum capacity. There can be little anticipated increase in the number of inpatient or outpatient services under the present situation. Limitations are principally those of space with respect to in-patient services, and space and clinic time with respect to outpatient problems. The consult service has been rapidly enlarging and makes great demands on our present staff.

Projected Plans and Recommendations:

It is quite obvious that, with the increasing number of patients entering the old age group, the burden weighs heavily on the Neurologic Service to anticipate an increased service responsibility in this community. At the present time we would not be capable of handling a five to ten percent increase in our yearly patient load in either the in-patient or outpatient areas. In anticipation of such an increase in the very near futures it would seem reasonable to make the following request.

l. That there be a slight increase in beds available to the Neurology Service,

2. That the Hospital support a third full-time neurology staff position (if, beginning in 1967, the U of M does not support the position100%),

3. That increased Clinic time be made available to the Neurology Department in view of anticipated increases in patient load,

4. That appropriate increases in nursing personnel and ward personnel commensurate with any contemplated increase in bed assignments to Neurology be made.

Respectfully submitted

M.G. Ettinger

Chief of Neurology

Hennepin County General Hospital

EEG DEPARTMENT HENNEPIN COUNTY GENERAL HOSPITAL

The Minneapolis General Hospital first acquired an electroencephalographic machine in June 1948. Sporadic records were obtained and interpreted by consulting neuro-psychiatrists who volunteered their help. In 1954, at the time the Neurology Service began functioning as an independent unit, statistics became available regarding the total number of records performed per year as well as a breakdown into patient classification by diagnosis, by location in the hospital as well as outpatient Department. A glance at Appendix I will reveal that there was gradual and steady growth in the EEG Department with respect to the number of records performed, utilizing one machine on a half-time basis until 1961 at which time the hospital saw fit, at Dr. Ettinger's recommendation, to hire a full-time EEG technician. From that time to the present, there has been a continued growth. In 1965, 1,344 EEG's were performed. This is sorely taxing the capacity of one unit and precludes the possibility of performing a number of special studies utilizing EEG which could be applied with advantage to our patient population at the present time.

UPDATING OF THE HISTORY OF THE NEUROLOGY DEPARTMENT, HENNEPIN COUNTY GENERAL HOSPITAL

In 1970 Dr. Riley left the staff to become a neurologist in private practice in Houston, Texas, and Dr. Alan Rubens was hired as his replacement and as Assistant Chief of Neurology. Dr. Rubens was trained in neurology in Philadelphia and subsequent to his training in neurology had trained at the Boston VA Hospital, under Dr. Geschwind and Dr. Benson, in Aphasia. Dr. Rubens, in addition, had spent a year on staff at the Boston VA and Boston University Neurology Departments. In addition to his active role in clinical neurology, he inaugurated an Aphasia Program at the General Hospital.

Dr. Manfred Meier, by this time, was consulting in neuropsychology and one of his trainees, Mrs. Leslie Arthur, a full-time psychometrist, was assigned to the Neurology Department.

Dr. Manny Stadlan was a consulting neuropathologist and was holding regular weekly teaching conferences in gross neuropathology. These proved to be very exciting and often were approached as C.P.C.s.

In July of 197 Dr. Ronald Cranford completed his training in Neurology and became the third full-time Neurology staff member to be supported by the General Hospital. Dr. James Moriarty was assigned part-time from the University to assist in the undergraduate education. In November 1971, under Dr. Cranford's direction, the Neurology ICU was opened as a three bed unit onAnnex 7. Throughout 1970, 1971 and 1972 Dr. Anna Ellington, who had been on sick leave from the University, returned on a half-time position, supported by General Hospital, to take care of our EEG program and read all of our EEGS. On July 1, 1972 Dr. William Hosfield joined our staff as the first Pediatric Neurologist in our institution, full-time. He was considered initially as 20% neurology and80% pediatrics, but from the beginning at least 50% or more of his time was devoted to Pediatrics Neurology. In addition, he was appointed Administrative Head of our EEG Unit and assumed responsibility for reading all the EEG records on children fifteen years and under. Dr. Ellington retained responsibility for reading all of the adult records.

In 1972 we obtained a Midliner Echogram and placed it under the direction of our EEG Technicians. By that time Joyce Markham had been joined by Rita Bednarek, who had become the second full-time EEG technician on June 29, 1971. Throughout the remainder of 1971 and 1972 Dr. Cranford developed the ICU with an increasing number of monitoring devices and a great deal of attention paid to training the nurses to recognize early changes in neurologic conditions.

Budget requests for 1974 included two new monitoring devices. One is a respiratory monitor and the second is equipment for monitoring continuous changes in intracranial pressure. The 1974 budget requests also included a fourth staff position requested to implement the new program called ‘Neurology Nurse Clinicians". It is our hope that we could provide some continuity of care to our ambulatory patients by nurses who follow up certain selected groups of neurology patients who return to our clinic repeatedly, for example: epilepsy, cerebrovascular disease, etc. At the time of this dictation, ie. June 1973, we have a vigorous and effective social worker, Paul Goldstein, who has, in addition to his routine chores as Neurology Social Worker, been busy organizing therapeutic groups, who meet on a regular basis. One group consists of relatives and friends of patients who recently had strokes and the second group is of young seizure patients. Both groups seem to be progressing very well. This has significantly contributed to the understanding of patient's problems by the participating members.

Our new hospital is planned for occupancy in the late summer of 1975, which is about two years from the time of this dictation. Dr. Ettinger has been a member of the Building Committee and we hope to have adequate office and working space in the out-patient area. Our in-patient unit will remain approximately the same size with twenty-one general beds and a six bed Neurology ICU.

M. G. Ettinger, M. D. Chief of Neurology

 February 26, 1974

During the past year the following events of significance have occurred:

Dr. William Hosfield, who was our first full-time pediatric neurologist, resigned on January 1, 1974, but beginning in July, Dr. Stephen Smith will join us as full-time pediatric neurologist. We are very fortunate in securing the services of Dr. Smith who will be completing his pediatric neurology training program. Not only is he a competent clinical pediatric neurologist, but he has done some excellent research work with electron microscopy, and is also vitally interested in neuromuscular diseases. We are looking forward to a significant contribution from Dr. Smith.

A number of other new personnel are joining us for varying periods of time on July 1, 1974. Dr. Mark Mahowald, who will be completing three years of neurology residency training program, will join us for one year to train with Dr. Rubens in aphasia and higher cortical function. He will bean associate physician on our staff for one year. Following that year, Dr. David Anderson will have completed his three years of training in neurology and will join us, hopefully, for an indefinite period of time as a fourth full-time neurology staff man. Dr. Anderson has background training in internal medicine, as well as neurology and is vitally interested in the number of acute medical problems that relate to our ICU and stroke patients. She will work closely with Dr. Cranford in further developing our interest and activities in these areas. In addition, he will probably be responsible for the Neurology Nurse Clinician Program. That was one of the principle justifications for the new staff position.

Dr. Barbara Patrick is current an intern in the RO program and has long been interested in the possibility of a neurology residency. She is a University of Minnesota student and is well known because of her part-time research activities on our service while she was a student. Dr. Patrick is looking for some kind of break between her internship and residency and has agreed to join us for one year as a research fellow in Neurology, concentrating on one or two clinical research project. She will be with us from Sept 1, 1974through June 30, 1975, at which time, hopefully, she will become a neurology resident with us at the University of Minnesota and affiliated hospitals.

Mr. Paul Goldstein, our Social Worker, resigned in January, 1974 because of an offer to become administrative head of a number of nursing homes in town. We have a very able new replacement, Barbara Johnston, who, I'm sure, will carry on adequately in Mr. Goldstein's absence.

Dr. Cranford passed his neurology boards this past year and has been concentrating on some work with blood levels of Dilantin utilizing intravenous Dilantin in the treatment of status epilepticus and frequent recurrent seizures. He has some very nice clinical data and will be presenting his first paper at an epilepsy meeting in the fall of 1974.

We have a new head nurse on the Neurology unit, Mrs. Carol Bird. She arrived in the fall of 1973 and has gradually been instituting a number of new and innovative changes in our nursing program, all oriented towards the final objective of "primary nursing care". Hopefully nurses will be assigned to specific patients they will not only work with during their inpatient period, but with whom they will relate on long term basis as the patients return to clinic. I would like to develop this nurse clinician concept so that many of our nurses can see their patients in the clinic in addition to caring for them when they are acutely ill in the hospital.

The new hospital is progressing satisfactorily. It is approximately 50% completed. The target date for completion is about fall or early winter of 1975. Since the center hospital will be completed by January of1976, our target date for moving into the new hospital will be approximately two years from now, i.e. February, 1976. Dr. Manny Stadlan, who for many years was an outstanding consulting neuropathologist, has left during the past year to accept a position in Memphis, Tennessee, at the University of Tennessee, with Dr. Robert Utterbach. He was replaced by Dr. Angeline Mastri, who continues to give us high quality neuropathology service and the teaching conferences in our weekly neuropathology sessions are of the highest quality.

UNIVERSITY OF MIAMI

MIAMI, FLORIDA 33152

June 26, 1975

Dear Milt:

This is just to express my thanks to you for your graciousness in picking me up, taking me to your conference and showing me around your shop. I did enjoy that morning a great deal. I was very much impressed by Ron Cranford and his especially lucid explanation of the work that he is managing in status. I feel I came away with a slightly different view of the problem, despite what I thought was a lot of prior experience. I am quite sorry that I didn't have an opportunity to spend more time with Rubens. Everything I have heard about him is good.

The real purpose of this letter is to congratulate you on having put together what is clearly an outstanding part of the University of Minnesota neurology training program. I had a chance to speak to some of the residents, feel that the clinical exposure under your aegis was superior in every way, and I thought it would please you to know this.

Best wishes.

Very truly,

Peritz Scheinberg,

M. D. Professor and Chairman

Department of Neurology

May 3, 1976

I mentioned in my last report (February 26, 1974) that Dr. Mahowald would be with us for one year and Dr. Anderson would come on full-time after that. Dr. Mahowald proved to be such a stimulating, enjoyable colleague that after letting him "dwindle" at the VA for nine months, I finally pressured Administration long enough and hard enough for a salary, and we were able to get Mark back with us in April of 1976. We now have six full-time people as follows: myself, as Department Chairman; Dr. Rubens as Assistant Chief of Neurology and Head of Aphasia and Higher Cortical Function Unit; Dr. Cranford; Dr. Stephen Smith, who is a pediatric neurologist; and Dr. David Anderson and Dr. Mark Mahowald, two young graduates of our training program.

Dr. Mahowald will assist us with EEGs, and Dr. Rubens will turn over the outpatient clinics to him. The most exciting news is the new hospital. I'm sitting in my new office today, having just returned from a week at the meetings of the American Academy of Neurology in Toronto. In my absence, the hospital move was initiated beginning with our offices. On Wednesday of this week, two days from now, all the patients will be moved. After so many years of waiting and planning and longing, we finally made it! It's a beautiful new hospital, and I'm sure it will help us give much improved care in both inpatient and outpatient areas. Our Neurology unit, as a whole, came out pretty well regarding space. We have nicely organized and coordinated Neurology Office and Aphasia Clinic areas, EEG has more than adequate space, and we have ample class and conference rooms for a change. Well, that's what comes from my being on the Building Committee for all those years ... we had to show some profit! Dr. Baker is retired officially as of March 31 of this year. Dr. Joe Resch is currently the Head of Neurology at the University of Minnesota. The Search Committee is active at the University, and Dr. Erland Nelson seems to be a front-runner. I would predict that Dr. Nelson can have the job if he wants it. If he doesn't take it, I think we may let Dr. Resch keep the job until his forced retirement in five or six years. It's a very difficult and not very attractive position because of the money problems, large tenured faculty, etc.

No new staff physicians are contemplated for the near future. Our primary personnel concerns relate to an additional secretary, and then building up our Aphasia program. Carol Bird continues to do an excellent job as head nurse, is gradually winning a number of the nurses over to her way of approaching clinical nursing. Barb Johnston, our social worker, is doing a good job and getting interested in doing something special with our stroke patients. Sue Mahanke has really risen to great heights this last year. She took the nurse practitioner course at the University, and was their outstanding student. She's shown great aptitude for being able to care for patients on her own, has been handling a number of seizure clinic patients very skillfully, with minimal backup now from Dr. Cranford. I think we will train her to takeover the continuity of care for some of our stroke patients. If we had two or three more like her, we'd be able to offer excellent continuity of care to outpatients.

Chris, our former secretary, is no longer with us. She's been more than ably replaced by Michele Fatze, with the backup from Marilyn Sullivan. Vickie Voigt in Aphasia is doing an excellent job, and all three secretaries will be together in a secretarial office area in our new building.

M. G. Ettinger, M.D.

Chief of Neurology

Hennepin County Medical Center

October 13, 1976

The Neurologic Service at the Hennepin County Medical Center (which moved into new quarters May 1976) is a 26 bed, administratively independent department. It has a six bed neurology intensive care unit and a 20bed general neurology ward. Admissions to the neurology inpatient service numbered over 700 last year, including many acutely ill patients. There is a large complement of patients with cerebrovascular disorders, seizure problems, and neurologic complications of alcoholism, diabetes and other medical diseases, many dementia syndromes, plus a smattering of coma patients of unknown etiology. There is a large neurology outpatient clinic which meets daily and serves a population of approximately 3,000 patients per year. In addition to the general neurology clinic, specialty clinics are held currently in the following subspecialty areas: epilepsy, cerebrovascular disease, neuromuscular disorders, and aphasia. Soon to be developed new clinics include headache clinic and possibly a vertigo clinic. A very busy consultation service renders neurologic evaluations for over a thousand referral cases per year from other inpatient units through the institution.

The current staffing includes six fulltime neurologists: the chief of service (Dr. M. G. Ettinger), four other fulltime adult neurologists (Drs. Rubens, Cranford, Mahowald, and Anderson), and one full-time pediatric-neurologist (Dr. Smith). In addition, special paid consultants contribute weekly to teaching conferences in the following areas: electroencephalography, electromyography, neuropathology, neuropsychology, pediatric neurology, and neuroradiology. Beside the six full-time neurologists in the institution, the practicing neurologists in town contribute their time to the Neurology Clinic, where they assist in the evaluation of patients and the teaching programs for both medical students and graduate students in the neurology residency program.

The hospital offers a full complement of diagnostic facilities including EEG, EMG, brain scanning, computerized tomography, neuroradiology, etc. The house staff (GI and G2) assumes the responsibility for patient care, generally under the direction of a senior neurologic resident.

The house staff complement at any one time consists of one senior neurology resident, two second year neurology residents, two second year medical residents, and three GIs who rotate from other services in the hospital through the neurology service. In addition, medical students are assigned from the University of Minnesota to our neurology program as follows: six (6)third or fourth year neurology students are assigned full-time (six weeks);twelve (12) second year medical students are assigned two half days per week for eight weeks. A number of advanced students in special or elective assignments also constitute part of the personnel complement of the department. The Neurology Department has developed a large aphasia and higher cortical function program within the department. This program it under the direction of Dr. Alan Rubens. Other employees currently active in the aphasia and higher cortical function unit include three full-time speech pathologists, a psychometrist, a full-time neuropsychologist, and a consultant in neuropsychology from the University program. A number of speech pathology students from the University of Minnesota are assigned to work in the program for varying periods of time.

The EEG lab currently is performing approximately 1,800records per year using two 16-chaniiel recording units. An additional portable8-channel unit is used for emergency recordings throughout the institution. The pediatric neurology program has been rapidly developing the past two years since the acquisition of our first full-time pediatric neurologist. A school learning disorder evaluation program has been a very vital outreach program into the Minneapolis community and suburbs, and pediatric neurology residents from the University program are now assigned to rotate through the pediatric neurology program at the Hennepin County Medical Center in addition to the pediatric residents who are also assigned on a two month rotation basis. A wide variety of clinical and basic research projects are being performed by various staff members of the Neurology Department. Opportunities for individual research experience are available in all areas.

June 29, 1977

The new Hennepin County Medical Center (opened May 5, 1976) is a 400-bed hospital, which it physically connected to a 700-bed private complex (Metropolitan Medical Center) via a 100-bed "center hospital” unit resulting in a 1,200-bed medical complex, containing a full complement of physicians specializing in all areas of medicine including internal medicine, surgery, pediatrics, ophthalmology, ENT, psychiatry, neurosurgery, rehabilitation, etc.

The Neurology Department is an administratively independent unit which includes six full-time staff neurologists, all currently certified in neurology, one in pediatric neurology. The inpatient neurology service contains two units: one, a 20-bed inpatient unit of 10 two-bed rooms, and the other, a 6-bed neurology intensive care unit. The inpatient service admits in excess of 800 patients per year, has a rapid turnover with a relatively short hospital stay, and admits a large number of acute neurologic problems, including all forms of cerebrovascular disease, coma, seizures, toxic and metabolic diseases, etc.

The outpatient department has a "neurology only” area which includes seven examining rooms and one larger conference room. It is staffed by full-time clinic personnel plus a recently acquired full-time neurology nurse practitioner. "General" neurology clinics are held every afternoon with the exception of Fridays, and specialty clinics currently in operation include stroke, aphasia, epilepsy, neuromuscular disease, and headache. The outpatient department sees approximately 3,200 patients per year.

A busy neurology consultation service renders opinions regarding approximately 700 patients a year. One of the full-time staff is assigned to cover the consult service at all times, and is available immediately for emergencies as well as daily consult rounds. The neurology residents. As signed for three-month periods to the Hennepin County Medical Center, will be assigned to all areas described, including inpatient, outpatient, and consult services.

A full range of diagnostic facilities is available within the institutional complex, including neuroradiology (brain scans, subtraction and magnification angiography, computerized tomography, etc.) along with a neuroradiologist who conducts weekly X-ray conferences. Also available are EEG and EMG; bacteriology and toxicology; electronystagmography; nerve, muscle, and brain biopsy studies with light microscopy and differential staining techniques, plus electron microscopy studies, etc.

A special aphasia unit that has 1,400 visits per year has been developed within the Neurology Department under the direction of Dr. Alan Rubens, and currently contains three additional full-time speech pathologists, a research neuropsychologist, and a number of graduate students in linguistics, speech pathology, etc. Neurology residents may elect to study aphasia and higher cortical function during their elective time.

Our EEG lab has two 16-channel EEG machines and performs many bedside studies including a large caseload of "brain death” diagnoses. The number of EEGs performed in 1977 was 2,300.

The house staff consists of the following: one senior neurology resident who is in charge of the inpatient service, two G2 neurology residents assigned for three-month intervals from the University, two residents from internal medicine at the G2 level or above assigned for two-month rotations, three to four GI level personnel (interns) representing all services having GI residents in the institution, six "full-time" Phase D medical students assigned for six weeks on Neurology, and twelve part-time Phase B students who are assigned two half-days a week for lecture and demonstration purposes.

The schedule of weekly activities includes many conferences and clinical round sessions conducted by staff, plus specially assigned review presentations by residents and weekly conferences in pediatric neurology, neuropathology, neurosurgery, electroencephalography, and neuroradiology.

There are available special research opportunities relating to ongoing research projects being conducted by neurology staff personnel. Students may participate in these projects during elective time. Currently, research is being conducted in the following areas at the Hennepin County Medical Center: cerebrovascular disease, clinical (special studies of therapy in the ICU, studies of predicting outcome in stroke patients) and basic studies(coagulation, platelet, and fibrinolysis abnormalities in stroke patients);multiple studies in aphasia and higher cortical function being performed under the direction of Dr. Alan Rubens in the aphasia program; studies in pharmacokinetics of anticonvulsant drugs; studies of etiology and therapy of dialysis dementia, study of memory and cognitive disturbances in Korsakoff's syndrome.

June 27, 1978

It's been a few years now since the last update. First, to fill in some personnel changes: The medical staff is essentially the same with a new addition July 1, 1978 of our second full-time pediatric neurologist, Dr. Gerald Slater. Gerry trained with us in pediatric neurology, and looks like a welcome addition. I am sure he will be of considerable help to Steve Smith, who's been overburdened with teaching and service activities in pediatric neurology. In addition, Dr. Smith has been developing very active programs in electronmicroscopy studies of nerve and cerebral biopsies. We have replaced Marilyn Sullivan, who was a neurology secretary for a number of years, with Pamela Thinesen. Michele is doing an excellent job and soon will be promoted to senior departmental secretary. Vickie is still with the aphasia program, and we have a fourth secretary assigned primarily to EEG, Mary Jorgensen.

We have been funded for our first G5 position and have hired Dave Good, who will be finishing our program to begin July I for one year as aG5 resident. Actually, he will be doing some research in the ICU with ICP monitoring, working generally on our stroke programs, doing some medical student teaching, and serving as an additional young staff man. At the same time, Dr. Rubens has hired another one of our recent graduates, Dr. Gary Platt, to spend a year as an aphasia fellow doing some research in aphasia plus helping out on the ward, with clinics and consults, and also with some medical student teaching.

We might as well let the record show now that Dr. Rubens has scored a major coup receiving a large, five-year contract from the federal government for the study of spontaneous improvement in aphasia following stroke. This grant has allowed him to hire large numbers of support people: neuropsychologists, speech therapists, biostatisticians, computer experts, nurse practitioners, and secretaries. There has been a major expansion of personnel in our department as a direct consequence of this research effort. It is certainly a tribute to Dr. Rubens that he was able to procure this project in competition with the rest of the country. The initial plans were to fund two or three projects as feasibility studies, but Dr. Rubens' grant was so far superior to all the others that the people with the money in Washington decided to put all their eggs in this basket and funded only one major study and that's ours.

We've been through a few social workers since my last dictation. Barb Johnston left and was replaced by Susan Bondow, who will be leaving soon and will be replaced by Paul Goldstein. Paul's now gone the full circle, as he initially started out as a neurology social worker and left the hospital to run a nursing home, came back to the hospital as a social worker in medicine, and has finally returned to the spot where he really belongs, and that's neurology. We're delighted to have Paul back.

Carol Bird has left as neurology nurse supervisor, and we have an excellent replacement in the form of Kathy Miller, who comes from Ann Arbor, Michigan. There was a rather long period following Carol's departure when we had no effective leadership on the ward and nurses' morale deteriorated. Kathy's gradually reestablishing the kind of nursing service that we all feel we need and can have on neurology. She's recently hired a head nurse from within our ranks which should further bolster our morale, Bill Borgman.

In our outpatient clinic, Sue Mahanke has left to go to the Comprehensive Epilepsy Program. A more than adequate replacement is Diane Dusek, who was ten years in practice with an internist, had extensive experience in other hospitals, and is a very mature and experience nurse practitioner. She's proving every bit as valuable as Sue was, and is rapidly developing expanded interests and capabilities.

Dr. Resch has been running the University reasonably effectively since taking over for Dr. Baker. The University has finally lost the large cerebrovascular research center grant but that was expected. A few people have been released. The one of most immediate concern is Phyllis Krull, who had been running our coagulation laboratory for over 15 years and who is no longer going to be with us. Funds for her salary came from the stroke research center grant, and in June of 1978 we closed the coagulation lab. Phyllis at that time was looking for a job elsewhere in the University program.

Dr. Resch has brought in some new staff people at the University, Dr. Birnbaum from New York who has a special interest in neuroimmunology, and Dr. Robert Roelofs who's been at Vanderbilt University for years. Dr. Roelofs was a former resident of ours in Minnesota and returns with expertise in nerve and muscle biopsy work, so I think we're gradually diversifying and strengthening the University neurology faculty. The situation at Ramsey seems stable and strong, although Al Hauser is leaving to go to a good job in epidemiology in New York. Probably our weakest link is the VA where Dave Webster has been holding things together, but does not seem to be able to recruit very strong faculty.

Our own situation here has been characterized not only by some problems with inpatient nurse morale, but also problems with staff morale. We've been forced to move from 33H (which we designed as our neurology inpatient unit) to 32G because of low occupancy figures. 32G was not well suited to our needs, and we are currently completing some fairly extensive remodeling which has improved the situation considerably. We need to improve the kinds of neurology admissions to continue to make this a high quality training program. It looks like one of my principal projects for the next year or so is going to be to convince the staff that we do have a favorable long-range capability and to replace some pessimism regarding our inpatient program with some enthusiasm and optimism. I don't think this is going to be too difficult. I believe we have a strong, viable department and are simply experiencing, in a somewhat more exaggerated form than usual, the ups and downs of departments in municipal hospital programs. We've been through these cycles before and have survived them; I am certain we will again.

Just as an illustration of our strengths, a listing of current projects includes the following: Huntington's Disease Clinic, Neuromuscular Clinic, muscle and cerebral biopsy program, aphasia and higher cortical function unit, special intensive care unit programs, Headache Clinic, and Diane Dusek's offer to our ambulatory patients neurocutaneous stimulation, relaxation therapy, and intensive outpatient education. New projects include a comprehensive stroke care program, a stroke evaluation study with Dr. Kiresuk and the people from Mental Health, participation in the International Cooperative Study of Extracranial/Intracranial Bypass Surgery for Stroke, the establishment of a sleep disorders center, expansion and formalization of our Headache Clinic, institution of intracranial pressure monitoring study in the ICU, and purchase of new equipment for auditory evoked potential studies.

I think with our current staff, current activities, improving situation on inpatient nursing, plus a little leadership from myself, we can get over this slight "slump" and look forward to new and exciting activities in the department. The long range viability of our institution looks reasonably secure. There is currently a long-range planning committee looking specifically into available options for us. I am sure the next report will sound a more optimistic note.

November, 1979

In reviewing my last dictation on June 27, 1978, 1 noted a good bit of attention was devoted to morale problems. To begin this update, I think those morale problems have largely been alleviated. I believe we have a strong, viable, active and exciting group now, who have all developed special interest areas of their own. For example, Dr. Rubens continues to actively lead the Aphasia contract as well as supervise the Aphasia and Speech Pathology section of our department. Dr. Cranford has developed national as well as local reputation for bio-ethics and the hospital has just formed one of the first Bio-Ethics Committees with Dr. Cranford as head. Dr. Anderson is working with non-invasive vascular studies and investigating Doppler and oculoplethysmography techniques. Dr. Mahowald is in charge of our EEG program, has developed an interest in auditory evoked potentials and is working with me in the Sleep Disorders Center. Dr. Smith is very active in neuromuscular disease and he and Dr. Roelofs have established a Neuromuscular Disease Clinic at the Universityof Minnesota and have been approved by the Muscular Dystrophy Scoiety ofAmerica as a muscular dystrophy clinic. Steve is also doing biopsy work, both peripheral and neuromuscular disease and central, with respect to brain biopsy, utilizing electron microscopy. Both he and our other pediatric neurologist, Gerald Slater are providing some outside consultation in pediatric neurology. Further Dr. Slater is very interested in sodium valproate as an anticonvulsant and has had some papers published and is currently writing a chapter in a textbook. Dr. Ettinger has been working hard along with Dr. Mahowald on developing the Sleep Disorder Center. We haven't widely advertised the Center yet. We've already seen 50 patients. We're remodeling an area on the floor above us for our sleep center, and have ordered some new equipment; including a Grass polygraph and Hewlett-Packard ear oximeter and we'll be ready soon to do all-night sleep recordings in our new sleep laboratory facility. We have recently been approved by the hospital administration for a full-time secretary for the Sleep Center. We'll probably transfer one of our current secretaries, Susie McKitterick and hire a new secretary to replace Susie in the neurology unit. The Huntington's disease program continues to do well and meets once month. Dr. Ettinger, in collaboration with Dr. Jack Sheppard from the University, has submitted a research proposal for a Huntington's disease Center without Walls and we're currently working with the state grant to initiate some epidemiologic, genetic, and basic research activities in Huntington's disease patients and families. Dr. Ettinger's recently had some conversation with the Alzheimer's disease organization, and collectively, they are considering the possibility of opening an Alzheimer's disease Clinic at our institution.

There has been some change in our secretarial personnel. After almost five years, Michele Fatze has left us to return to school and has been ably replaced by Vicki Kent. Susie McKitterick has indicated an interest in becoming the Sleep Disorder Center secretary and has been assisting Dr.Ettinger with sleep patients, has been active in getting out the sleep newsletter and also participates in the narcolepsy group meetings that have been held to date. Sue Counter has left us and we are currently looking for anew aphasia secretary. Mary Jorgenson is still working with us and we will be recruiting for a new secretary as indicated above, shortly.

We had an addition to our medical staff as of July of this year. Dr. Barbara Patrick joined us. Dr. Patrick, who is a familiar face around here, was first a medical student with us, then took some research time with us, interned with us; after her internship, spend a year as a research fellow with us and then had her residency with us. We're glad to have Barb back. She's doing an excellent job. She's in charge of our out-patient program and will be training in our new nurse practitioner. Which brings me to the next point. Diane Dusek, who has been our nurse practitioner for three years, will be leaving to pursue other professional interests December 1, 1979. We are currently interviewing for a replacement and Barb Patrick will be training in Diane's replacement. We'll surely miss Diane. She's helped us understand how a nurse practitioner can function effectively within our unit and we're looking forward to working with her replacement. Barb Patrick is continuing the work Dave Good started with the Comprehensive Stroke Care Program and that seems to be going very well. In fact, the Wednesday chart rounds are becoming a very popular place for many disciplines to meet and interact and the room is getting too crowded to hold the number of people in attendance. Barb further has improved our relationships with MMC rehab. She is spending a fair amount of time over there with our patients. We're keeping more direct control over our patients who are transferred to rehab and Barb is interacting with the people over there, giving lectures, attending conferences and generally improving our image in MMC rehab as well as sharing continuity of care, and seeing that proper patient referrals are made back to our own hospital personnel, when appropriate.

There have been a few additions to Dr. Ruben's contract personnel. Loren Jordan has come on board. He's a computer man with a neuropsychology background. He has promised to help us computerize some of our departmental activities, once he gets the Aphasia contract information flowing as smoothly through the computers.

Pat Wahoske has taken over for Mike Johnson as head of our speech program. She has had a number of new people working with her including Thelma Fung, Jan Schaub, and Nancy Niccum. Since Pat's taken over, there has been a significant increase in activity in this area. We're supplying more services; the group is considering long-range objectives and in short, seems to be functioning much more efficiently than it has in the past.

I think I've covered our EEG department in the past. We now have three very capable EEG technicians, Katie Junhke, Linda Dagrud, and Claudett Yutesler. They're doing an excellent job and have taken a real interest in the sleep program and are alternating in the overnight and all-day sleep studies. I think we have a very strong EEG department. I hope we can hold on to all these people for awhile.

SUMMARY: At least the perspective on the department in November 1979 looks good. We're busy, new programs seem to be developing or expanding, everybody is busy with patient care and teaching in addition toothier own special interests, and I hope the next report can forecast as optimistic future as this one.

January 1984

It appears as if I have let allot of time lapse since my lost update which was dated November 1979.

Regarding our neurology staff, we have essentially the some group with one recent addition. Drs. Rubens, Anderson, Cranford, Mahowald, Patrick, Smith and Slater have all been around for a number of years now and we have just received approval from both the hospital and the fledgling practice plan, Hennepin Faculty Associates, for a new addition to our staff of Dr. Scott Bundlie. Scott come through our residency program, spent two years as a post-graduate fellow, working full-time with us and has developed skills in both the sleep area and the evoked potential area. He is being hired primarily to help us with our sleep center expansion plans.

Regarding the Sleep Center. My last update indicated we were just getting started. We now have a very active sleep center program. Our two rooms are being used every night of the week and we are beginning to fall behind in referrals. We have a large and active multidisciplinary sleep center faculty. Our staff includes a sleep center secretary, Susan Seeman; four techs including a senior sleep laboratory technologist, Andrea Patterson, Stephanie Thole, Michele Trufant, and Mary Stock. We have just convinced the hospital to purchase some ambulatory equipment for us for in-home sleep monitoring. Drs. Mahowald and Bundlie will develop that program. We are also interested in the very near future of working with Urology, Psychiatry, and other departments in developing an impotency evaluation program.

There has been quite a bit of turn over in our secretarial staff. Currently Kathleen Hein has replaced Vicki Kent who was the senior department secretary for a number of years. Mary Brown remains the EEG secretary. Cynthia Kleinendorst is the Neurology secretary and Doreen Engebretson is the Aphasia secretary.

The EEG department has been expanded to include evoked potentials and that is gradually becoming a larger and larger component in this groups activities. We have the some capable three EEG techs we have had for some years now; Katie Juhnke, Linda Dcigrud, and Claudett Yutesler.

On the ward, Bonnie Watkins is our nursing supervisor and is doing an outstanding job. There is better stability and improved morale amongst the ward nurses than we have noticed for a long time. They are improving their nursing skills. They are learning more ICU techniques and things are very stable in that department. Our new social worker is Ed Biren who has been very active in special clinic activities and support group activities.

Our clinic operation under the direction of Dr. Barbara Patrick is slowly improving and enlarging. Our Huntington's disease clinic continues as a very active and important program which is multi-disciplinary which involves people from genetic counseling, patient advocate (Sally Hogan), our nurse practitioner Beryl Westphal, and a new program that has opened in our area is the decision by Oak Ridge Nursing Home to become a center for Huntington's patients requiring hospitalization. In addition, they are offering daycare and temporary lodging programs. This is probably the first such in-house program for HD patients in this country and is modeled after the Furst unit in Australia.

Probably the biggest news is the decision of the medical faculty to organize into a practice group. After long difficulty negotiations with the County a contract between the new practice group called Hennepin Faculty Associates (HFA) was signed and we are now busy with many committees trying to reach a target date of 1 April 1984. Dr. Ettinger is right in the middle of all of this activity. He is a member of the Board of Directors, Secretary of the Organization, a member of the Executive Committee, and was on the negotiating committee. Dr. Schultz is Chairman of the Board of Directors and Executive Committee. Dr. Fred Shapiro is the President of the Practice Plan.

Our Speech and Language program is an excellent one thanks to Pat Wahoske's expertise and guidance. Currently members of her department include Karen Orcutt and Maxine Slobof.

Dr. Gail Risse is our Neuropsychologist, and Elizabeth Destafney is our psychometrist rounding out our staff of professionals. They have been with us for a long time and continue to do outstanding work. They are collecting data for a number of publications including a longitudinal serial study of the Huntington's patients, special testing of corpuscavernosum patients in collaboration with the University Epilepsy program and a number of other projects.

The report would not be complete if I did not pay some special attention to our Nurse Practitioner, Bootz Westphal who is doing an outstanding job of providing continuity of care to large numbers of patients with chronic neurologic conditions such as epilepsy and to our outstanding clinic nurse Jan Schluter who has also become very active in our sleep center program. Jan has been called upon to give a number of lectures and presentations to nursing groups and other groups on various sleep topics and has just been asked to write a chapter on sleep disorders in a nursing textbook.

In summary, the perspective on our department in January1984 suggests that is it a strong viable and well functioning department that should enjoy a good year assuming I can get the physicians to document all of their charges for the practice plan. I will try to make the next update within a year or so.

M.G. Ettinger, M.D.

Chief of Neurology

Hennepin County Medical Center

August 6, 1986

In early 1953, the Medical Director of Minneapolis General Hospital, Dr. Thomas Lowry, approached Dr. Harold Noran, a practicing neurologist in Minneapolis regarding the establishment of a neurologic unit at the Minneapolis General Hospital. Prior to that time hospitalized neurological patients had been seen by downtown consultants who had volunteered their time to provide the hospital with neurological coverage. No teaching program in neurology had been developed for the interns or residents. Following discussion with Dr. A.B. Baker, Professor and head of the Neurology Department at the University of Minnesota Hospitals, a neurology program was initiated at Minneapolis General Hospital in July 1953 which was affiliated with the University of Minnesota and under the direction of Dr. Harold Noran. Dr. Baker agreed to assign a neurology resident to the service and Dr. Lowry who was also the Chief of Internal Medicine assigned a medical resident. Two rotating interns were also assigned to the service at that time.

The first neurology patients were admitted principally on the medical service, but were placed in beds wherever they were available throughout the hospital, often on urology or ENT services. Approximately 15beds were designated as neurologic beds. Two rotating interns and two residents were responsible for the evaluation and care of these patients and they were supervised by Dr. Noran who made daily word rounds on the service.

In late 1954 in cooperation with Drs. Noran and Baker, a geographically and administratively independent neurology department was established on station 7 of the annex building. 28 beds were assigned to Neurology and Dr. Baker appointed a part-time instructor from the University of Minnesota Neurology staff to assist Dr. Noran in the supervision of the teaching program in Neurology. Dr. John Logothetis held this position from 1954 through1956.

In 1957, a three year training grant in Neurology was obtained from the United States Public Health Service through the efforts of Dr. Noran and Dr. Baker. The training grant supported some salary items for residents, an EEG technician, and part-time staff. Throughout the three-year period from 1957 to 1960, Dr. David Mendelson was assigned from the University and Dr. Noran continued as Chief of Service.

In 1960, Dr. Milton G. Ettinger was appointed as the first full time faculty in the program. The training grant from the Public Health Service had lapsed and the support of the Neurology program was contributed principally by the University of Minnesota with some slight contribution from the hospital. From approximately 1963 to the present time, the Neurology Department has had three residents assigned from the University Neurology program, generally one senior resident and two first or second year residents. Additional residents from Internal Medicine, Psychiatry, and Family Practice rotate through the program and interns from a wide variety of training programs also receive some training in Neurology.

Beginning in 1964, medical students were assigned by the University of Minnesota to the Neurology Department at Minneapolis General Hospital. That assignment has continued to date with both Phase B and Phase D students rotating through the service.

Early neurology staff, in addition to Dr. Ettinger, included: Dr. A. Ellington who was on staff from 1964-1969 and Dr. William Riley who was on staff from 1965-1970. Dr. Riley was awarded the Distinguished Teaching award by the University of Minnesota Medical Students in 1966.

In 1970, Dr. Riley left the staff to become a neurologist in private practice in Houston, Texas. Dr. Alan Rubens was hired as his replacement and was appointed as Assistant Chief of Neurology. Dr. Rubens, in addition to being trained in Neurology had received additional training in Behavioral Neurology and shortly after his arrival at our institution developed an active Behavioral Neurology program with the addition of Neuropsychology and Speech and Language Pathology programs. Dr. Rubens left the Hennepin County Medical Center in June of 1986 to become the Chief of Neurology at the University of Arizona, Tucson. During his 16 years on staff, Dr. Rubens made many major contributions as an outstanding teacher and clinician. In addition, he was awarded the largest single grant ever awarded in aphasia by the National Institutes of Neurologic Diseases for a five year study on the Recovery of Aphasia Following Cerebrovascular Accident. Dr. Rubens collected a large, multi-disciplinary research team. The publications that continue to eminate from that research project are providing the framework for understanding the natural history of the recovery of aphasia following stroke and have proven to be a valuable contribution to the literature in that area.

In 1971, Dr. Ronald Cranford joined the staff. In addition to his work in developing our Neurology Intensive Care Unit and being the first to publish guidelines regarding the utilization of intravenous Dilantin for the treatment of acute seizure disorders, Dr. Cranford has developed a national reputation as an expert in biomedical ethics. He currently enjoys many prestigious appointments including Associate Editor of the journal Law, Medicine and Health Care. He is the President Elect of the American Society of Law and Medicine and was a participant on the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.

Additional Neurology staff and their special areas of interest or expertise include: Dr. David Anderson who has also received the Outstanding Teacher Award from the University of Minnesota Medical Students. Dr. Anderson's commitment and dedication to medical education are widely recognized. In addition, he has numerous publications in cerebrovascular disease, evoked potentials, etc.

Dr. Mark Mahowald was for many years the supervisor of our EEG Department and along with Dr. Ettinger developed the Minnesota Regional Sleep Disorders Center. Currently he is spending full time with the Sleep Disorders Center.

Dr. Barbara Patrick has maintained the Huntington's disease Clinic since joining our staff and also has developed expertise in electromyography. Dr. Patrick also holds specialty clinics for patients with movement disorders (and/or Parkinson's disease.

Dr. Scott Bundlie is a fairly recent addition to our staff. He has a special interest in ambulatory monitoring for both EEG and Sleep Center patients. He is developing our program in the Sleep Center for monitoring nocturnal penile tumescence in the assessment of impotence. Dr. Bundlie is also interested in stroke and head injury.

Dr. Stephen Smith, a pediatric neurologist, has developed a major referral activity in the area of nerve and muscle biopsy interpretation. In addition, he is active in assessing brain biopsies using both light and electron microscopic techniques. Dr. Smith also has an active interest in Huntington's disease Clinics, has been involved in national and local ataxia societies, and conducts special clinics for patients with neuromuscular disease at both the University of Minnesota and at our facility.

Dr. Gerald Slater, our second pediatric neurologist, has been actively involved in research of anti-epileptic drugs and more recently has conducted a study of the efficacy of hyperbaric oxygen therapy in patients with chronic multiple sclerosis. In addition to his clinical activities, Dr. Slater is currently actively involved in the administrative aspects of Hennepin Faculty Associates and serves as Treasurer of that organization and Chairman of the Finance Committee.

Our newest arrival, Dr. Frederick Langendorf, began with us in July 1986 as Dr. Rubens' replacement. Dr. Langendorf, following his neurological residency has had a one year Fellowship in EEG and evoked potentials and has taken over our EEG and evoked potential programs for Dr. Mahowoild. In addition to these activities, Dr. Langendorf will be developing a head injury clinic for the evaluation of patients with mild to moderate head injuries.

The current areas of interest in the department are:

1. The growth and development of the Minnesota Regional sleep Disorders Center which will probably be expanded from a four to an eight bed unit in the near future.

2. the continuing major commitment of all the faculty to education of the house staff and medical students which as resulted on two occasions in the awarding of the Distinguished Teaching Award by the medical students to a neurology faculty person.

3. Recent interest in a coordinated institution-wide head injury program with a particular emphasis on an evaluation clinic for patients with mild to moderate head injuries.

4. Continuation of special programs in Huntington's and other extra pyramidal diseases, neuromuscular disease, and cerebrovascular disease.

1990-1995 by David Anderson

The department faculty has changed since last entry and the change includes an increase in size. Al Rubens left to be Chair of Neurology at the University of Arizona in 1986. Fred Langendorf, an electroencephalographic ande pileptologist, took his place. Two years later William David was recruited. Dr. David, an MD PhD trained in neurology in the Harvard-Longwood Program, had just completed fellowship training in EMG at the Lahey Clinic. Expansion of EMG services and of Steve Smith's neuromuscular program was envisioned with the addition of Dr. David. It became quickly apparent that Dr. David was not only a talented electromyographer but also an outstanding clinician. Dr. Ettinger had become increasingly convinced that a pain program would be a valuable addition to the medical center. In 1988 he offered the PGY5 position to a promising residency graduate, Miles Belgrade, whose professional goal was to develop a pain service. Dr. Belgrade's training included a stint in Sri Lanka where he became skilled in traditional acupuncture which was to be included in his armamentarium. Confirming Dr. Ettinger's impressions, demand quickly developed for Dr. Belgrade's services once they became available. When the fellowship year was nearing completion, Dr. Ettinger requested a faculty position for Dr. Belgrade who accepted an invitation to continue.

A1990 update on the veterans of the department finds Ron Cranford busy as ever with biomedical ethics activities. His expertise was in constant demand for legal cases (e.g. Karen Quinlan) as well as by the media, governmental agencies, the American Academy of Neurology, and other entities. David Anderson continued to be involved in medical education and became a participant, along with Scott Bundlie and others from HCMC cardiology, in the Stroke Prevention in Atrial Fibrillation (SPAF) Trial, and NIH funded multicenter project. Mark Mahowald was developing the Minnesota Regional Sleep Disorders Center into one of the largest and most highly respected sleep centers in the nation. A unique strength was the tradition of interdisciplinary cooperation present from its very beginning. The sleep group, including psychiatrist Carlos Schenck, Mark Mahowald, and Scott Bundlie, described the rapid eye movement (REM) movement disorder in 19xx, putting the Minnesota Regional Sleep Disorders Center forever on the academic map. Fred Langendorf and Bill David were co-directors of the electrophysiology activities of the department. The quality of these services was outstanding. Fred was also very involved in education and collaborating with University-based colleagues studying the neurologic aspects of HIV infection. Scott Bundlie divided his time between the Sleep Center and general neurology. Steve Smith was very involved at the University, where he and Bob Roelofs provided high quality neuromuscular services, including clinics for ALS and muscular dystrophy. Gerry Slater became involved in HFA financial matters and was eventually elected treasurer of the practice plan. He showed great ability in this area and also became a participant in HFA politics. As mentioned, Miles Belgrade joined the faculty, and the pain program was flourishing although disadvantaged by marginal support for other providers from the hospital. Last but not least, Milt Ettinger's leadership became an increasingly important factor in the early life of the faculty practice plan. Milt served on both Board of Directors and its Executive Committee.

It was hoped that the University neurology struggles were over. After 6 years of interim leadership by Art Klassen, a permanent chair for the department was named in 1986. Dick Price brought with him or soon recruited a number of excellent faculty including: John Sidtis, a neuropsychologist and collaborator in investigating the neurologic aspects of HIV infection; Costantino Iadecola, a basic researcher-clinician with a focus in cerebrovascular physiology; Elizabeth Ross, another basic-researcher-clinician with a focus in developmental neurobiology and genetics; Robert Gross, an epileptologist and clinical neurophysiologist; Karen Hsiao, a basic researcher-clinician with focus on genetics and degenerative diseases especially prion-mediated disease; Chris Gomez, a basic researcher-clinician with focus on genetics and ataxia; John Day, a basic researcher-clinician with focus on muscle disease and neurophysiology; Kendra Peterson, a clinician trained in neuro-oncology; and John Corboy, a clinician trained in infectious disease. Dr. Price also brought David Rottenberg with him from Cornell-Memorial Sloan Kettering. Dr. Rottenberg's special interest was in brain imaging and positron emission tomography. He became director of the VA's PET service. The Price years began with turmoil as he discharged several long time support personnel who complained officially triggering an official investigation by the University. Also, relationships between the existing senior faculty and the new administration got off to a rocky start.

The residency had withstood the stress of uncertain leadership better than might be expected, although there was evidence of erosion of its reputation with fewer candidates, especially those training in the US, applying for training. We had also experienced the unpleasant and disruptive phenomenon of having unfilled slots after the match. Bob Roelofs was named program director prior to Dr. Price's advent. He was retained in this position in the new administration and provided needed stability and commitment. Frequent crises and chronically poor resident morale resulted from a continuing commitment to provide full house staff coverage for the four public teaching hospitals that had made up the program over the preceding 4 decades. The coverage needs were no longer in synch with the available trainees because of reduced numbers of non-neurology trainees on the neurology services and frequent holes in the neurology resident roster. For many reasons, it was perceived that the residency must be downsized. This would further stress the old coverage expectations. Dick Price was interested in retaining all hospitals in some capacity but there was concern about what role each hospital would play.

The department weathered the move from 33H to 32G. Neurosurgery shared the new unit with neurology. Although all trauma cases continued to be housed on the22s, non-trauma neurosurgical cases were cared for in the 14 regular beds and 4ICU beds on 32G. Neurology nurse supervisors included Bonnie Watkins, Kathleen Miller, and Shelley Gilbert. Other important contributors were Carole Ann Smith and Eileen Pouliot. After a sojourn in Rochester Minnesota, Mary DuPlessis-Tchida who had been supervisor of the neurology clinic in the late'80s, returned to become nurse supervisor of 32G. She further developed a crack unit of neuroscience nurses. Neurology continued to receive superb support from the social workers assigned to it by HCMC. These included Ed Biren and Bonnie Liesenfeld. Physician leadership in clinic changed from Barb Patrick to Miles Belgrade. Jan Schluter, whose activities in recent years had been in the Sleep Center, was recruited to become clinic administrator. Clinic volumes were little changed.

Other department areas were stable. Neuropsychology continued under Gail Risse's leadership. She was assisted by Sheila Cox. Elizabeth DeStafney and Janine Hawkins provided neuropsychometric support. Pat Wahoske's speech group left neurology for an independent status, emphasizing its multiple roles as a diagnostic and rehabilitative service. The neurodiagnostic laboratory group was unchanged with Katie Juhnke, and Linda Dagrude. Quality of work continued to be excellent. Kathy Hein's office secretarial staff functioned well although people came and went over the years.

1995-2000

Milt Ettinger became 65 in 1995. He announced his plan to retire as chief on that occasion well in advance. He recommended that David Anderson, who had been assistant chief after Al Rubens' departure, be made interim chief. A search was launched in early 1995. In September, David Anderson became permanent chair. Milt continued a small clinical practice in the sleep center.

Milt's last years before semi-retirement were enormously productive. He became the second Chairman of the practice plan, Hennepin Faculty Associates, in 199x, following Al Schultz. Milt brought mutual respect and civility to the leadership, where those operating principles had not always been followed. He was in yoke with President Fred Shapiro, an enormously creative, and talented but relentless physician-executive. Perhaps unexpectedly, the tandem worked extremely effectively, bringing to HFA stability, growth and prosperity and at the same time supporting continued and expanded academic excellence.

Three major faculty changes occurred in the department over this interval. Barb Patrick, a fine general neurologist, esteemed colleague and friend left to join Group Health as a staff neurologist. We felt the poorer for many reasons, including our new womanless status as a faculty.

Miles Belgrade was lured away by the Sister Kinney Institute at Abbott Northwestern Hospital to expand and diversify its pain program. There was discussion about what direction to take with Miles' departure. The pain program was a success within the bounds imposed by lack of other involved physicians and limited support for other essential providers. The institutional need was obvious but had been only partially met by the existing program. Now it would be significantly shrunken, because Miles would take with him Mark Roa, a talented biofeedback expert. Finally, the pain program had not been shown to be financially rewarding. On the other hand, the program played an essential role in the care of a particularly difficult patient group. Furthermore, a potential replacement for Miles was available. Al Clavel, a product of the residency program and previous private neurologist, had been a pain fellow in Mile's last year. The decision was made to continue the pain effort with Al as the new director of the Hennepin Pain Clinic. Al felt strongly that he must be supported by a psychologist and by a replacement for Mark Roa. Sue Breeden and David Belmore became members of the new pain program whose approach was based on the biopsychosocial model of chronic pain and whose special expertise was in myofascial mechanisms of pain.

After personal setbacks and minor professional scrapes, Gerry Slater left the department and HFA to make a new start as a private pediatric neurologist in Colorado. Steve Smith was increasingly active in neuromuscular activities, particularly muscle and nerve histopathology for which he had developed a well-deserved regional reputation. Hence there was no question that a replacement for Gerry must be recruited. Fortunately, Bob Kriel, expert physician, experienced clinical investigator, and respected teacher, was interested in leaving Ramsey Clinic Associates (RCA) for a new practice home. Bob, like many colleagues in RCA, was dismayed by internecine conflict within the practice plan and threats to and from the hospital. Seeking stability and a more peaceful work environment, he joined the department in 1990. He brought with him longstanding clinical and investigatory interests in childhood epilepsy and head injury. His academic productivity was uninterrupted and continued to be substantial.

The department veterans continued to be productive in diverse ways. Ron Cranford was heavily invested in biomedical ethics activities with a well-established national reputation. A less enviable facet of his fame was that it included being a lightning rod for those in the Right to Life movement; a special lock was installed on his office door to protect against mischief by zealots. He became assistant chief and clinic director when Dave Anderson became chief. Mark Mahowald was increasingly productive academically and in public service on behalf of the sleep disorders center and department. He became recognized nationally as a leading spokesperson for sleep disorders education and research. Fred Langendorf and Dave Anderson were awarded a National Institute of Drug Abuse grant in 19xx to investigate the effects of chronic cocaine use on brain volume and function. Recruiting suitable subjects proved to be rate limiting because isolated use of cocaine was uncommon among inpatients at collaborating treatment centers. Fred was named director of education for the department in 1995. Bill David and Fred developed a fellowship in neurophysiology with balanced experience in electrophysiology and electromyography with their first fellow, John Doyle. Bill was a collaborator in a new neuromuscular program set up as an HFA clinic. Steve Smith's activities at the University were curtailed with Bob Roelof's death in19xx and the evolution of a strong in-house neuromuscular group under the direction of Gareth Parry. Steve withdrew from the University neuromuscular activities devoting his energies to developing a new HFA Neuromuscular Center. With him came many loyal patients. Within the Neuromuscular Center, Steve setup a full-service, interdisciplinary clinic for ALS. Its excellence was recognized by accreditation through the ALS Society of America (ALSA), which has accredited only 13 such centers from around the country. Scott Bundlie increasingly became a mainstay in the service and teaching programs of the department. An outstanding general neurologist, he also participated in multiple subspecialty clinical programs including sleep and the Huntington's clinic.

The hoped for stability of the University neurology program was, unfortunately, not to be. By the early '90s, Dick Price had run amuck of many powerful medical school figures, foremost among which was Roberto Heros, Chair of Neurosurgery. Bright and creative as he was as an academician, Dick's leadership vision for the department was anachronistic in some respects; he saw it succeeding in traditional academic ways isolated from the other university departments. He believed that neurology's growing indebtedness was not his fault, and he took credit for the spectacular traditional successes of his brilliant young faculty contingent. Meanwhile, the medical school, the university hospital and the faculty practice plan were under siege because of medical market forces that made the academic medical center noncompetitive. Dick was not perceived as a team player in this time of crisis when different skills and leadership were required. It was a time when bold moves were in vogue, and Dick became victim of that mentality. He was asked to give up his chair. Moreover, the medical school determined that the search for a replacement would be internal, saving the expense of a national search. Candidates were Ken Swaiman, the interim chair; Gareth Parry, the residency program director recruited when Bob Roelofs became ill; Dave Knopman; Gary Birnbaum; and Manuel Ramirez. Eventually, Gareth Parry was named chair as 1996 began.

The residency, meanwhile, struggled in the early '90s, despite the strong leadership of Gareth Parry who made a number of difficult decisions based on educational rather than service considerations. Ramsey, later renamed Regions by Health Partners, was dropped from the regular rotation of residents. Recruiting, nevertheless, was increasingly a challenge. In part this reflected a national phenomenon. Neurology was less attractive for a variety of reasons: Primary care was at its zenith in popularity; neurology was perceived as overpopulated and underpaid. The growing proportion of international medical graduates filling neurology training slots was viewed as an indication of the noncompetitiveness of the field among US medical graduates. The Minnesota program filled each year, although barely and sometimes after the match, and IMGs became the majority of our residents. It is unfortunate and unjust that our trainee's ethnicities influenced how they and our program were perceived. Most were bright, hard working individuals that we could take pride in calling our own.

HCMC administration viewed the neurology service inpatient volumes, even with augmentation by the non-trauma neurosurgical cases, as inadequate to justify the costs of a separate unit on 32G staffed by its own nursing pool. A bitter pill was swallowed by neurology and Mary DuPlessis-Tchida's excellent neurology nursing staff in 199x, when 32g and the neuroscience ICU were closed. The nursing staff was dispersed among the other HCMC nursing pools. We thought at length about where our inpatient service should be. We felt a natural tropism for the medicine service; we shared a cognitive tradition with internists, and we knew and respected the HCMC medicine faculty. And we had long been involved in training the medicine residents. On the other hand, we valued our relationship with our neurosurgeon colleagues, Gaylan Rockswold and Tom Bergman, whose patients could not be dislodged from the surgery floors. We hoped to maintain and expand our interactions with the neurosurgeons. We believed that nursing expertise would be nurtured if surgical and medical neuroscience cases could be concentrated on the same nursing stations. Eventually we decided that we would throw our lot with the surgical inpatient services, using the SICU for our high intensity cases and the 22s for routine admissions.

Neurology clinic, meanwhile, was flourishing. Early on the faculty committed to providing continuity in follow-up, and each staff person had individual follow-up clinics each week. Consequently, although new patients continued to be seen by students and residents prior to staffing, only faculty saw follow-ups. Neurology clinic was one of the first to be run in this way in HCMC, although most followed as the hospital and practice plan gradually underwent metamorphosis from a resident- to a faculty-run institution. Neurology clinic was also a leader in using medical transcription for faculty notes. This initiative was pushed forward by Ron Cranford. The legibility of communications from neurology clinic became a matter of pride for us. Experienced and committed personnel under the supervision of administrator Jan Schluter facilitated clinic improvements. Shelley Anderson became the principal clinic nurse in 199x. Somehow Shelley was able to be both patient- and physician-advocate. She kept the best interests of our patients foremost but also eased the labors of residents and staff in clinic. She also developed expertise in subspecialty areas, especially pain management and epilepsy. Part-time participation of experienced neurology nurses Deloris Peterson and Paula Welna assured consistent high quality of nursing care. The Barbs (Mendes and Kangas) and Pat Higgens (after closure of 32g) continued as valued clerk-receptionists under supervision of clinic scheduler Alan Bernhardt. Finally, Bob Russell was the competent and helpful clinic nursing assistant, a patients' advocate and a cheerful workmate.

The neuro-diagnostic laboratory, also under Jan Schluter's administrative supervision, was staffed by Katie Juhnke, Linda Dagrud and Lori xxxx. The laboratory was increasingly involved in intraoperative monitoring for endarterectomy and spine surgery cases. The number of EMGs increased, while EEG activity stabilized. Evoked potential numbers dropped, probably as a result of the availability of MRI as a diagnostic modality in cases of possible multiple sclerosis. Service office personnel included Vickie Williams, Angie xxxx, xxxx, supervised by Kathy Hein.

While HCMC was unrivaled for its stated mission, its more conventional partner, Metropolitan Medical Center (MMC), attached Siamese Twin-like over Chicago Avenue, fell on hard times in the '80s, as the pressures of health care reform worked to reduce the number of inpatient beds available in the Twin Cities. A series of mergers and reorganizations ensued. Mount Sinai, a nearby hospital closed, and its business was shifted to MMC, which was renamed Metropolitan-Mount Sinai. That configuration proved unsuccessful, and in 19xx, Metropolitan-Mt. Sinai was closed, and the nearly empty building was put up for sale. The County bought the parts of the building most adjacent to HCMC, sections A, B and C, allowing welcome expansion, while the D section was purchased by HFA. An impact of these events on the neurology department was an increase in the size of its neuropsychology section. The old MMC had developed an excellent, KARF-accredited acute rehabilitation unit, the Knapp Rehabilitation Center (KRC). Though still an MMC program, KRC became HFA control when Steve Fisher became its director in 19xx. With closure of Metropolitan-Mt. Sinai, HCMC took over KRC, assigning its contingent of neuropsychologists to HCMC neurology. At about the same time, Gail Risse left HCMC and the department to join John Gates in launching a new epilepsy program, Minnesota Epilepsy Group. David Tupper was recruited to be the new director of an expanded HCMC neuropsychology section, which was to include Scott Miller, Jim Thompson, xxxxxxxx, and yyyy yyyy.

 Finding our way through the challenges of the last five years of the Second Millenium was made easier by the stability of the faculty over this era. David Anderson served as Chief, while Ron Cranford was Assistant Chief and Clinic Director. Mark Mahowald was Director of the Minnesota Regional Sleep Disorders Center and Sleep Disorders Clinic. Scott Bundlie was Director of Inpatient Neurology. Fred Langendorf was Director of Education for the Department, and he and Bill David continued to Co-Direct the Neurodiagnostic Laboratory. Al Clavel was Director of the Hennepin Pain Program. Steve Smith was Director of the HFA Neuromuscular Center. Bob Kriel was Director of Pediatric Neurology.

All faculty were involved in education and creative and scholarly activities essential to individual self-expression and the department's mission as an academic enterprise. David Anderson gave up his Directorship of Undergraduate Education at the University, but taught on site and served in education administration through the Academy of Neurology. Heal so continued to be involved in scholarship, participating in the wind-down of the Stroke Prevention in Atrial Fibrillation project. Ron Cranford was active as a widely respected expert in neurology-flavored bioethical issues and court cases. Mark Mahowald's international influence in sleep medicine continued to grow as did his scholarly productivity. He was promoted to full professor in1996. Scott Bundlie divided time between general neurology, especially stroke, and the sleep disorders center. His reputation as a talented and entertaining speaker grew locally and within the national sleep disorders set. Fred was involved in education activities on site and through the University. He was also organizer for the national meeting of the Society for Medical Problems of Musicians and Dancers for several years. His local reputation for thoughtfulness and fairness was reflected in appointment as Chair of the HCMC Institutional Review Board, bringing with it a stipend from the Hospital. Bill David spearheaded a department initiative to develop a steady influx of industry and other money to complement our income, the so-called "third stream” effort. The overall success was mixed through no lack of hard work on his part. At the same time, Bill forged strong working relationships with several other HFA faculty. These relationships are bound to bear fruit in the future in joint scholarly endeavors. Al Clavel began a database on Hennepin Pain Program clients. This should prove a unique resource, since few if any programs serve patients like ours. Steve Smith, along with Bill David, expanded the Neuromuscular Program, whose reputation for excellence made it formidable competition for the University's own neuromuscular program. Their efforts to become involved in multicenter trials were finally rewarded after several frustrating exclusions in favor of other local centers. Bill was asked by Gareth Parry to be program director for the newly ACGME accredited combined HCMC-Fairview University-VAH-Minnesota Epilepsy Group residency in neurophysiology. Bob Kriel's collaboration studying the efficacy of rectal diazepam for cluster seizures finished its work, and results were published in several journals, including the N Engl J Med. Bob also remained interested in pediatric head injury and authored an article about accidents related to automatic garage door openers.

Several part time physicians made important contributions over this era as well. Milt Ettinger saw patients in the Sleep Disorders Center where he was also willing, when asked, to listen and provide wise counsel. Steve Janousek, a well-regarded young pediatric neurologist member of Park Nicollet and later the Noran Clinic, was recruited to provide coverage for Bob Kriel when Steve Smith turned his full attention to developing the neuromuscular program. Steve Janousek started his own weekly clinic at HCMC and covered when Bob Kriel was away. Through Steve Janousek, Bob became a member of a cooperative of pediatric neurologists that cross-covered weekend call community-wide. This plan reduced weekend night call frequency, although call itself was more daunting when one's number came up. Steve Janousek fit the department's and HCMC's needs well. A natural and interested teacher, he became a very popular consultant and resource among the pediatric staff and trainees. Brent Clark took over neuropathology responsibilities from Angie Mastri and Joho Sung. High quality neuropathology conferences continued twice monthly.

Martha Nance became the third Director of the Huntington's Clinic in 199x (her predecessors were Milt Ettinger and Barbara Patrick). Martha was an ideal choice. She was trained in neurology and genetics and board certified in each. She had spent a year at HCMC in a general clinical fellowship in 199x-y, when she first became involved in the Huntington's Clinic. Thereafter she was a faculty member at the VA hospital and later joined the Park Nicollet group. That she remained committed to the Clinic despite her other responsibilities and changing circumstances is a tribute to her interest and sense of mission. Genetic testing became widely available at about the time that Martha became Clinic Director. In part through lessons learned at HCMC, Martha became an internationally recognized expert in the medical and bioethical ramificationsof genetic testing for Huntington's disease. She also became widely respectedfor her public service contributions to the Huntington's disease community through volunteerism in the Huntington's disease Association of America (HDA). Largely through Martha's influence, the HCMC model for interdisciplinary care for Huntington's families was adopted by the HDA in its initiative to improve services to its members by certifying and funding exemplary centers. HCMC's Center was the fifth to be certified by the HDA in 1999.

The University Neurology Department's circumstances improved under Gareth Parry's leadership, although the process proved painful. Finances were a major problem, in part because of longstanding fragmentation of patient care revenue, an important portion of which did not flow into the department itself but went to individual faculty members. Gareth undertook to fix the structural problems that complicated the department's financial status. His efforts were resisted by several powerful senior faculty members, who had been stalwarts of the department for decades. Although the problems were eventually corrected, the process caused dissention. The HCMC group was affected indirectly in 1997 by financial hard times at the University. Almost simultaneously in the late spring, Gareth was confronted by the need to cut his faculty's salaries and the loss of several residents from the program. To soften the blow to his own beleaguered staff who had just received bad salary news, he restructured the residency so that trainee coverage was uninterrupted at the University and VAH, while HCMC was left out.

Response to the crisis of May-June, 1997 was one of our department's better hours, although credit for a successful response is deserved not only by ourselves but by the larger HCMC community. In the aftermath of that time, we are more aware of our good fortune in calling HCMC home. At greatest risk in late May1997 was neurology's ability to maintain a 24h/day inpatient service, loss of which would have had significantly adverse financial ramifications for the department. Without neurology trainees, the traditional model of nightly in-house resident coverage on neurology was impossible, and daytime coverage would by necessity be quite different. To continue the service, several painful sacrifices were necessary. Most of our teaching conferences were discontinued. Staff agreed to assume a hybrid resident-staff role. The Department of Medicine through Chairman Bill Keane and Program Director Morrie Davidman offered backup medicine PGY2 resident night coverage for PGY1s and medical students who would carry the neurology beeper in house each night. The ER Department through liaison Michelle Biros agreed that ER residents and staff would call neurology faculty directly, a la private hospital settings, carryout recommendations from neurology, and arrange follow-up through neurology clinic, obviating the need for in house consultations at night. To facilitate care of our patients by this system, we developed standing orders and treatment algorithms for the common presentations to the inpatient service: ischemic stroke with and without rt-PA administration, intraparenchymal hemorrhage, first seizure, breakthrough seizure, anticonvulsant intoxication, and headache.

A second crisis which continued to play out through this era was departmental financial instability. The practice plan was unexpectedly successful in its first decade of operation. In that time of plenty, department shares of money for physician reimbursement were not tied to revenue generation but to academic productivity. With this system in place, strong patient care revenues plan-wide, and a sweetheart share of County pass-through money, neurology did well financially and physician salaries increased regularly through the early'90s. Even before mid-decade, HFA, like other physician groups, began to struggle. In response, the leadership determined that each department would be accountable for its own financial fate by restructuring the system by which money for physician salaries was distributed within the plan. Also for the first time, each department was held responsible for a component of its own facility expenses in the HFA clinics. In addition, annual distribution of County pass-through money was reformed using a formula that rewarded each department for current relevant activities. Finally, the number of providers in each department was carefully scrutinized in view of available revenue sources; "overmanned" departments were pressured to “right-size" by several incentives or be penalized. Neurology was adversely affected by these necessary interventions. Had they been enacted all at once and without accommodation for our circumstances, their effects would have been devastating. So far we have survived because of the unselfishness of the faculty, the wisdom of HFA leadership, and the beneficence of our HFA community. We paid for our survival by lower salaries than we could earn elsewhere in the community. We also accepted substantial departmental dependence on several revenue-generating activities, specifically the sleep and neurodiagnostic laboratories, and on the good will of other HFA departments. We also cut our costs in painful ways including reducing the size of the HFA neuromuscular program. As this era draws to a close, we hope that these and other responses will turn our fortunes around.

In1995, HCMC promised, as conditions of employment when David Anderson became chief, that neuroscience nursing expertise efforts would be concentrated on the22s and that communication between neurology and nursing would be facilitated by creation of a new position, a designated neuroscience resource nurse. HCMC was good at its word; promises were implemented by Nursing Administrator Chris Wolohan. Mary DuPlessis-Tchida was named neuroscience resource nurse in 1996. Scott Bundlie presented several in-service classes to the surgery-trauma-neuroscience unit nursing staff. Finally, the standing orders, developed in response to the resident shortage crisis of 1997, were applied. All of these had positive effects on the department's adult inpatient activities. Most important was Mary DuPlessis-Tchida, a highly respected, experienced, no-nonsense patients' advocate, who created speed and efficiency where they had previously been believed impossible. Also important for improved services were Social Worker Extraordinaire Brian McNeill and Nursing Supervisor Carolyn Schaust. Unlike the national trend of decreasing inpatient numbers, HCMC's admissions remained stable, although lengths of stay shorter, through the last years of the century averaging about 600 annually. Inpatient consultations as well as neurology service patients were combined to comprise the inpatient service, staffed by a single faculty member. Inpatient consults averaged about600/year. Typically, neurology service patients were staffed in the morning and consults in the afternoon.

In 1999, several intermediate level beds were opened on 22E. Neurology had lobbied long and hard for an intermediate unit for neuroscience patients. Many of our more seriously ill patients, such as those with strokes and seizures, would be more appropriately managed in such a unit than in the SICU, from which they were often "bumped" to accommodate more needful multiple trauma patients. The final impetus for opening the unit, however, was an acute hospital-wide need for such beds precipitated by a Twin Cities area hospital bed crunch compounded by chronically full HCMC ICUs. We made our case that, when the dust settled, the unit should be a predominantly neuroscience area, arguing that neurology had spearheaded the effort, prepared admission criteria and initiated staff training. While the unit is still new, experience to date has been positive in that there are usually beds available for appropriate neurology patients.

            Neurology outpatient activities became increasingly subspecialized during this era. Joining the existing HCMC subspecialty clinics (Pain, Huntington's, sleep) and the HFA neuromuscular center were several new clinics on the HCMC side: seizure clinic (Langendorf, Anderson, Kriel), neurogenetic clinic (Nance), and stroke clinic (Anderson, Bundlie). Also participating in the seizure clinic were nurse practitioner Beryl Westphal and Pharm D Jon Jancik. The interdiscplinary stroke clinic included representatives from physiatry (Ken Britton, SteveFisher, John Bower), neuropsychology (David Tupper, Jim Thompson), speech pathology (Lisa Wiktor), Brian McNeill and Mary DuPlessis-Tchida. Personnel in the existing subspecialty programs were fairly stable. An exception was the Pain Program where psychologist Sue Breeden was replaced by Shelley Curran and she, in turn, by Joan Callier. Beryl Westphal left the Pain Program to be nurse specialist in the Huntington's Center of Excellence. Rosemary Dulac, a Pharm D, joined the Pain Program on a part time basis. David Belmore continued as biofeedback technologist. Fixtures in Huntington's Clinic included neurologists Martha Nance and Scott Bundlie, psychologist Jeff Boyd, neuropsychologist David Tupper, speech pathologist xxx yyy, geneticist Carol Ludowese, chaplain xxx yyy, and advocate xxx yyy, research coordinator Dawn Radke and, of course, Beryl Westphal. Important contributors in the Neuromuscular Center were neurologists Steve Smith and Bill David, physiatrists Charlotte Rhoer and xxx yyyy, and nurse specialist Cathy Nowariak.

We hypothesize that service to patients with subspecialty problems improved with the advent of subspecialty clinics mainly because their interdisciplinary format simplified and facilitated management of complicated and chronic illnesses. Support for our hypothesis exists in the program databases, in various stages of operation, that track patient outcomes. On the other hand, the composition of general neurology clinics was affected adversely by the skimming away of patients. General neurology clinic became a predictable diet of back aches, headaches, and Medical Assistance forms.

            The neuro-diagnostic laboratory underwent several changes during this era. EMG operations were separated from EEG, and an experienced and talented EMG technologist, Rick Salxxx, was hired. Rick assisted Bill David and Rick Taylor of cardiology in establishing protocols for a joint autonomic assessment laboratory. Rick died suddenly and unexpectedly early in 2000, and to this point no replacement has been named. With the development of the seizure clinic, it was increasingly apparent that EEG video monitoring would be useful. The equipment, which arrived in early 2000, was to be deployed in the intermediate care unit. Meanwhile, routine EEGs, operative monitoring, and evoked potentials continue at about the same volume.

            When David Anderson became chief in 1995, he asked Kathy Hein (soon to become Kathy Jensen) to remain in a new capacity, department administrator, in recognition of her strong administrative skills, which had been further honed by graduate work. Perceived as invaluable as well were her long service in the department and her experience with, and knowledge of, the administrative operations of the County. Kathy accepted the invitation requiring a change in employer from Hennepin County to HFA. She tracked financial and volume data and tackle denumerable important projects that benefited the department. The service office staff was stable with the very able Ilene Kanne as lead secretary assisted by Terri xxx and xxx yyy of the neurodiagnostic laboratory.

            As the era drew to a close, our circumstances are in continuing flux. On the University side, Gareth Parry resigned as Chair in 1999. David Knopman has served as interim Chair prior to himself leaving the University to continue his career at the Mayo Clinic. The search for a permanent chair winds down as I write this. There is much for the new chair to tackle at home in the Fairview-University Hospital. The clinical enterprise, small in recent years, was further depleted by recent loss of respected clinicians, including Gareth Parry, Dave Knopman and Prafal Kelkar, who was the program director of the core residency. An important priority will be reestablishment of services to restore departmental clinical credibility and to facilitate clinical teaching. The HCMC staff's quality and stability are potential resources for the department at large at this time. Our fine faculty members, already fully committed in on-site activities, are well suited to assume roles in the larger department. Bill David, for example, is an excellent choice to take up program directorship for the core neurology residency with Prafal Kelkar's departure. Uncertain is how new leadership will view dispersal of department powers and prerogatives from the University group itself. Also uncertain is the ability of the HCMC group to assume new responsibilities given our financial circumstances.

Also in flux is the organization of HCMC's clinical services. The clinical departments and ancillary services have been reformatted into Clinical Business Units (CBUs): Surgery, Specialty Medicine, Primary Care, Behavioral Services, and Emergency Services. After much discussion, neurology was removed from the Specialty Medicine to the Surgery CBU. The rationale was to maintain our inpatient unit in the surgery-trauma-neuroscience area and to facilitate development of a neuroscience center of excellence by occupying the same CBU as neurosurgery. Neuropsychology has, however, been assigned to the Behavioral Services CBU. Otherwise, it remains to be seen what effects CBUs will have on the department.

            Inmid-2000 Steve Smith announced that he would be leaving HCMC after 26 years to join another pediatric neurologist in practice in Colorado Springs, CO. He will continue to read histopathology of muscle and nerve through the HCMC pathology department. Steve leaves behind an outstanding neuromuscular program and the accredited ALS Center. Bill David is the heir apparent to these programs. It is unclear whether Bill can cover the clinical load, particularly if he becomes involved in residency program directorship. We do plan to begin recruitment for a second predominantly or full-time sleep neurologist. It is not clear whether there are adequate revenues to support a replacement for Steve, in neuromuscular diseases.

Appendix I For 1966

Social Worker                                   K. Anderson              Full Time

EEG Technologist                           J. Markham                Full Time

1.5 Clerk/Typist                                R. Nichols                 Full Time

                                                            H. Scheibel               Full Time

8-10 Medical Students from the University of Minnesota Medical School assigned to Neurology for 10-week periods. At all times, we have medical students on the service as of September 1965.

Position Schedule summary - Present and Projected

Position                                                         Budgeted      Actual        Requested    Probable 

*Chief of Service                                                 1                 1                      1                  1

**Assist Chief                                                      0                  0                     1                  1

***Medical Instructor                                         1.5               1.5                  1.5                0.5

            (1full time, 2 quarter time)            

EEG technician                                                   1                 1                      2                  2

Clerk-Typist 1                                                      2               1.5                     2                  2

                           Total               5.5               5.0                  7.5                6.5

Total Salaries per 1966 salary schedule):   $53,838                                                $73,374

(If U of M supports 1 full-time Med Instructor position)$59,598

*Salary paid through University of Minnesota

**Salary to be paid through University of Minnesota

***Salary of full-time medical instructor paid through University of Minnesota; the two quarter-time positions are paid at HCGH.

Neurology Residents (per agreement of Affiliation with U of M

                                                                               Budgeted1966                    Requested1967

1 First year resident @$4,500                  

1 Second year resident @$5,000                                    3                                      3

1 Third year resident @$5,500    

Plus tuition @$524 x3                               

                                                                                                            Total$16,572

TOTAL NUMBER OF EEG'S PERFORMED

1954 299 (1/2 time technician)

1955 327

1956 429

1957 495

1958 506

1959 510

1960 701

1961 889 (full time technician)

1962 1082

1963 974

1964 1228

1965 1344

1 Technician

16 Grass EKG $10,250

1 Smith-Kline Echoline-20 Unit $6,900

In 1965, the hospital purchased a new Grass eight-channel machine to replace the unit that been in constant operation since 1948. This old unit was not considered useable and did not warrant repair.

Recommendations regarding future growth and development in this area include the obvious necessity at the present time of expanding our one-machine, one-technician operation to accommodate a larger number of patients and also to perform special procedures which are indicated from time to time in certain patients. I would recommend that we purchase a second EEG unit suitable for special EEG studies; this would be a 16-channol Grass EW machine. Also, that we hire a second full-time EEG technician. I believe these steps are necessary to keep pace with the increasing service obligation as well as the requirement for rendering the boat possible care to the patients in our hospital.

APPENDIX 2

Neurology Department

Hennepin County General Hospital

Physician staff

Position                                  Name                       Hours and Status

Chief of Service                 M. Ettinger                  Full-time

Instructor                              W. Riley                      Full-time

Ped-Neurol                         M. Blaw                       4hr/wk

Neuropathology                  E. Stadlan                    4hr/wk

*Attending (neuropath)      P. Silverstein              4hr/wk

*Consultant                         H. Noran                     6hr/wk

*Attending (EEG)               R. Stoltz                      4hr/wek, 4 mo/yr

*Attending                           H. Berris                     4hr/wek, 4 mo/yr

*Attending                           M. Hurr                        4hr/wek, 4 mo/yr

*Attending                           C. Baker                     4hr/wek, 4 mo/yr

*Attending                           L. Farber                     4hr/wek, 4 mo/yr

*Attending                           R. Galbraith                4hr/wek, 4 mo/yr

Neurology Resident           Vacant                        Full Time

Neurology Resident           J. Allen                        Full Time

Neurology Resident           F. Baren                     Full Time

Medical Resident               R. Stenlund                Full Time

Psychiatric Resident         Vacant                        Full Time

Neurology Intern                 Three                          Rotate every 25 days

*Voluntary Medical Staff

Nursing staff

Marolyn Olson

Dorthea Brumbough

Grace Edwards

J. Lindsoe

Lois Smith

Karen Matheny

Patrician Ramberg

Carol Cutsforth

Nurses Aides

Marianne Bergstrom

Rosalie Harris

Evelyn Patterson

Edith Franklin

Ellen Harris

Ward Clerk

Bette Doherty

Orderlies

Claude Micheau

Gerald Rieswitz

Gary Vick

David Bushard

Mark Virnig