Cover Story
A Neurologist's Legacy
How A.B. Baker helped make Minnesota a national player in neurology.
By Kate Ledger
Throughout medical school in her native Spain, Paula Martinez, M.D., felt drawn to the field of neurology. As she began to plan her career, she considered where in the world she might go in order to do brain research. Even from where she studied in the sunny city of Córdoba, Minnesota was on her radar.
What caught her attention first was the research being done here. While reading about drugs capable of crossing the blood-brain barrier, Martinez homed in on a mention of the Alzheimer’s Research Center at Regions Hospital in St. Paul. She moved to the Twin Cities nine years ago after medical school to do studies at the center, which conducts research on new drug-delivery systems. Realizing she missed patient care and well-aware of Minnesota’s strong tradition in neurology training, she decided to do a residency. Four years ago, Martinez was pleased to match at the University of Minnesota. “There’s great opportunity here, many different hospitals and many different types of cases,” she says. Now, she’s working on a fellowship in clinical neurophysiology at the university, and applying diagnostic techniques such as electromyography to neuropathies and degenerative diseases such as ALS.
The clinical and research environment Martinez found in Minnesota, with depth in a range of neurology subspecialties, was more than a century in the making. “The quality of neurology practice in the state is extraordinarily high,” says David Anderson, M.D., who’s served as chair of the University of Minnesota’s neurology department for the last nine years and will leave the post this year. “In both academic centers and in the community, we have strong programs in general neurology and stroke, epilepsy, geriatric and behavioral neurology, multiple sclerosis, and peripheral neurology. Essentially all the neurology subspecialties are well-represented.”
The state boasts two renowned academic training programs—the neurology department at Mayo Clinic has been ranked No. 1 by U.S. News and World Report since 1992 and has one of the largest neurology residency programs in the United States, and the University of Minnesota is widely known for its rigorous training program and for its ongoing research on conditions such as Alzheimer’s disease, muscular dystrophies, stroke, autonomic disorders, Parkinson’s disease, and inherited ataxias. (Both institutions’ residency programs were among the first in the United States to be accredited.) In addition, nearly 300 neurologists are practicing in Minnesota—that’s more per capita than in most states, according to the American Academy of Neurology, and a number of hospitals have strong neurology departments: Mayo Clinic was rated first in the nation in neurology and neurosurgery by U.S. News and World Report last year; Abbott Northwestern Hospital was ranked 31st, and the University of Minnesota Medical Center-Fairview and United Hospital in St. Paul were among those that also scored highly. The state has several large, vibrant private neurology practices as well. “There is competition,” Anderson acknowledges, “as everyone strives to be great.” Minnesota also is home to a number of national and regional neurology societies that were either founded in the state or have relocated here. Much of this activity can be traced to the influence of one powerful and enterprising figure, A.B. Baker.
The Power of One
Minneapolis-born, Abe Baker was a whip-smart student, who received his bachelor’s degree from the University of Minnesota in 1929 at age 20. Within three years, he had attained three more degrees from the university, including a master of science degree, a medical degree, and a doctorate in neuropathology. By the 1940s, he was already a professor of neuropathology and neuropsychiatry at the university and had an impressive track record in research, having isolated a virus that causes hemorrhagic encephalitis. In 1947, he became head of the division of neurology within the department of neuropsychiatry. But even before he assumed a leadership role at the university, Baker had begun to make an impression felt beyond the walls of the institution.
As soldiers returned from the war, he began thinking about the role that neurology could play in rehabilitating disabled veterans and established one of the first programs for chronically disabled patients at the Veterans Affairs Medical Center in Minneapolis. It was an approach that caught on nationally, leading to the expansion of the field of rehabilitation and the establishment of departments of physical medicine and rehabilitation at medical schools throughout the country.
Baker went on to edit a neurology reference text, the first of its kind for the field in the United States. When it was finally published in 1955, the three-volume Clinical Neurology was highly sought after; he published a four-volume second edition in 1962.
A dedicated, vociferous instructor who prepared meticulously and worked tirelessly, Baker was known—even by students far beyond neurology—for his commanding personality and high expectations. “His system of problem solving was not unique, but he taught it with greater passion and effectiveness than almost anyone,” Anderson says. “The medical school’s generic graduates were better neurologists than many specifically neurology-trained products of other schools. The medical school attracted more than its share into the specialty.” In fact, the department went from having one trainee at the time Baker arrived to having more than 20 within two decades.
Years later, Baker would give a talk to the American Neurological Association describing how neurologists had been trained up to that point: “Formal coursework of any type was almost nonexistant. The entire program was carried out by the professor and the trainee [who] … was expected to acquaint himself with all aspects of neuropathology and neuroanatomy—mostly by personal instruction and through the diligent use of the library. … Basic clinical orientation was often obtained from reading.”
Baker was a strong believer in bedside teaching and was known in particular for his thorough methodology for diagnosing a patient. “Abe taught a system for analyzing clinical information that pretty consistently led to the diagnosis,” remembers Anderson, who entered medical school in 1965 and had Baker as an instructor for clinical neurology. “He taught us to localize the lesion in the nervous system and classify it as focal, multifocal, or diffuse. Then he taught that we should consider the onset and course of the symptoms and the nature of the patient, including age, gender, and medical risk factors. Then we could develop a differential diagnosis that generally included the actual diagnosis. This process was for me and my colleagues incredibly interesting, intellectually satisfying, and it ultimately helped us be good doctors for our patients.”
Anderson was one who returned to Minnesota after a residency in medicine at the University of Rochester in New York to continue training in Baker’s department. He remembers how along with Baker’s passion came a demand for excellence. “I remember being awed and afraid. He was a small man physically, but very powerful, and he made his trainees want desperately to please him. … We all did our best. He held an 8 a.m. Saturday morning, two-hour session. Nobody dared ever not go.”
Neurology expanded at the University of Minnesota with Baker as division head. He established the residency program, which was accredited in 1958. Neurology became a full-fledged department in 1969 with expertise in neuropathology, electrophysiology, neurochemistry, and electromyography. The research space grew from a single room to an entire corridor.
During his tenure, the VA Medical Center, Ancker Hospital (which would later become Regions Hospital), and Minneapolis General Hospital (now Hennepin County Medical Center) became affiliated with the university as training sites. The new full-time neurology staffs at those institutions all felt the guidance and direction of Baker’s team. “His local legacy was an extremely high level of neurologic sophistication in the community,” Anderson says.
High Society
The contribution that was most widely felt was Baker’s work to establish a national society for neurologists. At the time, the American Neurological Association was the sole professional organization of its kind in the country, and it had a reputation of being restrictive, even elitist. To join, physicians had to present a thesis that was voted on by members, typically East Coast and European neurologists. “It was a dead-man’s-shoes organization,” says Case Western Reserve University neurologist Robert Daroff, M.D., who served as a president of the society in the 1990s. “Somebody had to die for you to get in.”
When one of Baker’s neurology residents, Joseph Resch, M.D., pointed out that no society existed for young physicians to learn from others in the field, Baker rallied supporters from three other Midwestern medical schools, and together they established the American Academy of Neurology in 1948. It was created as “an egalitarian organization,” says retired Minneapolis neurologist James Allen, M.D. It provided continuing education, holding annual meetings at which new research findings were presented. It drew in young clinicians and established a much-needed professional network. Baker served as its president for its first two years. Throughout the decades, the academy produced several publications: Two that exist today are Neurology, the most widely read peer-reviewed journal in the field, and Neurology Today, a newsletter that highlights scientific advances for a more general readership.
It also provided a platform for advocacy. On the academy’s behalf, Baker went to Washington to lobby for the establishment of a neurological division at the National Institutes of Health (NIH). The National Division of Neurology and Allied Diseases (now the National Institute for Neurological Disorders and Stroke), formed in 1950, became only the third medical division within the NIH and was considered a surprising addition, given that the field had fewer practitioners than most other specialties. Baker had put Minnesota on the national neurology map. “He really brought recognition to the hinterlands from the coast,” says Anderson.
Lasting Influence
Baker recognized the wealth of expertise that surrounded him. He recruited neurologists from Mayo to build his program at the University of Minnesota. In 1964, he brought William Kennedy onto the faculty. Kennedy had trained in the department chaired by Edward Lambert, M.D., a pioneer in electromyography (EMG). His charge at the university was to establish EMG and neuromuscular histopathology services. Kennedy went on to discover a rare, genetic neurological condition known as Kennedy disease, which he found by tracking church records at St. Paul Cathedral, analyzing medical histories, and corroborating birth and death dates with gravesites in the state.
Baker retired in 1977 and died in 1988, but there’s no doubt his enterprising spirit has continued to have an effect on the field. During his career, Baker taught hundreds of neurologists, many of whom went on to become department heads at institutions around the country. The American Academy of Neurology has become the largest organization for neurologists, with more than 22,000 members from all over the world.
What’s more, some of the state’s neurologists have also followed in Baker’s footsteps, continuing to think about the needs of their field on a national level. In Rochester, the American Association of Electromyography and Electrodiagnosis was established in part by Mayo neurophysiologists in 1953. (Today it’s called the American Association of Neuromuscular and Electrodiagnostic Medicine, publishes the journal Muscle and Nerve, and has an independent credentialing board for physicians who use electrodiagnostic techniques.) Another national society was conceived when Kenneth Swaiman, M.D., who trained under Baker as one of the first pediatric neurologists, recognized in 1971 that there was no organization for specialists like him. “I went to the meetings, and I knew there were pediatric neurologists there, but we didn’t know each other,” he says. He sought support from colleagues, polled physicians, and a year later established the Child Neurology Society, also in the Twin Cities.
Over time, the presence of the American Academy of Neurology ultimately brought additional national neurology societies to Minnesota. The ANA, which had been located on the East Coast since its establishment in 1885, moved its quarters to Minneapolis in 1984. “There was already a critical mass here,” points out Swaiman, who practiced at the University of Minnesota until he retired 10 years ago. The area also became home to the American Society of Neurorehabilitation, the American Society of Neuroimaging, and the Association of University Professors of Neurology, the academic arm of the field.
In more modest ways, Baker’s ingenuity touched physicians in private practice throughout the state. The Minneapolis Clinic of Neurology and Psychiatry was cofounded in 1955 by Baker protégé Joseph Resch, who would come back to lead the university’s neurology department after Baker retired. But the clinic, which eventually focused on neurology, would continue to grow ambitiously. By the 1980s, it had nearly 20 neurologists on staff, making it at the time “one of the largest neurology practices in the world,” says Allen, who joined and led the practice that came to be known as the Minneapolis Clinic of Neurology. Also a trainee of Baker’s, Allen points out that the practice’s leaders ascribed to the idea that it wouldn’t do to simply sit and wait for patients. The clinic was first located in Minneapolis in the Medical Arts Building. As the area’s hospitals moved out toward the suburbs in the 1960s, the clinic bought land and built a facility in Golden Valley and slowly began opening satellite offices in suburban areas including Edina and Burnsville. “The idea was to be where the patients and the referring doctors were,” Allen explains.
By the 1970s, the clinic began offering its services to more distant outposts, sending a neurologist once a week to see patients at St. Cloud Hospital. “Other communities started approaching us,” Allen says, and the clinic began flying a practitioner one day a week for outreach services to rural towns in Minnesota, South Dakota, and Wisconsin. “It was unusual,” he acknowledges, noting that the clinic served as many as 30 sites, “but for a small town, where it wasn’t feasible to have a neurologist, it was a way to get much-needed services. It was also helpful for farmers who didn’t want to drive into the big city.”
Over time, private clinics began to recruit subspecialists to treat specific conditions, building expertise within the practices. “So in the community practices around the state,” Allen says, “there continue to be strong programs in treatment of stroke, epilepsy, peripheral neuropathy, muscular dystrophy, and other conditions.”
The Future Meets the Past
The field of neurology has undergone major changes since Baker’s time. Neuroimaging techniques such as CT and MRI are able to detect pathologies that previously couldn’t be seen. New drugs are available to treat conditions such as epilepsy and Parkinson’s disease. “We can do more for patients than ever before,” acknowledges Swaiman.
At the University of Minnesota, the teaching of new neurologists is forward-looking and focused on finding even better ways to diagnose and treat patients. But it also involves taking stock of the past. Much about the history of the department is now available on the website of Kennedy’s lab (http://kennedylab.med.umn.edu/HistWeb/template.php?page=home), including speeches by and eulogies of some prominent historical figures. Kennedy has also been part of a recent effort to hang portraits of Baker and of some of the other founders of Minnesota neurology on the walls within the department. “They’re people who can inspire the new residents in the field,” he says. “It’s good to look up and see those figures and remember how it started.” And, he adds, “it’s like peer pressure. The message to them is, now it’s your turn.” MM
From “Nervous Diseases” to Neurology
The story of how Minnesota became an incubator for the field of neurology doesn’t start or end with A.B. Baker. It began more than a century ago, with a general practitioner named C. Eugene Riggs, M.D. Born in Ohio, Riggs trained to be a physician in Nashville and Baltimore, and then in Europe, where he took courses in nervous diseases. He came to Minnesota in the early 1880s. Like other doctors of his time, he was a general practitioner who also volunteered his teaching services at a medical college. But Riggs maintained his deep interest in neurology and psychiatry and became the first instructor in those fields at St. Paul Medical College. (He’s been referred to as the first neurologist of the northwest.) When Minnesota College Hospital formed in 1888, he became its first instructor of nervous and mental disorders, working within the department of medicine. He went on to cofound and become the first president of the Minnesota Neurological Society in 1909. So dedicated was Riggs—who attained membership in the prestigious American Neurological Association—that he gave teaching hours freely for the next 25 years.
At the time, physicians who dealt with matters of the brain were trained in both neurology and psychiatry. “But neurology was a relatively new field, so they earned a living practicing psychiatry,” says William Kennedy, M.D., who came to the University of Minnesota as a young neurology faculty member in 1964 and has compiled some of the early history of the state’s neurology tradition. In 1905, Arthur Hamilton, M.D., a Minneapolis private practitioner in the two fields, was recruited to the university to teach neuropathology and a year later expanded the curriculum to include clinical courses in nervous and mental diseases. One of his students was Henry Woltman, M.D., Ph.D., who in 1930 became one of the early heads of the section of neurology and psychiatry at Mayo Clinic.
In Rochester, neurology had been seeded in 1913 with the recruitment by the Mayo brothers of Walter Shelden, M.D., an internist who had practiced in Minneapolis and had taught at the University of Minnesota. Shelden had a special interest in neurology. At the time, neurology at Mayo “had its base in internal medicine,” notes Mayo neurologist and neurology history buff Christopher Boes, M.D. “It was a little bit different from other places outside of the Midwest, where neurology tended to be done in a neuropsychiatric hospital separate from the general medical hospital.” But even under Woltman, the section remained staunchly associated with the department of medicine, Boes says. “Neurology at Mayo was always wherever the sick patients were.”
New developments arose at Mayo that would have worldwide impact. One researcher, Edward Lambert, M.D., Ph.D., was recruited in 1943 to study how g-forces cause pilots to pass out. He invented many tricks—still in use today—to prevent blackouts. After the war, Lambert made his mark investigating neurophysiology testing. He became a pioneer in electromyography, establishing Mayo as a critical EMG presence in the state and country. Those techniques enabled him to help identify a rare impairing autoimmune disease that was named Lambert-Eaton myasthenic syndrome and also Lambert-Brody myopathy.
In the Twin Cities, another Hamilton protégé, John Charnley McKinley, M.D., had a different vision for the future of neuropsychiatry. A big thinker who had a career-long devotion to treating the mentally ill, he rose to the position of chief of internal medicine at the University of Minnesota. But his plan was to separate neuropsychiatry from medicine. McKinley was jointly responsible for creating the Minnesota Multiphasic Personality Inventory, the MMPI, an exam still used to measure emotional stability and psychopathology. He managed every stage of the construction of a new psychiatric patient unit. Then, when his tenure as chief ended, McKinley set his aim on creating a department of neuropsychiatry separate from medicine in 1943. He went on to become head of that department.
When McKinley suffered a stroke four years later, A.B. Baker became head of the neurology division within McKinley’s department and put his stamp on the field and the practice of neurology in Minnesota. Since then, the field itself has gone through significant changes. “Neurology went from being a very esoteric specialty, where it just gave names to diseases, to one that was very practical, involved in treatment, and much more patient-oriented,” says retired Minneapolis neurologist James Allen, M.D.
In clinical diagnostics, the EMG lab Lambert established at Mayo Clinic nearly half a century ago has become the largest in the United States, conducting more than 15,000 studies a year to diagnose problems such as carpal tunnel syndrome and pinched nerves. And there continue to be important research collaborations between neurologists at the university and Mayo, including significant projects on Alzheimer’s disease. One important one involves University of Minnesota researcher Karen Hsiao Ashe, M.D., a recent inductee to the Institute of Medicine, and Ronald Petersen, M.D., Ph.D., director of Mayo Clinic’s Alzheimer’s Disease Research Center, who have collaborated on studies of a mutant protein that may be responsible for Alzheimer’s disease.
Says Kenneth Swaiman, M.D., a retired pediatric neurologist from the University of Minnesota: “It’s an exciting time to be in neurology, and Minnesota happens to be a great place to be."
Kate Ledger is a St. Paul freelance writer and frequent contributor to Minnesota Medicine.