In 1889, a young man named Emmet Rixford enrolled in Cooper Medical College in San Francisco. He quickly became a favorite of the college’s founder, Levi Cooper Lane, and was soon assisting Lane with surgeries. He’d sterilize equipment, sponge “generations of pus and blood” off his mentor’s apron, and sit up all night with post-operative patients, listening to vegetable-delivery carts rumble down Mission Street.
Rixford was also responsible for anesthesia. Using a mixture of alcohol, chloroform and ether, he’d put patients under—and then ventilate them when the concoction brought their breathing to a halt.
“Generally the slower of the externs was stuck, as we said, to give the anesthetic,” he wrote in the Journal of Western Surgery in 1933, adding wryly, “In this way, I had personally a very large experience in administering anesthetics.”
The young doctor’s account is one of the few mentions of anesthesia services in the days before Cooper Medical College became the Stanford School of Medicine. After that merger in 1908, anesthesia would evolve into its own division with six specialist physicians. But one thing remained the same: Anesthesia would remain under the domain of surgery.
In 1959, all of that was set to change. The medical school’s transition from San Francisco to Palo Alto was shaking up the faculty, and the anesthesia division of the surgery department needed a new leader. The only problem? None of the candidates were interested in playing second fiddle to surgery. The pressure was on for the school to give anesthesia a department of its own.
Building a Department
Dr. John Bunker was a visiting professor at University of California, San Francisco when the Stanford Chief of Surgery offered him a job as anesthesia division head. Bunker agreed—with one condition. “I said I would accept if anesthesia was a separate department,” Bunker says.
It wasn’t the first time that demand had come up. The school’s first candidate for the job had dropped out of consideration because the school refused the same request. This time, perhaps realizing that no top-tier candidate would settle for division head when they could be department head somewhere else, the school gave in. The department of anesthesia was born.
Settling into the new Palo Alto location was like building a medical school from scratch, Bunker remembers. He set to recruiting faculty, and with the help of new researchers like Richard Mazze and Ellis Cohen, grant dollars began to roll in.
But a growing research department created new challenges. Anesthesia had only a small, inadequate laboratory, Bunker says, and even that was under threat. One day, he recalls, famed urologist Dr. Thomas Stamey came to him and suggested that urology needed that lab space more than anesthesia. The memory of that skirmish still makes Bunker laugh.
“You can imagine how far he got with me,” he says. After 12 years of building the department, Bunker stepped down to focus on his research in surgical epidemiology. He’d stay with the department until 1989, serving again as an interim chair from 1983 to 1985, before leaving for the University College London Medical School.
Putting Patients First
After Bunker stepped down, Dr. Philip Larson, an alumnus of the Stanford undergraduate program and a McGill-educated anesthesiologist, took over the job. While his predecessor had focused on research, Larson had his heart set on turning Stanford anesthesia into a clinical crown jewel.
“I was hired to develop a better balance between research and clinical care,” he says. “They didn’t have hardly any residents, the clinicians who were there were pretty much people who came for a year and went, and there wasn’t much focus on the clinical service.”
Larson quickly took over administration of the Intensive Care Units, redesigning the floor plan for extra efficiency and hiring Dr. Myer “Mike” Rosenthal as medical director of the new adult ICU. Along with other faculty including Dr. Aubrey Maze and Dr. Al Hackel, Larson helped develop a pediatric ICU. He also oversaw the development of sub-specialties in the department, including neurosurgery, pediatrics and cardiac anesthesia. Throughout it all, Larson dealt with the challenge of working in a shared space with two private anesthesia groups that occasionally lured away his staff with better pay.
Under Larson’s reign, the department also opened a pain clinic and gained “superb” residents and faculty, Larson says. Having transformed the clinical side of the department into a force to be reckoned with, Larson stepped down in 1982 and stayed on as emeritus chair — “the easiest job in the world,” he jokes — until 1993, when he went on to revitalize the anesthesia department at UCLA.
Finding a Middle Ground
Dr. Ellis Cohen and Bunker served as interim leaders while the school searched for a new chair. In 1985, the school hired Dr. Barrie Fairley from his post as Chief of Anesthesia at the San Francisco General Hospital. Fairley’s goal was to find the middle ground between research and clinical care, balancing the two missions of the department. Fairley also oversaw the department’s move into the new Stanford hospital in 1989 and the repurposing of their former quarters in the Grant building into laboratory and office space.
“We moved into nice new shiny, spacious space with a good recovery room facility, with good preoperative space,” Fairley says. “It was remarkable.”
It was also a time of big technological changes, both in medicine and in general. New therapies and diagnostic tests meant anesthesia had a growing role outside the operating room. The increasing complexity of the field led to a nationwide change in anesthesia training from an internship plus two years to internship plus three, completely revamping the way Stanford trained residents. The department got its first personal computers in 1986, and their 10-megabyte hard drives seemed revolutionary.
Outpatient surgery was booming, and thanks to a move to shorten hospital stays, even patients facing major surgery would arrive on the same day as their operation. In response, the department opened a pre-anesthesia clinic where patients could come in the days before surgery for anesthesia evaluation. Stanford started performing liver and kidney transplants, creating new anesthestic challenges. And Lucile Packard Children’s Hospital opened in 1991, skyrocketing the number of pediatric anesthesia cases.
In other words, it was a busy seven years, and by 1992, Fairley was ready to retire. He went back to school to get degrees in Spanish and Latin American History, completing a bilingual Master’s thesis on anesthetics used by the Incas 400 years before anesthesia was officially discovered.
Dr. Frank Sarnquist served as interim Chair for several months until Dr. Donald Stanksi from the Palo Alto Veterans Administration Medical Center took over the department.
Stanski’s five-year tenure was a time of great growth. Research boomed, and at the Palo Alto VA and the labs of Drs. Mervyn Maze, Steven Shafer, David Gaba, Steven Howard, Jeffrey Baden, Richard Mazze and Susan Rice became internationally competitive.
“It was a remarkable growth period for integrated basic to clinical research,” says Maze, who was vice-chair for research in the Stanford Anesthesia department during the 1990s. “There were numerous discoveries that started in the basic arena and became commonplace in clinical medicine.”
In spite of these successes, the five years that Stanski spent as chair were a particularly challenging period in the school’s history, thanks to financial hardships and complaints of gender discrimination in various departments throughout the hospital.
In 1997, Stanski moved on to become vice-president of scientific and medical affairs at Pharsight Corporation, which provides software and consulting expertise to pharmaceutical start-ups. He later became Chief Medical Advisor at Rosa Pharmaceuticals. Meanwhile, Sarnquist took over the department yet again while the Dean conducted a new search.
During this tumultuous time, the anesthesia field was in the midst of an identity crisis. Popular opinion held that medical treatments would soon defeat infectious disease and negate the need for surgery. Dire predictions about the future of anesthesia hit the front page of the Wall Street Journal in 1995. Medical school deans warned students away from the field, and private practitioners believed the hype and stopped hiring.
The hysteria reached a high point in 1996, when only 169 U.S. medical school graduates applied for over 1,000 residency slots in the country.
“The Wall Street Journal article was the real nail in the coffin,” Sarnquist says. “Every hip medical student who was thinking about making the big bucks just read in the bible of big bucks that there wouldn’t be any jobs. The whole thing was just nonsense.”
The lack of applicants crippled anesthesia research programs across the country. Stanford was spared the worst of the fallout, thanks to its attractive location in Silicon Valley at the height of the tech boom, but it was a struggle. At the same time, hospital-wide financial difficulties led to a costly merger attempt with UCSF that eventually failed.
“We made it through quite well, though not perfectly well,” Sarnquist says. “If someone were to ask me my best accomplishment as Chair, it was that I managed to keep a scientific program at Stanford going during that time.”
After the challenges the department had faced, “I saw my job basically as getting the department to function as a team again,” Sarnquist says.
Taking the Next Step
Chair came to an end, and Dr. Ronald G. Pearl took over leadership duties from Sarnquist. Pearl had been at Stanford since his residency in 1977. As Chair, he inherited financial troubles stemming in part from the anesthesiologist shortage of the previous years. Research needed strengthening, and the clinical program needed more faculty. Pearl was able to get financial support from Stanford and Lucile Packard Children’s Hospital to put toward these goals.
“During the past 11 years or so, we’ve had tremendous clinical growth,” Pearl says. “Pediatric anesthesia has probably more thanof time, and basically everything has grown. We have also had great expansion in research in terms of grant money, in terms of publications, and in terms of faculty involvement, particularly on the translational research side.”
“Ron Pearl has really been the one that has taken Stanford to the next step, and that is the national and international recognition of a truly full and complete academic department that deserves to be recognized among the top five in the country,” says Rosenthal, who has known Pearl since his residency days. Pearl’s leadership has earned him praise outside of Stanford as well.
“He’s well-respected and well-liked,” says Dr. Mervyn Maze, who now heads the UCSF anesthesia program. “I have seen what an effective leader he’s become of a stellar department.”
Growth has brought its own set of challenges, including the perennial space constraints that would sound familiar to Bunker and his staff of 50 years ago. But the strengths of the department have also remained consistent, Pearl says.
“Things which have remained constant are the quality of the people, which has been superb, and their real dedication to the department and to Stanford,” Pearl says.
Over five decades, the anesthesia service at Stanford has evolved from a band of a dozen doctors to a thriving department with over 200 faculty, staff, fellows, residents and interns. In Emmet Rixford’s day, anesthesia may have been a task for “the slower of the externs,” but today, it’s one of the most coveted careers in medicine. And while Stanford’s department of anesthesia may have started as a subdivision of surgery, it has established itself as a national leader in teaching, research and clinical service. Not bad for a mere 50 years.