May 31, 2012 - By Kris Newby
John Bunker, MD, a pioneer in evidence-based medicine who early on warned of the pitfalls of the U.S. medical system’s fee-for-service payment method and the founder of the Department of Anesthesia at the Stanford University School of Medicine, died on May 4 in London of multi-organ failure and other causes. He was 92.
Bunker, professor emeritus of anesthesia and of health research and policy, was best-known for initiating the first epidemiologic study of surgical mortality, and for leading the study group that produced the landmark book Costs, Risks and Benefits of Surgery. “Bunker’s bible,” as it was nicknamed, provided surgeons with easy-to-use tables and decision trees that summarized mortality rates, age-related risk assessments and quality-of-life impacts for the most common surgical procedures. It also served as a cautionary tale for hospitals, insurers and policy-makers, warning of the risks of widely adopting new surgical procedures before outcomes were adequately understood.
“Bunker had the courage to raise cost and safety questions that previously had not been studied, and anesthesia, surgery and patients are far better off for his leadership,” said Alain Enthoven, PhD, the Marriner S. Eccles Professor Emeritus of Public and Private Management and a core faculty member at Stanford’s Center for Health Policy.
Bunker’s early research focused on the effects of anesthetic agents on the liver, and in 1963 he published a study in the New England Journal of Medicine suggesting that an unusually high number of deaths due to toxic hepatitis may have been caused by use of the then-new anesthetic, halothane. This landmark study led to his appointment chairing a subcommittee of the National Halothane Study, sponsored by the U.S. Department of Health, Education, and Welfare, where he worked with a team of statisticians, epidemiologists, pathologists and internists to analyze data from almost 900,000 surgical patients in 34 hospitals. The result was the first set of guidelines for defining safety limits for the use of halothane and other anesthetic agents.
He also assembled a large body of data on operations and operative mortality, questioning the high rates of surgical procedures in the United States and suggesting that financial incentives could be unduly influencing medical decision-making. Some of his seminal ideas were outlined in his influential paper titled, “Surgical manpower: A comparison of operations and surgeons in the United States and in England and Wales,” published in the New England Journal of Medicine in January 1970.
In this article he wrote, “Fee for service may tend to increase the number of operations in cases in which indications are borderline,” and, “Prepaid group [medical] practice halves the numbers of operations and surgeons.”
These and other works made him an early champion for a health-care system with salaried physicians and clinical decisions driven by evidence-based studies, which seems particularly relevant today, as the U.S. government grapples with ways to stem the country’s rapidly rising health-care costs. Indeed, Bunker was at the forefront of the drive to inform clinical practice with thorough external data reviews, encouraging practitioners to supplement their individual expertise with knowledge of systematic research. This evidence-based-medicine approach has in the last few decades become a linchpin of the U. S. health-care system.
Bunker earned his undergraduate and graduate degrees from Harvard University, graduating from medical school in 1945. From 1946 to 1947 he served in the U.S. Navy as a surgeon in China and Guam.
After returning from the war, he worked in the anesthesia research program at Massachusetts General Hospital under Henry Beecher, MD, the renowned scientist who championed the federal rules on human-subject research and obtaining informed consent from those who participate in clinical research studies.
In 1960 Bunker moved to Stanford to become the founding chairman of the Department of Anesthesia, which had previously been a division of the surgery department.
While running the anesthesia department, Bunker worked on studies of acid base balance, citric acid intoxication and the metabolic effects of blood transfusions. He wrote several books, including The Anesthesiologist and the Surgeon: Partners in the Operating Room, which documented his relationship with Norman Shumway, MD, the heart transplantation pioneer and professor of cardiothoracic surgery. He also explored ways to recruit more women in medicine, suggesting reforms in the NEJM editorial, “The case for more women in medicine: The Stanford program.”
Bunker’s passion for anesthesia safety, surgical manpower and operative mortality eventually led to his resignation as chairman of anesthesia so he could pursue an opportunity to serve as a visiting professor in the Department of Preventive and Social Medicine at Harvard Medical School in 1973. During his time at Harvard, he worked with eminent statistician Frederick Mosteller, PhD, and published his third book, Costs, Risks and Benefits of Surgery.
In 1975, he returned to Stanford, playing an active role in the Department of Anesthesia Pain Clinic, as well as serving as the acting head of the department. Together with other health-care policy experts, including Enthoven and Harold Luft, PhD, Bunker published an additional 26 papers in the field of epidemiology. This work provided the intellectual foundation for Stanford’s Health Research and Policy Department, which was founded in 1981 with Bunker as a faculty member.
“John Bunker’s passion and energy revitalized health services research at Stanford. Under his leadership, the teaching and research programs expanded; he helped lay the groundwork for the current Department of Health Research and Policy, which includes biostatistics and epidemiology, as well as health services research,” said Victor Fuchs, PhD, the Henry J. Kaiser Jr. Professor Emeritus.
In 1989, Bunker was named an emeritus professor of anesthesia and of health research and policy at Stanford.
In later years, he retired to England as a visiting professor in the Department of Epidemiology and Public Health at the University College London Medical School, where he continued to write and direct research studies.
During his final days, his daughter, Jane Bunker, said Bunker was lucid, upbeat, gracious and pain-free. She added, “Ever the doctor, he took great pleasure in discussing his case with the young doctors in the West Middlesex University Hospital, where he was a patient.”
Bunker’s children also felt that his colleagues — many of whom shared his passion for mortality studies — would want to know his exact cause of death, which was listed on his death certificate as multi-organ failure, staphylococcus aureus bacteremia, bronchopneumonia, hypertension, chronic kidney disease, bronchiectasis, ischaemic heart disease and paroxysmal atrial fibrillation.
Bunker is survived by his first wife, Mary Bunker of Albuquerque, N.M.; his second wife, Lavinia Loughridge of Twickenham, England; his children, Jane Bunker of Truro, Mass., Katherine Black of Albuquerque, John Bunker Jr. of Palermo, Maine, and Emily Joyce of Brewster, Mass.; his stepchildren, Juliet Booth of Twickenham and Jonathan Booth of Henley, England; and his grandchildren, step-grandchildren and great-granddaughter.
At Bunker’s request, a small family memorial service will be held in August at his childhood home in Truro. In his honor, his children have set up the John P. Bunker Memorial Lecture Series at Truro Center for the Arts. A yearly lecture will address subjects ranging from art to literature, philosophy to opera. Donations in his name may be made to Truro Center for the Arts at Castle Hill, P.O. Box 756, Truro, MA, 02666.
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