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John Bunker
Stanford Medical History Center
Obituary
John Bunker Anaesthesiologist and pioneer in evidencebased medicine. Born on Feb 13, 1920, in Boston, MA, USA, he died of multiple organ failure and other causes on May 4, 2012, in London, UK, aged 92 years. John Bunker, who dedicated most of his long career to analysing the costs and benefits of surgical procedures, was a force in establishing evidence-based medical care in the USA and UK. “He will be most remembered for pioneering research in evaluation of costs, risks, and benefits of surgery, opening up whole new fields of evaluating surgical and medical care. He set the bar higher for standards of evaluational research in this field”, says Alain Enthoven, a professor emeritus of public and private management at Stanford University and a member of the Center for Health Policy there. As a young professor at Harvard University in the 1950s, Bunker studied the metabolic effects of anaesthetics on the liver and questioned whether halothane, a general anaesthetic adopted by hospitals in the mid-1950s, was the cause of fatal liver necrosis in patients. By the early 1960s, US hospitals reported at least a dozen cases of death due to liver necrosis after anaesthesia with halothane, prompting Bunker, who was then at Stanford, and his colleagues to initiate the National Halothane Study to compare the effects of halothane and other anaesthetics on the liver. It was one of the first large-scale clinical studies to use the then new power of computing to analyse a massive dataset: more than 850 000 cases of general anaesthesia in 34 hospitals. The researchers couldn’t determine whether halothane caused massive liver necrosis, but their data indicated that halothane was safer than other anaesthetics. 1052
They attributed most of the cases of fatal liver necrosis to the nature and complexity of the operations and patients’ previous health rather than to the anaesthetic. The study also revealed a surprising finding: the number of deaths from surgery varied between hospitals and patients’ health history or the nature of the operations they underwent didn’t account for the difference. This observation sparked Bunker’s interest in the rate of mortality associated with surgery. In a seminal paper published in The New England Journal of Medicine in 1970, he reported that rates of surgery in the USA were double those in the UK and suggested that financial incentives for clinicians accounted for the greater number of operations in the USA. Many other studies of variations in surgical rates within and between countries followed and the medical community acknowledged that the use of health care at the time was not based on evidence of its effectiveness or efficiency. Bunker became a vocal advocate for evidence-based medicine and urged the medical and public health communities to reflect on the purpose and intended beneficiaries of health care. During the 1970s whilst he was at Harvard, Bunker, together with Jack Wennberg, Fred Mosteller, and others, organised a seminar series to investigate the variations in surgical data. In 1977, the group published the groundbreaking book Costs, Benefits and Risks of Surgery, a cost-benefit evaluation of surgical procedures and a description of methods for assessing operations that could be applied to new procedures. A survey of health professionals in 2006 considered it among the top books published in health-care services in the past 150 years. Bunker earned a medical degree from Harvard University in 1945. He interned for a year in Boston and then, for the next 2 years, served in the US Navy as a surgeon in China and Guam. He trained in anaesthetics at Massachusetts General Hospital and, in 1950, joined the faculty at Harvard. 10 years later he became the founding chairman of the Department of Anesthesia at Stanford University. From 1973 to 1975, he was a visiting professor in the Department of Preventive and Social Medicine at Harvard. Stanford established a Department of Health Research and Policy in the early 1980s and Bunker returned to serve on the department’s faculty, becoming professor emeritus in 1989. Later, Bunker moved to the UK as a visiting professor at University College London. “Bunker’s work is not accepted as much as it should be. In the UK there is still the idea that we need much more health care than we are getting. Bunker would recommend that more health care be tied to outcomes, not to the needs of hospitals and doctors”, says Klim McPherson, a professor of public health epidemiology at the University of Oxford. Bunker is survived by his first wife, Mary Bunker; his second wife, Lavinia Loughridge; his four children; and his two stepchildren.
Alison Snyder www.thelancet.com Vol 380 September 22, 2012
Obituary
John Bunker Anaesthesiologist and pioneer in evidencebased medicine. Born on Feb 13, 1920, in Boston, MA, USA, he died of multiple organ failure and other causes on May 4, 2012, in London, UK, aged 92 years. John Bunker, who dedicated most of his long career to analysing the costs and benefits of surgical procedures, was a force in establishing evidence-based medical care in the USA and UK. “He will be most remembered for pioneering research in evaluation of costs, risks, and benefits of surgery, opening up whole new fields of evaluating surgical and medical care. He set the bar higher for standards of evaluational research in this field”, says Alain Enthoven, a professor emeritus of public and private management at Stanford University and a member of the Center for Health Policy there. As a young professor at Harvard University in the 1950s, Bunker studied the metabolic effects of anaesthetics on the liver and questioned whether halothane, a general anaesthetic adopted by hospitals in the mid-1950s, was the cause of fatal liver necrosis in patients. By the early 1960s, US hospitals reported at least a dozen cases of death due to liver necrosis after anaesthesia with halothane, prompting Bunker, who was then at Stanford, and his colleagues to initiate the National Halothane Study to compare the effects of halothane and other anaesthetics on the liver. It was one of the first large-scale clinical studies to use the then new power of computing to analyse a massive dataset: more than 850 000 cases of general anaesthesia in 34 hospitals. The researchers couldn’t determine whether halothane caused massive liver necrosis, but their data indicated that halothane was safer than other anaesthetics. 1052
They attributed most of the cases of fatal liver necrosis to the nature and complexity of the operations and patients’ previous health rather than to the anaesthetic. The study also revealed a surprising finding: the number of deaths from surgery varied between hospitals and patients’ health history or the nature of the operations they underwent didn’t account for the difference. This observation sparked Bunker’s interest in the rate of mortality associated with surgery. In a seminal paper published in The New England Journal of Medicine in 1970, he reported that rates of surgery in the USA were double those in the UK and suggested that financial incentives for clinicians accounted for the greater number of operations in the USA. Many other studies of variations in surgical rates within and between countries followed and the medical community acknowledged that the use of health care at the time was not based on evidence of its effectiveness or efficiency. Bunker became a vocal advocate for evidence-based medicine and urged the medical and public health communities to reflect on the purpose and intended beneficiaries of health care. During the 1970s whilst he was at Harvard, Bunker, together with Jack Wennberg, Fred Mosteller, and others, organised a seminar series to investigate the variations in surgical data. In 1977, the group published the groundbreaking book Costs, Benefits and Risks of Surgery, a cost-benefit evaluation of surgical procedures and a description of methods for assessing operations that could be applied to new procedures. A survey of health professionals in 2006 considered it among the top books published in health-care services in the past 150 years. Bunker earned a medical degree from Harvard University in 1945. He interned for a year in Boston and then, for the next 2 years, served in the US Navy as a surgeon in China and Guam. He trained in anaesthetics at Massachusetts General Hospital and, in 1950, joined the faculty at Harvard. 10 years later he became the founding chairman of the Department of Anesthesia at Stanford University. From 1973 to 1975, he was a visiting professor in the Department of Preventive and Social Medicine at Harvard. Stanford established a Department of Health Research and Policy in the early 1980s and Bunker returned to serve on the department’s faculty, becoming professor emeritus in 1989. Later, Bunker moved to the UK as a visiting professor at University College London. “Bunker’s work is not accepted as much as it should be. In the UK there is still the idea that we need much more health care than we are getting. Bunker would recommend that more health care be tied to outcomes, not to the needs of hospitals and doctors”, says Klim McPherson, a professor of public health epidemiology at the University of Oxford. Bunker is survived by his first wife, Mary Bunker; his second wife, Lavinia Loughridge; his four children; and his two stepchildren.
Alison Snyder www.thelancet.com Vol 380 September 22, 2012