Up to 11: Speaking with Dr. Steve Shafer on Dr. Ted Eger and his Autobiography of a Persistent Anesthesiologist

Author: Bram N. Harris

September 28, 2021

As many reading this likely know already, anesthesiology lost a pillar of the specialty in 2017 with the passing of Dr. Ted Eger II. What may be less widely known is that, in the years leading up to his passing, Dr. Eger was compiling the pieces of an autobiography detailing his life and work. Dr. Eger had spent two years working with Dr. Steven Shafer, his friend and colleague, in an effort to complete the autobiography despite his declining health. Sadly, Dr. Eger passed away before completing his autobiography. That was not the end of the story.

In the years after his death, Dr. Shafer, in collaboration with Dr. Eger’s widow, Dr. Lynn Spitler, completed the work he’d begun. The final result was Autobiography of a Persistent Anesthesiologist.

The Foundation for Anesthesia Education and Research (FAER) is pleased to share that Autobiography of a Persistent Anesthesiologist will be available for purchase through Wolters Kluwer and Amazon on October 1 and October 23, 2021, respectively. To honor the memory of Dr. Eger and his vast contributions to anesthesiology, Drs. Shafer and Spitler have chosen to donate the proceeds from this publication to FAER. They felt this was very in keeping with what Dr. Eger would have wanted and FAER wholeheartedly thanks them for this generous gift.

“Ted was absolutely dedicated to advancing the training of residents and young faculty. Although we never discussed [donating the proceeds to FAER] with Ted, we are certain it is what he would have wanted,” Steve Shafer, MD; Professor of Anesthesiology, Perioperative, and Pain Medicine at the Stanford University Medical Center; Editor-in-Chief, ASA Monitor; Member, FAER Board of Directors.

I was fortunate enough to sit down with Dr. Shafer and pick his brain about Dr. Eger and Autobiography of a Persistent Anesthesiologist. To better understand Dr. Eger and the book, though, it is first important to understand more about Dr. Shafer himself.

Like many, Dr. Shafer did not begin his medical journey knowing he wanted to pursue anesthesiology and research.

“When I matriculated to medical school, I wanted to go into pediatrics. My goal since I was a kid was to be a pediatrician. That was my goal until my pediatric rotation, when I realized I couldn’t deal with screaming children, or the distraught and overcontrolling parents. My pediatrics rotation completely changed my mind about going into pediatrics. Which is one of the things you do in medical school. 

“I was very attracted to surgery and really enjoyed my surgery rotation quite a bit, as did my then wife, Dr. Audrey Shafer. She and I were both talking about going into surgery and asked, ‘How could two surgeons have a life together? That just doesn’t seem possible.’ But we also really liked anesthesia, so jointly we decided anesthesia was the correct choice for us. So, it was made to try and find a way of having a life outside of medicine with Audrey, but one that looked like it would be a challenge and a great deal of fun professionally. Anesthesia presented a balance between something that was professionally fun, satisfying, yet still challenging, and an opportunity to have a life outside of medicine. 

“As for the research part, that happened almost (or very much) by chance. I have been writing software since I was a kid. I founded a software startup before medical school, and ran it during my five years of medical school. I founded another start-up in my last year of medical school, and ran it throughout residency. Neither company still exists. During my last year of medical school, I also wrote EEG processing software for an Assistant Professor at Stanford: Don Stanski. For me, it was really a way of earning extra cash during medical school. Don needed someone who could write software for Fourier and related analyses for EEG processing. After my anesthesiology residency I approached Don for a postdoctoral fellowship in clinical pharmacology. 

“I was planning on going into private practice. I wanted to be in the Bay area, and thought coming back with Don would afford me a chance to see what opportunities existed there. It was also an excuse to spend another two years programming. So, I started developing software for computer controlled drug delivery and I got hooked on clinical pharmacology. I felt that in pursuit of clinical pharmacology I could continue to leverage my facility with computer programming in a field that desperately needed someone who could write software.”

Though the specifics may vary from person to person, Dr. Shafer’s story is still a familiar one. Once it became apparent his original plans weren’t a good fit for him, he realigned his plans and selected a new path to pursue.

On the topic of his career in anesthesiology and research, Dr. Shafer went on to share recommendations he had for early career investigators hoping to follow in the footsteps of Dr. Eger.

“I would say at the top of the list is to find the right mentor and the right environment. Ted’s mentor was John Severinghaus, a phenomenally brilliant researcher and anesthesiologist. Ted hooked up with John initially at the University of Iowa, where John was in the residency class ahead of Ted. Then Ted specifically went to UCSF to be a fellow with John. They worked together for about five or six years before Ted went out on his own. Even though Ted became well recognized as a scientist, John was always there. Ted would not have accomplished what he accomplished without John Severinghaus and without the support of UCSF. So, mentorship and environment are at the top of the list as prerequisites for academic success. Any other institution and with any other mentor Ted Eger would not have had the career and success he had.

“The next thing is that Ted recognized early on, and it’s more true today than ever, that you have to commit yourself to the research. Ted would tell people, ‘Choose money or fame. You can’t have both. If you want to make money, go into private practice and you’ll do very well financially. Nobody will know who you are, but you’ll do well financially. On the other hand, if you want to be famous, go into research. You’ll give talks all over the world. People will know who you are. You’ll be famous. However, you’ll never have the money that your friends in private practice will earn. You can’t have both, choose one or the other.’ 

“Ted also would tell you that if you want a successful research career, you have to commit to it and be persistent. Only persistence will get you through the challenges of becoming a successful investigator.”

It was Dr. Shafer’s change in course from pediatrics to anesthesiology that would eventually lead him to cross paths with Dr. Eger. From there, it was Dr. Shafer’s pursuit of research that would help cement their decades-long friendship.

“I first met Ted back when I was a medical student interviewing at UCSF for residency. I went up there for an interview and met several faculty members. The first one was a very, very enthusiastic professor named Ted Eger. He asked me a bunch of probing questions. I had no idea I was talking to the Ted Eger. He introduced himself, but I had no idea who he was. It wasn’t until at least a decade later that we became friends.

“I subsequently interacted with Ted on a number of things involving pharmacology of both inhaled and intravenous anesthetics. Ted was intrigued by the way I was modelling recovery from anesthesia, so we collaborated on the model of recovery from anesthesia. Then Ted asked me to attend some of his program project events. He had a program project, ‘Understanding Anesthetic Mechanisms’ in about 2000. Ted asked if I could join up with the program project, which I did, becoming a consultant for it. Eventually that was where I met my current wife, Pamela Flood, where she was a consultant as well.

“During the program project, Ted and I became very close. He was one of the key mentors, both in my academic trajectory and guiding me through some challenging personal times as well. Ted was excellent at everything, including mentorship.”

“Ted balanced his life well. His academic life was unbelievably innovative and productive, but he also led a rich family life as well. Ted had exceptionally strong connections with his wife, his children, his friends. He kind of did everything fully. To use a reference from Spinal Tap, when it came to research, when it came to his personal life, his family life, Ted turned it up to 11.”

Anyone can relate to Dr. Shafer not initially registering the full gravity of who he was speaking to during he and Dr. Eger’s first meeting. After all, knowing the name and work of such an influential individual is one thing. Standing face-to-face with that person is quite another. 

For those less familiar, Dr. Shafer happily spoke about the work that helped launch Dr. Eger into anesthesiology stardom.

“Ted Eger created the body of science that guided the clinical administration of inhaled anesthetics and the scientific study of inhaled anesthetic pharmacology. He created the concept of MAC, the ‘minimum alveolar concentration associated with a 50% probability of movement in response to supramaximal noxious stimulation.’ MAC was a readily measured and clinically important index of anesthetic potency. The concept of MAC led to studies of the relationship between dose, in units of MAC, and the physiological effects of anesthetics including awareness, memory, blood pressure, electroencephalogram, cardiac output, ventilatory drive, liver function, immune function, etc. MAC also led to studies comparing the effects of inhaled anesthetics on humans with the effects on other forms of life, and to the studies on the mechanism of inhaled anesthetics. Any proposed mechanism of inhaled anesthetic pharmacology had to account for MAC.”

Simultaneously, Dr. Eger’s contributions to the practice of anesthesiology, the study of anesthesia, and medicine beyond these spheres extend well past his introduction of MAC.

“Dr. Eger figured out a measurement that has been an anchor of anesthesia research for the past 60 years. This body of research would not have been possible without MAC. This changed anesthetic delivery from an art to a science, because in the science of clinical pharmacology potency is everything. Unless you adjust for the potency in terms of anesthetic effect, analgesic effect pain relief, or any other measure of drug effect, you can’t put drugs on a common scale. Anesthesiologists have, I think, been at the forefront of clinical pharmacology for many years because of the foundation of potency as a clinical measurement of anesthetic dose. 

“Dr. Eger also worked out the details of uptake and distribution. He did this well before more complex models had been developed for intravenous drugs. Dr. Eger put together models for uptake and distribution in the 1950s and 1960s. Similar models for the IV drugs were only developed a decade or two later. Ted’s work with inhaled anesthetics is one of the reasons that if you look at advances in understanding drug behavior, many of the innovations have been led by anesthesiologists. Ted was responsible for advancing the bar of scientific rigor in the area of clinical pharmacology.”

Clinical pharmacology is just one of the areas that benefited from Dr. Eger’s research and findings. Dr. Eger’s work also advanced the fields of neuroscience, cognition, and molecular biology. The questions Dr. Eger asked over his career, and the tools/answers he offered in response, opened the door for a myriad of new avenues of research. 

It is difficult to look at such a paragon of science and medicine without mythologizing the man himself. However, while Dr. Eger was obviously a person of great intellect, there is a key characteristic to which he attributed his success in anesthesiology and science. As Dr. Shafer described:

“We’ve all had the experience of going to a lecture and having no idea what was being talked about, not being able to follow what is going on, feeling stupid because we were totally lost, and not wanting to utter a word for fear of revealing our cluelessness to everyone else. However, after the most difficult and intractable presentations, Ted would raise his hand with a deeply probing question, and it would be clear he understood every word.

“It wasn’t just brilliance. In his autobiography, Ted included a quote from Calvin Coolidge on the topic of persistence:

‘Nothing in this world can take the place of persistence. Talent will not: nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not: the world is full of educated derelicts. Persistence and determination alone are omnipotent.’

“It was to persistence that Ted attributed how he turned around a pretty lackluster high school career into getting into medical school and pursuing anesthesia. It really was persistence that took him from being a dabbler with equations and uptake and distribution to finally writing them all on punch cards in Fortran and feeding them into a computer at Berkley. It was the persistence that took him from having some crude measurements to actually taking animals and cutting them up and looking at the concentration of anesthetics in all the organs. It was persistence that had him, for over 20 years, go back to the NIH every four years to ask for more money to continue figuring out how inhaled anesthetics worked. Ted’s persistence was his supernatural power.”

With all this in mind, the appeal of an autobiography from such an exceptional physician-scientist should be readily apparent. Those close to Dr. Eger, including Dr. Shafer, recognized this fact. It was thanks in-part to them that Autobiography of a Persistent Anesthesiologist was able to come to fruition.

“Dr. Eger was encouraged by his wife and friends to write an autobiography. He started the project in 2015 and exchanged several preliminary chapters with his family and some close friends. He had never done anything like this before and did not like the result. He reached out to me in 2016 to see if I would edit it for him. I agreed. My wife, Pamela Flood, who was also close to Ted – he introduced us to each other – agreed to help as well.

“The chapters arrived as unformatted Word documents needing considerable editing. I organized the text temporal sequence, separated the science from the personal life, and integrated the slew of pictures Ted sent along into his story. By mid-2017 we had first drafts of every chapter. However, the chapters on MAC and pharmacokinetics were still very rough. These were long, complex, and needed considerable work to convey the science without losing the autobiographical narrative. In July 2017 we met for a weekend in San Francisco, agreeing to finally crank through these. We finished and celebrated by watching Hamilton.

“That was the last time Ted worked on the autobiography. He passed away in August. Every chapter had been through one revision, but there were many loose threads in the narrative. Completing the autobiography fell to Ted’s widow, Dr. Lynn Spitler, and me. It would take another four years.”

Compiled by Dr. Eger and lovingly fine-tuned by those close to him, Autobiography of a Persistent Anesthesiologist is the culmination of years of passion for anesthesia, science, and life. This, in turn, points to some of what readers can expect from Dr. Eger’s autobiography, reflected on by Dr. Shafer.

“I hope readers can connect with Ted’s deep appreciation for the mystery of anesthesia. We turn the brain on and off, render the body insensate, and then allow it to reboot itself, and everything is just fine. Ted never lost his sense of astonishment and wonder at our ability to produce anesthesia. He also never lost his curiosity about this state: what exactly is anesthesia? How is this even possible?

“For hundreds of anesthesiologists and scientists, knowing Ted Eger was one of the rewards and highlights of academic practice. His boyish enthusiasm for science and discovery inspired residents, colleagues within UCSF, and outside collaborators. His encyclopedic knowledge of anesthetic pharmacology also demonstrated the rewards of knowing your field deeply. Finally, his genuine love of people was ever on display. He held yearly conferences where scientists from around the world would convene on San Francisco (or Mendicino) to talk about science. Ted paid for everyone. I contributed little science, so I often did magic shows before the final dinner. These retreats, uniformly called ‘Ted Fests,’ created lifetime bonds among colleagues with shared interest in anesthetic pharmacology.

“I hope that readers of his autobiography will come to know Ted Eger after reading his book and will incorporate into their lives his love of science, medicine, and anesthesiology.”

Part of the joy of Autobiography of a Persistent Anesthesiologist is all that it can offer to each reader. Whether someone personally acquainted with Dr. Eger, or a physician-scientist already immersed in the field he did so much to revolutionize, an aspiring anesthesia-investigator taking their first tentative steps on their journey, or anyone in-between, Autobiography of a Persistent Anesthesiologist will prove an enjoyable, valuable read to all who approach it.

Drs. Shafer and Spitler further broadened the scope of who would benefit from Autobiography of a Persistent Anesthesiologist through their choice to donate the proceeds to FAER.

“By circumstance and, perhaps, intuition, Ted found himself exactly at the nexus of anesthesia practice and science in 1960. Clinical practice and science have both advanced exponentially since then. Where is the new nexus from which a young investigator will launch profound changes in our specialty? We don’t know – these things are only obvious in retrospect. However, FAER is constantly looking for that by asking young investigators to submit grants on their areas of interest. FAER, and only FAER, is focused on nurturing scientists advancing our specialty as Ted did.”

On behalf of FAER, thank you, Drs. Shafer and Spitler, for honoring the memory of Dr. Eger with this generous gift. We are honored to advance the passion of Dr. Eger through our dedication to supporting the future of the specialty.

We will end with an excerpt from Autobiography of a Persistent Anesthesiologist. Pulled from a section titled “I Wrote This for You,” this harkens back to recommendations Dr. Shafer offered earlier in this article and speaks directly to the physician-scientists FAER strives to nurture and support.

“If you are a young anesthesiologist contemplating a career in investigation, then the lesson I hope you take from this book is that you need a lifetime of persistence, a great mentor, a great environment, and some good luck. If these come together for you, then I hope you can tell the world, and perhaps me, how general anesthetics work their magic! Please do, because I wrote this for you.”

Visit FAER’s Purchase Support page for options on buying your own copy of Autobiography of a Persistent Anesthesiologist, as well as other publications whose proceeds are donated back to FAER.