MJJC Exclusive Q&A with Dr. Steve Shafer Part 1

This is Part 1 of 3 of Dr. Steve Shafer's answers to MJJCommunity questions. In this first installment Dr. Shafer will be answering questions about Michael Jackson, himself (Dr. Shafer) and Conrad Murray trial in general.

 

Questions about Michael Jackson in general

MJJC: Have you ever listened to Michael Jackson’s music and if yes, what song is your favorite?

Dr. Steve Shafer: I grew up listening to Michael Jackson’s music, just like the rest of the world. Thriller was the only album that I knew well, and “Beat it” is my favorite track from it. The message and the music both appealed to me.

MJJC: What was your opinion about Michael Jackson before this trial?

Dr. Steve Shafer: I knew very little about his personal life, other than the occasional sensational headlines. I intentionally read nothing about his life before the trial, because I did not want to introduce bias into my testimony. I’ve read a lot since the trial.

MJJC:Did your opinion about Michael Jackson change during and after this trial? Positively or negatively, and what is your current opinion about Michael Jackson?

Dr. Steve Shafer: Yes. During the trial I saw him as a patient, just like many patients I’ve cared for. During the trial I had no mental image of Michael Jackson as an icon or famous entertainer. He was a patient who died receiving medical care. It was important to keep focused on him as a patient.

Having said that, I was conscious that his interactions with Conrad Murray were, in part, a tragic side effect of his wealth. I spent 20 years on the faculty at Stanford University, and more recently at Columbia University. Patients who are very wealthy often choose a big-name medical center. Most wealthy patients are very kind and decent people. However, I occasionally encounter a wealthy patient who believes that because he or she is rich, he or she can simply tell me how to give anesthesia. That is what they are used to: giving orders and having people say “yes.” I believe that Michael Jackson fell into this trap: believing that he could tell doctors what to do and expect them say “yes.” This doesn’t excuse his doctors for saying “yes.” However, wealth and fame can be a curse.

My opinion of Michael Jackson is that he was an immensely gifted musician, entertainer, and genuinely compassionate individual. However, he was thrust into (well deserved) stardom as a youngster, and spent his entire life under the glare of public scrutiny. That does not seem like a blessing to me. To me it seems like a tragedy. He never lived a normal life.

MJJC: During the trial, the defense and various media outlets repeatedly called Michael Jackson a "drug addict". Based on your knowledge and research in this case, would you say that Michael Jackson was a "drug addict" or not?

Dr. Steve Shafer: “Addiction” is a lay term, not a medical term. The correct medical term is substance dependency. You will find an accurate explanation of this in Wikipedia. You can also find a good description at http://www.csam-asam.org/pdf/misc/DS..._diagnosis.doc.

I think Michael Jackson likely had a dependency on sedatives at the time of his death, because he was receiving intravenous sedatives every night. That type of regular exposure is almost certain to cause dependency.

MJJC: Can Dr. Shafer render an opinion on the chronic condition of Michael’s lungs (respiratory bronchiolitis, multifocal chronic interstitial pneumonitis, chronic inflammation)? Some TV doctor (Dr. Drew) alleged that it could be due to continuous/long term Propofol use. However MJ is known to have Pleurisy at 1977 and reported to say “he had a blister on his lungs” in later years. Could it be caused by the Propofol or could it be related to his Lupus?

Dr. Steve Shafer: Propofol is commonly used for infusions in intensive care units. I am not aware of any primary effect of propofol on the lungs. However, because Michael Jackson’s trachea (windpipe) was not protected while he was receiving propofol, he could have regularly inhaled small amounts of saliva or regurgitated stomach contents while anesthetized from propofol. That can damage the lungs and produce chronic inflammation.
Questions about Dr. Shafer in general

MJJC: Since your father passed away during the trial, was it hard to do the testimony? (and please accept our most sincere condolences for your loss)

Dr. Steve Shafer: I’ve shared with some members of the MJJCommunity my personal story about my father’s passing. I’ll spare you the details, other than to say that for me, the trial brought me an unexpected gift: the chance to be with my father when he died. Had it not been for the trial, I would have been in New Jersey. As it was, I was at his bedside, offering love and morphine. (I can only hope that one of my kids decides to take up a career in anesthesia.)
During my testimony, I felt that my father was beside me. It gave me confidence, particularly during cross examination. I knew that since my Dad was with me, I’d be OK.

MJJC: During testimony we learned that you drank Propofol. Did you drink it before you conducted the scientific research? What prompted you to drink it yourself?

Dr. Steve Shafer: I knew that the defense would reject animal studies as not applying to humans, just as Paul White did when asked about animal studies of propofol in urine. There is no way that I could conduct a human study in the US in three months, so I thought the best evidence I could get was to simply drink propofol and report if it had any effects. I knew the pharmacology well enough to be absolutely certain it was inert.

About a week later my colleague Pablo Sepulveda in Chile told me he would be able to conduct a clinical trial in volunteers. That made my drinking propofol completely irrelevant.

However, please remember that propofol is unique in the complete “first pass” metabolism. One should not try this with other drugs. Indeed, many drugs on the anesthesia cart would be fatal if consumed like that. This should not be attempted as a party trick!

MJJC: Any comments on Mr. Chernoff referring to you as a "cop"?

Dr. Steve Shafer: No, that’s his job. It didn’t bother me at all.

MJJC: During your cross examination Defense asked "Are you aware that everything you said here was your merely your opinion?" In your answer you concluded that this was an interesting question- where does 'personal opinion' end and where does "Dr. Shafer" begin? So did you, Dr. Shafer, come to any conclusion in this conundrum? Do you consider it wise or even desirable to split your mind in the Dr. figure- and Steven Shafer? Is it even possible to do so? What would the result most likely be? Could there be considerable "strength" in a personal, honest opinion?
Dr. Steve Shafer: I thought about that question quite a bit afterwards. I was not expecting it, probably because I am not an experienced expert witness. This was only the second time I have testified in court.

Mr. Chernoff was playing to my scientific training. Scientists are reluctant to state that something is a certain fact. There is evidence, and conclusions, but science is always open to new evidence and new conclusions. His asking me “wasn’t your testimony entirely your opinion” was an invitation to say “yes”, based on my interpreting “your opinion” as referring to my scientific opinion. If I had answered “yes,” it would have opened the door for him to say in his closing statement “Dr. Shafer himself admitted that his views were just his opinions.” That would play to the common use of “opinion” as mere speculation unsupported by data.

There were two aspects to my testimony: standard of care, and propofol pharmacology. I need to discuss fact vs. opinion for these separately.

Many aspects of the “standard of care” have been codified by organizations. For example, the American Society of Anesthesiologists has practice guidelines that very clearly spell out the standard of care during administration of anesthesia. My testimony was based largely on those guidelines. One could argue that it was merely my “opinion” to represent the published guidelines of the American Society of Anesthesiologists as fact. However, it is a fact that they have published guidelines on the standard of care, and those published guidelines were the basis of my “opinion.”
There are aspects of the standard of care are not covered by published guidelines because they are self-evident. I believe doctors should not lie. I believe Conrad Murray’s misrepresentation of the drugs that he gave to Michael Jackson was an unconscionable violation of the standard of care. Is it my opinion? Yes. However, I think every person on the planet shares my opinion that a doctor should not lie. Similarly, it is my opinion that doctors must place the interest of their patients ahead of their personal interests. That is my “opinion.” However, again I think it is an opinion that is universally shared. Can that be dismissed as “mere opinion?”

Regarding the scientific part of the testimony, my “opinion” is that of an expert in the field. The simulations I presented were mathematically accurate representations of the pharmacokinetics. Baring a mathematical error on my part, the simulations show exactly the blood and effect site propofol concentrations predicted by specific pharmacokinetic models for specific doses. The “expert” aspect is to decide what doses should be simulated, and whether these are likely scenarios. I did a lot of simulations, and even shared with the defense my spreadsheets so that they could do simulations as well. I chose some over others based on data. That is an “expert opinion.” However, it is more scientifically precise to say “conclusion, based on the data” that to call it “opinion”, since the latter implies uninformed speculation.

MJJC: Did it amuse you like it did many when Dr. White was called "Dr. Shafer" several times in court by Prosecution, Defense and even the Judge?

Dr. Steve Shafer: Yes. I think everyone was amused.

MJJC: Have you met any of the Jackson Family before, in between or after the trial? If so did they ever asked you any medical questions?

Dr. Steve Shafer: I spoke with them briefly several times walking to or from the courtroom. They were very kind, and offered condolences on the death of my father. I shared that we both had suffered loss, and offered condolences in return. I appreciated their kindness.

MJJC: Did your life change after this trial? If yes, positively or negatively?

Dr. Steve Shafer: I learned a huge amount from the trial, including:

• A lot about the pharmacology of propofol and lorazepam (I did a LOT of reading to educate myself on the issues, and to respond to claims made by the defense).

• Something about how the criminal justice system works. I was impressed by what I saw. In particular, the office of the District Attorney was absolutely honest and transparent. This was not a “game.” It was an attempt to determine the truth.

• Different approaches to discerning truth. In science, “truth” is determined by experiment, observation, peer review, and the ever-questioning nature of science. In science, the burden of proof is on the person making the claim. In criminal law, “truth” is determined by a jury that arrives knowing almost nothing, the exact opposite of peer reviewers. In criminal law, the burden of proof is on the prosecution. The defense can assert anything without evidence. I learned that both systems work.

I have received wonderful feedback from my professional colleagues. It won’t change me, but it has been rewarding.
I have had very kind letters from the Michael Jackson community. I did not expect these, but they have been appreciated.

MJJC: What do you think about Michael Jackson fans love and appreciation towards you? Do you know that many fans publicly express their love and gratitude to you, and use your pictures and quotes to express themselves? What do you think about that?

Dr. Steve Shafer: It didn’t expect it! However, I do understand that not knowing what happened to Michael Jackson has been a cause of considerable pain to his millions of fans. If my testimony was helpful, and perhaps brought a closure to his passing so they can again focus on his music and message, then I’m honored to have had the opportunity.

I have tried to answer many of the e-mails I have received. I am appreciative of the kind comments I have received from his fans all over the world.

MJJC: Now that the trial is over what’s next for Dr. Steve Shafer? Returning to practice? Teaching? Patient education and advocacy?

Dr. Steve Shafer: All of the above.

I did not watch the first two days of Paul White’s testimony, because I was back in the operating rooms at Columbia University giving anesthesia. I love clinical anesthesia. I love taking care of patients. We all need to define who we are. For me, it’s simple: I’m a doctor. I care for patients. If I ever stop caring for patients, I won’t know who I am. That’s what I do.

Having said that, my work as Editor-in-Chief of Anesthesia & Analgesia requires about 60 hours per week. Even during the trial I would go home and read a dozen new submissions every night, assign editors and reviewers, and process another dozen decision letters. I will be doing that every day until my term as Editor-in-Chief ends in 2016.
I continue to teach. You will get a laugh at the most recent lecture I have given at Columbia: the role of clinical pharmacology (e.g., pharmacokinetics) in the trial of Conrad Murray.

Anesthesia & Analgesia is the largest medical journal in the field of anesthesiology. I use Anesthesia & Analgesia as a platform to advocate for patient education, patient care, and patient safety (http://www.anesthesia-analgesia.org). Only rarely does that involve my own writing. The Journal advances patient care through editorial policies anchored in doing what is best for patients.

I continue to pursue my own research, primarily modeling the behavior of drugs used in anesthesia. Much of this is now in collaboration with my wife, Pamela Flood, who is the chief of Obstetrical Anesthesia at the University of California in San Francisco.

I am actively involved in developing new drugs to improve the safety of anesthesia and pain management. In 2003 I co-founded a biotech company to develop better drugs for anesthesia and pain management. You can find it at http://www.pharmacofore.com. Our work is progressing well, and this also consumes some of my attention.
MJJC: How the medical community has responded/reacted towards you since your testimony?

Dr. Steve Shafer: The response has been uniformly positive. There has been considerable appreciation that I spoke for the values that physicians hold, as well as for clearly explaining the medical and scientific issues involved. I didn’t testify to garner any attention or recognition, and it makes me a little uncomfortable. However, the validation of my testimony from my medical colleagues has been affirming that I did the right thing.

MJJC: Did media approach you for interviews? If yes, why didn’t we see you on TV?

Dr. Steve Shafer: Yes, I was approached, but I don’t think the interviews were aired. I think the reason is that they didn’t like my answers. I was asked about what I thought Conrad Murray’s sentence should be. I answered honestly that I didn’t have the background to judge that. I said that our lawmakers determine the appropriate sentences for criminal behavior, and judges then impose sentences based on the dictates of the law. I said that this was really a question for Judge Pastor, who IS an expert. I don’t think they liked that answer. They probably hoped for something much more vengeful from me.

I was asked how I felt about my role in convicting Conrad Murray. I honestly replied that I don’t think I had much of a role. Conrad Murray gave Michael Jackson propofol in a bedroom, with no training, no monitoring, no backup, no accountability, abandoned him to talk on the phone, and then lied about his action. His guilt was obvious when the facts emerged in 2009, and it just as obvious after my testimony.

MJJC: One of the most shocking parts of Dr. White’s testimony was when he admitted that he had not fully reviewed the current scientific literature on Propofol. Under cross-examination he also admitted that had not completely read the journal articles that were used to create the Propofol simulations that he presented as the basis of his court testimony. As a scientist I found this to be extremely irresponsible professional behavior. Can you please discuss how you prepared for your testimony in this trial?

Dr. Steve Shafer: I spent dozens, and perhaps hundreds, of hours in preparation. I read well over 100 papers. I analyzed the data numerous ways, and even made my spreadsheets available to the defense. I did the “heavy lifting” that is expected of an expert. This isn’t unique to this case – it’s how I approach everything I do.

MJJC: Judge Pastor picked out Murray's recording of MJ as the piece of evidence that affected him the most during the trial. Was there any one thing that affected Dr Shafer in all the evidence that he looked at?

Dr. Steve Shafer: Yes, the consistency Conrad Murray’s behavior. In the sentencing hearing Judge Pastor outlined in detail Conrad Murray’s pattern of repeated lying, self-serving actions, and reckless disregard for the wellbeing of his patient. That was what I saw also.

MJJC: How did you decide to choose your profession? What did it start with?

Dr. Steve Shafer: Many physicians choose a medical career very early in life. I knew from the time I was 9 years old that I wanted to be a physician. The inspiration was my pediatrician. He seemed to know absolutely everything, and I was amazed at the breath of his knowledge. Additionally, every year he spent several months on the “Ship Hope” practicing medicine in third world countries. I profoundly admired his sense of service to others. That was my role model

MJJC: Did any of your parents relate to medical sphere?

Dr. Steve Shafer: I am the first physician in my family. My father was a management consultant, and my mother was a housewife. Both of them took pride in having a son who went to medical school. I became the family resource for all medical questions.

MJJC: Did your father know about your intention to take a stand in Conrad Murray's trial? If yes, what were his thoughts about it, if any?

Dr. Steve Shafer: Yes. He liked it a lot. He told me it made him proud. He was also aware that I was visiting him every day because I was in Los Angeles for the trial.

He watched my testimony on Thursday morning, and died that evening.

Questions about trial in general

MJJC: What do you think about DA Walgren?

Dr. Steve Shafer: He is brilliant, dedicated, and absolutely honest. He worked incredibly hard. I think he got about 4 hours of sleep every night of the trial.

Part of my job was educating Mr. Walgren in the science. By the time of the trial, he was occasionally correcting my calculations! He was so effective when dealing with expert opinion in part because he truly understood the scientific principles.

As a taxpayer, it is amazing that attorneys like Mr. Walgren work for the State of California at a public servant’s salary. We are really getting our money’s worth!

MJJC: Did you see Judge Pastor give his sentencing statement? Any comments on that?

Dr. Steve Shafer: Yes, I watched it live. I smiled when Judge Pastor used specific words and ideas that I introduced in my testimony. Also, having read all of the documents numerous times, it was clear to me that Conrad Murray repeatedly lied. However, that was irrelevant to my testimony, and so I appropriately kept that opinion to myself. I appreciated hearing the judge, who is better able to judge Murray’s veracity than I am, lay out the pattern of self-serving lies by Conrad Murray.

MJJC: Do you think Murray just made a 'fatal mistake' or do you think it’s something more?

Dr. Steve Shafer: The fatal mistake was saying “Yes” to Michael Jackson’s request for a physician to administer propofol. That was followed by innumerable other fatal mistakes, but it all traces back to the initial lack of judgment.

MJJC: Do you believe Murray got the appropriate charge of Manslaughter or do you believe what he did was much more serious that it should have been something like Murder 2?

Dr. Steve Shafer: I’m not qualified to judge this, and am very glad I was not asked for an opinion on this during my testimony. I am glad he was found guilty. That was important: doctors are accountable for their actions. We are not above the law.

I only gave one television interview after the trial, because I had to teach a course (www.nonmemcourse.com) immediately after the trial. I was asked what I thought about the fact that the worse possible sentence was 4 years in jail. I answered that I wasn’t qualified to render an opinion. I think they wanted a much more bloodthirsty response, because they never ran the interview.

MJJC: What kind of punishment would be appropriate in your personal opinion?

Dr. Steve Shafer: Emphasizing that this is just my uninformed personal opinion, I believe that he must lose his license, never practice medicine again, and be accountable to the Jackson family. Please let me emphasize again that criminal punishment isn’t something I know about.

MJJC: In his closing argument Ed Chernoff stated once more that "lack of record keeping did not kill Michael Jackson". Would you find this a particularly irresponsible assumption- especially in light of your lengthy and detailed explanation of Pharmacokinetics and Pharmacodynamics? Would Ed Chernoff's closing argument be especially irresponsible and outrageous- considering that the assumed physician did not keep any records?

Dr. Steve Shafer: Mr. Chernoff’s statement is false. The lack of record keeping did contribute to Michael Jackson’s death. Without records Conrad Murray could not look for trends, such as seeing if larger doses were needed each day. Without records Conrad Murray could not look at past doses to determine what was a safe dose, and what was a dangerous dose.

Record keeping re-enforces vigilance. When you write down the vital signs every 5 minutes, it forces you to keep an eye on the patient. Record keeping would have forced Conrad Murray to stay close to Michael Jackson and continuously write down vital signs (at a minimum he had the pulse oximeter on the finger and could physically count the rate of breathing and heart rate). Record keeping would have forced Conrad Murray to monitor the intravenous infusion rate. Record keeping might have kept Michael Jackson alive. Thus, Mr. Chernoff’s statement is false.

MJJC: Lots of hyperbole has been made of the IV tubing/matching/non matching. Could you explain in detail once more (with no defense attorney interrupting) why this has no bearing on the statements made by you?

Dr. Steve Shafer: I initially believed that the IV tubing that Conrad Murray purchased in large quantities from Sea Coast Medical was non-vented, because I did not see the vent in the picture taken by the medical examiner, no vent is described in the product description from Sea Coast Medical, and I was unsuccessful in my initial effort to purchase the tubing from Sea Coast Medical. It turns out that it was vented, which I only realized after I physically examined the tubing in court.

However, the fact that thesmaller infusion set was vented only increases the ease with which Conrad Murray set up the infusion, and the ease of concealing the tubing set on the day Michael Jackson died.

However, it still comes back to the big picture: Conrad Murray was giving Michael Jackson an anesthetic drug in his bedroom with inadequate training, inadequate monitoring, and no backup. That is why Michael Jackson died. None of these issues changes the big picture.

Note: Part 2 of 3 will be posted December 21st.