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Published On September 9, 2015

MILESTONE

The Codman Affair

Ernest Amory Codman, a pioneer in medical quality assessment, made his stand with a cartoon in 1915. It did not end well.

Debates in medicine are not uncommon. But few reach the pitch of the one started by Ernest Amory Codman, which came to a head a century ago.

Codman, a graduate of Harvard Medical School, joined the surgical staff of Massachusetts General Hospital in 1895. He was at the forefront of developing X-ray imaging techniques, and his textbook on the subject—the first written in English—remains pertinent today.

But Codman’s true passion was hospital reform. He proposed an outcome-tracking method he called the “end result system.” For each surgical patient, Codman believed, the attending physician should fill out a 5-by-8-inch card that included basic demographic information, plus the diagnosis and an account of how the surgery went. It should also—and here was the rub—track both the short-term outcome of the treatment and the health of the patient a year later.

“[E]very hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful,” Codman wrote, “and then to inquire, ‘If not, why not?’”

Codman practiced what he preached, to an unflinching degree. After a woman died following a gallbladder operation he performed, his report read: “I made an error of skill of the most gross character and even failed to recognize that I had made it.”

Implementing such a system, Codman said, would not only help surgeons learn through their collective successes and mistakes, but also ensure that promotions were based on merit. “[I]t will do much toward weeding out the super-annuated, the lazy and ill-trained surgeons of your community, even though they hold high places,” Codman wrote.

Frustrated that MGH did not adopt his tracking measures, Codman resigned his full-time position in 1911 to do what few doctors have done before or since: He opened his own hospital. With a dozen beds in a Beacon Hill brownstone, he and his staff were able to track the status of every patient.

Determined to spread the word, Codman printed the results of tracking for two years at his hospital—a rate of one complication in every three patients—and sent them to hospitals throughout the nation. He asked for their complication rates in return. None reciprocated.

It was on Jan. 6, 1915, that his long-simmering exasperation boiled over. Codman chaired a meeting of the Suffolk District Surgical Society. Among the luminaries in attendance was Boston’s Mayor James Michael Curley, a champion of public health initiatives.

After several speakers had their turns, Codman took the podium and unveiled a cartoon he had commissioned on a piece of paper as large as a bedsheet. In the center, an ostrich with her head buried in the sand is surrounded by dozens of golden eggs she has laid. She represented local surgery patients who, in the absence of the result-tracking system he championed, enriched MGH in blissful ignorance.

Among others depicted in the cartoon were the hospital’s board of trustees, who wonder whether she’d stop laying golden eggs if “we let her know the truth about our patients.”

Jaws dropped. Some in the audience stormed out. Codman, long tolerated as a well-meaning provocateur, had crossed the line. He was told to resign his chairmanship of the group and, when referrals from other physicians dwindled, his income dropped by nearly 40% over the next year. It was not until 14 years later that he was reinstated at MGH.

Codman died of melanoma in 1940, and did not live to see his ideas fully embraced. But his tireless efforts led directly to the creation of The Joint Commission, an independent nonprofit that upholds safety and quality standards across more than 20,000 health care organizations in the United States. And at MGH, the target of his provocations, the Edward P. Lawrence Center for Quality and Safety has developed a Web-based safety reporting system where employees share information about errors or potential errors.

For his part, Codman had a hopeful, if melancholic, sense that his end-result system would take root.

“Through much of my life I have suffered somewhat from a sense of isolation, because I have always been thinking, or saying, one thing or another, with which doctors did not agree,” Codman wrote when he was in his sixties. “Honors, except those I have thrust on myself, are conspicuously absent on my chart, but I am able to enjoy the hypothesis that I may receive some from a [future] generation.”