As we make our way into the second century of the American College of Surgeons (ACS), I think it worthwhile to revisit our beginnings with a look back at one of our Founders, Ernest Amory Codman, MD, FACS – a man who was profoundly influential but flawed, visionary but, in his own words, quixotic.
Dr. Codman’s story is woven into the fabric of our College and has had a visible imprint on our Quality Programs. Dr. Codman’s greatest contribution to medicine was The End Result Idea, which centered on the common-sense notion that every hospital and every surgeon should follow every patient long enough to determine whether the treatment was successful, and to inquire, “If not, why not?”
In 1911, he opened the 12-bed Codman Hospital near Harvard Medical School and Massachusetts General Hospital (MGH), Boston, MA, where he was on the faculty and in practice. He established the hospital to test his ideas and kept records on each patient for a year, rating the outcomes with absolute honesty. Five years later, Dr. Codman published his findings in A Study in Hospital Efficiency, offered free of charge to ACS Fellows. The book was a marvel of public reporting – a concept unheard of at the time.
Back at MGH, Dr. Codman was convinced that outcomes rather than seniority should determine a surgeon’s promotion at academic medical centers and called for adoption of this policy. This suggestion ran counter to the practice at MGH at the time, and the senior surgical leadership did not take kindly to the proposal. He stepped down from the MGH staff in 1914, and on the day he received acceptance of his resignation, he asked (with more than a little irony) to be appointed surgeon-in-chief because of his superior outcomes. This request was denied.
On January 6, 1915, Dr. Codman used his position as chair of the surgical section of the local medical society to push his End Result Idea. At the conclusion of a slate of speakers on hospital efficiency, accurate measurement of outcomes, and standardization, Dr. Codman unveiled a six-foot cartoon that depicted the medical community and the leaders of Harvard and MGH as caring only about the golden eggs being kicked to them by an ostrich with its head in the sand.
With that gesture, Dr. Codman managed to offend just about everyone in the surgical and education community. He was forced to resign his chairmanship of the surgical section and was dropped from the Harvard faculty.
In 1920, Dr. Codman sought and was given the opportunity to develop the ACS Registry of Bone Sarcoma – the first cancer registry in the nation and a precursor to the National Trauma Data Bank® and the National Cancer Data Base. With a disappointing initial response to his call for cases, Dr. Codman wrote that the ACS expects more from Fellows than dues payments. “It expects any Fellow who has undertaken the care of a case of bone sarcoma to give the other members of the College, and through them to the rest of the profession, the benefits of the experience gained.”
Take heed of that injunction. We owe it to each other and to our patients to improve our profession actively and continuously, to increase knowledge, and to innovate. Be involved in shaping the changes in health care delivery, in advocacy, and in giving back to society.
Eventually, Dr. Codman and his ideas regained a level of acceptance. He was reinstated at MGH in 1929, and when he died in 1940, the hospital trustees paid him tribute. Posthumous accolades, however, were not enough to compensate for his depleted finances, and before his death, he told his wife not to purchase a headstone. For 74 years his ashes had lain in an unmarked grave at Mount Auburn Cemetery, Cambridge, MA. On July 22, 2014, the College and other organizations placed a memorial headstone at the site.
Dr. Codman’s life is a lesson in contrasts. With a century’s hindsight we see the strength of his pioneering ideas. At the same time, however, he proves that it is not sufficient to have a good idea. You must apply leadership to get others to accept new concepts and programs.
Dr. Codman predicted the future of health care, but his vision has yet to be fully realized. We have registries, such as the ACS National Surgical Quality Improvement Program; clinical guidelines; and statistics on outcomes for hospitals, practices, and disciplines. However, we have yet to establish a methodology to assess and compare the outcomes of most individual surgeons accurately.