Curtis Margo
Tampa, Florida, United States

There are few treatises in the annals of history that have noticeably altered the course of medicine. The first and most conspicuous would be The Corpus, a collection of more than fifty essays attributed to Hippocrates of Cos.¹ Among its many gifts to the healing arts was the notion that disease is not due to supernatural causes. Illness and disability are instead knowable through careful, systematic observation. With disease detached from superstition, it became understandable. The origins of such profound and far-reaching ideas in medicine are rarely traceable to a single work. One recent candidate, however, is the concept of accountability proposed by E.A. Codman in The Study in Hospital Efficiency.² This little remembered book, published in 1918, laid the groundwork for the quality improvement initiative by arguing for study and analysis of surgical outcomes and for the necessity of transparency. A half century later, this means of accountability would become an imperative of organized medicine.

Background

Ernest Amory Codman (1869–1940) was born and raised in Boston. He graduated from Harvard Medical School in 1895, when the field of surgery was leading medicine into its golden age (with the aid of anesthesia and sterile technique).³ After graduation, Codman spent time in Europe observing experienced surgeons before starting practice at Massachusetts General Hospital (Fig 1). An early adopter of new technologies, he was one of the first to apply X-rays to patient care. He was also a contemplative observer, which led him to ponder disparities in the delivery of care, variations in the availability of basic hospital equipment, and reasons for poor record keeping. His musings, however, often led to action. In an effort to improve the environment in which surgeons worked, he chaired the Committee for Hospital Standardization in the American College of Surgeons, an organization he helped establish in 1910. His expertise in surgery had been obtained mostly through trial-and-error, like other surgeons of this era. For Codman, learning through mistakes was agonizing because it came at the expense of patients. He envisioned a method of learning surgery through constructive feedback that would minimize surgical misadventures by methodically documenting procedures that worked and those that did not, and could identify surgeons who needed remedial help. He also wanted to make the information accessible.

The book

A Study in Hospital Efficiency as Demonstrated by the Case Report, of the First Five Years of a Private Hospital consists of three parts (Fig 2).² Part I is where Codman introduces the “end result idea,” a plan designed to collect clinical data and analyze surgical outcomes in terms of success or failure. The notion behind the end result idea was straightforward. One would not perform a procedure unless it worked. Surprisingly, there was little evidence that many commonly performed procedures actually accomplished what they were intended to do. This lack of information was particularly true in the “long-term.” Given the large number of clinical variables involved in each case, assessing outcomes would be the most efficient way to determine if surgery accomplished its goal. The definition of long-term, although a bit nebulous, meant at least beyond the time of hospital discharge. It was a field of study virtually unexplored.    

In order to appropriately test his hypothesis, he needed to collect diagnoses, record pre- and post-operative clinical findings, and then obtain follow-up after hospital discharge. This was not possible until Codman could free himself from meddlesome hospital administrative oversight. In 1911, he opened a private hospital so he could catalogue and track each patient admitted for surgery. As time consuming as the work was, relevant data were collected and analyzed. Codman acknowledged that the integrity of the system demanded the honesty of surgeons, who must subordinate their interests (presumptively pride) to the goal of his mission. He was willing to lead by example, placing his own record on display. He classified undesirable surgical outcomes as “C” for calamity, or beyond operator control; “P” for patient/disease-related, or the inevitable result of illness; and “E” for error, or preventable mishap. From August 25, 1911 through July 19, 1916, Codman recorded clinical information on 337 consecutive surgical patients. The abstracts of these patients were notable in their focus, brevity, and frankness. Gravely ill patients and those with advanced disease—particularly cancer—made up a substantial proportion of cases.

The objective of this experiment in record keeping and analysis was to provide constructive feedback to surgeons by revealing areas of surgical care that required improvement. The category of surgical error (E) was carefully scrutinized and subcategorized. Errors were attributed to either a surgeon’s lack of technical knowledge, skills, or surgical judgment, or lack diagnostic acumen. Error due to lack of equipment was listed as an institutional fault. Cases classified as errors were described in considerable detail in the text to permit additional scrutiny. Codman was not hesitant to point out his own mistakes and what could be learned from them.

The system of indexing served other purposes, including statistical studies on morbidity and mortality. Anticipating pushback from hospital administrators and physicians, Codman listed seven potential objections to the implementation of the end result idea—and then quickly refuted each.

Parts II and III of the book were called “The Financial Report” and “The New Organization,” respectively. They dealt with medical economics and the phenomenon of competition among surgeons and hospitals, topics seemingly tangential to clinical outcome research. Understanding hospital finances, he argued, was essential to ensure hospitals were able to purchase state-of-the-art equipment and to pay qualified surgeons for their work. Part III of the book deviated further from his central theme, portraying a vision of medicine dominated by specialists in the future.

Immediate reaction

The publication of A Study in Hospital Efficiency was not well received by the medical community. The bluntness of his criticisms and inability—or unwillingness—to disguise surgical errors in euphemistic jargon were only part of the problem. It was simply unthinkable at the time to discuss surgical mistakes, even privately, among colleagues. In response, community doctors shunned him and referrals stopped. Codman volunteered for service in World War I, which temporally removed him from the hostile work environment. After returning to Boston, however, he was forced to close the hospital. No one seriously contested his thesis, but as soon as the book was out of print, pressure to consider or even discuss the study of clinical outcomes was easy to ignore.⁴ Those who looked into the end-result idea after World War II felt Codman had oversimplified surgical error by too narrowly focusing blame, but never disputed the value of documenting clinical outcomes to improve patient care.

Legacy

Codman was not the first to promote outcome research in medicine; that distinction goes to Florence Nightingale.⁴ He was, however, the first surgeon to endorse its importance and to forcefully argue for its implementation along with appropriate information sharing and disclosures. The idea was too radical for the time and it took decades to gain any support in organized medicine. Although a discussion on how this uncomfortable awareness of accountability shaped the multi-faceted quality of care initiative in the latter part of the twentieth century is beyond the scope of this essay, a few events will put Codman’s idea into perspective. In 1987, the Joint Commission on Accreditation of Hospitals (JCAH) finally accepted the need to study clinical outcomes as part of measuring quality of care.⁵ Implementation was nevertheless challenging. Physicians and hospitals were reluctant to document clinical outcomes, citing a variety of problems, including medicolegal. Under increasing pressure, the JCAH compromised, offering an alternative method that measuring “quality” through “structure” and “process.” When it was obvious that poor clinical outcomes still occurred when adequate “structures” were present (e.g., working EKGs, functional defibrillators, etc.), and appropriate “processes” were in place (e.g., signed medical charts, completed physical exams, etc.), proponents of the quality of care movement fought on. Congress eventually stepped in to create the Agency for Health Care Policy and Research in 1989, whose major mission was to conduct outcomes research and disseminate the results.⁶

The study of medical outcomes has since become widespread and nuanced, and much of this subtlety was anticipated by Codman. He understood that poor outcomes were correlated with the severity of underlying disease and the number of associated medical disorders (co-morbidities). Today physicians and statisticians struggle to adjust for these variables so that physicians do not deliberately shy away from the sickest patients for fear of accumulating unfavorable results. Unlike the nearly mythical Hippocrates of Cos, the name of Ernest Amory Codman remains largely unknown, yet his contributions to the practice of medicine are in many ways as influential.

References

1. Hippocrates. The Corpus (Kaplan Classics of Medicine). New York: Kaplan Publishing, 2008.
2. Codman EA. A study in Hospital Efficiency. As Demonstrated by the Case Report, of the First Five Years of a Private Hospital. 1918. Forgotten Books, republished 2012.
3. Mallon WJ. Ernest Amory Codman: The End Results of a Life in Medicine. Philadelphia: WB Saunders Company, 2000.
4. Millenson ML. Demanding Medical Excellence. Doctors and Accountability in the Information Age. Chicago: University of Chicago Press, 1999.
5. Schroeder SA. Outcome assessment 70 years later: Are we ready? N Engl J Med 1987;316:160-2.
6. Gray BH. The legislative battle over health services research. Health Aff (Millwood) 1992;11(4):38-66.