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An editorial in the New York Times of 28 December 1999 praises the US Veterans Administration (VA) hospital system for publicly reporting their medical errors. The VA reported 3000 medical mistakes resulting in 700 patient deaths during the 18 months up to the start of 1999. There will be strong pressure for all US hospitals to follow this painful path of public admission of error in spite of the threat of litigation. This expectation will not stop at the borders of the USA.
Ernest Amory Codman, MD (1869–1940) has already “been there and done that”. He created his own “End Result Hospital” in Boston, Massachusetts, 1911–1917 where errors in diagnosis and treatment were recorded for every patient, all patients were followed years after discharge to evaluate the end results of care, and all this was publicly reported in the hospital's annual report. For example: “Patient #18, Feb. 11, 1912. Female 38. Intermittent right-sided abdominal pain and no attack of jaundice. Pre-op diag. - gallstones. Operation (Codman) - no gallstones. Appendix removed, not abnormal. Complications - mild sepsis in abdominal fat not delaying convalescence. Attack (of) malaria in second week. Parasite demonstrated. Result. July 24, 1916. Well, scar OK, minor complaints (error of diagnosis and error due to lack of care)”.1
All patients were described and followed in the same way to link the resulting health status back to errors in care. Always the controversialist, Codman sent copies of his annual reports to leading hospitals across the USA challenging them to do the same. He argued that prospective patients want to know the results of the care provided when they choose a hospital.
Codman carried the logic of the basic idea of linking process and outcome throughout his work. As a medical student he and Harvey Cushing started anaesthesia charting. Codman was a founder of the American College of Surgeons and chaired its End Result Committee which eventually evolved into today's Joint Commission on the Accreditation of Healthcare Organizations.
He was a surgical volunteer who helped to care for victims of the munitions ship explosion in Halifax, Nova Scotia on 6 December 1917 which killed 3000 people and injured 20 000 others. He closed his hospital (for ever, as it turned out) and left the next day to help. He kept end result cards on each patient there. To this day the City of Halifax gives a large Christmas tree each year to the City of Boston in thanks for those volunteers.
After serving as a military surgeon during World War 1 he returned to practice in Boston and started his registry of bone sarcoma which linked the process of care with outcomes. This became the forerunner of cancer registries.
Codman also made important contributions to surgery including his privately printed 1914 book, The Shoulder, the first medical book on this topic and now considered a classic.2 The first chapter of this book is Codman's autobiography where he lists his publications as “Advertisements”. He thought most medical publications just reported good results on selected patients and not failures or the outcomes of all patients taken together. He said there was little to learn from success and much to learn from failure and error. The concluding chapter of this surgical text was about money and fees. He said that the economics of practice defines the care given and urged that every such text should include a chapter about the treatment consequences of medical business.
Codman and his wife Katy provided the Boston residence for Alice Hamilton MD, the first woman faculty member of Harvard Medical School and a founder of occupational health in the USA. They were both active in the woman's peace movement along with Emily Balch, a relative by marriage who later won the Nobel Peace Prize for her work. Katy visited the jailed Sacco and Vanzetti who were supposed terrorists, executed for murder, and defended by many in America's most famous trial of that era.
At long last we now have a superb full length and, in all likelihood, definitive biography of Codman written by William Mallon, an orthopaedic surgeon at Duke University, after a decade of research. Mallon's years of work clearly show in his exhaustive search for records, getting the facts right, and covering the many diverse strands of Codman's life.
Codman said that his contributions would be forgotten after his death and then accepted several generations later. Mallon's biography is helping to fulfil Codman's prophecy.
If you care about quality of care evaluation, you should know about Codman. I strongly recommend Mallon's biography to your attention.
William J Mallon. (Pp 196; US$65.00). Philadelphia: W B Saunders, 2000. 0 7216 8461 0