Ernest Amory Codman

Ernest Amory Codman (born December 30,1869, Boston, Massachusetts, U.S.—died November 23, 1940, Ponkapoag, Massachusetts) was an American surgeon known for pioneering the use of process-and-outcome measures, which he referred to as “end results,” to improve the quality and safety of health care. He also made significant contributions in the fields of radiology, anesthesiology, shoulder physiology and surgery, duodenal ulcer surgery, and the study of bone sarcoma.

In 1889, before he graduated from Harvard College (1891) and Harvard Medical School (1895), he started a yearly log of his bird-hunting efficiency. He recorded the number of shots fired (process) and birds killed (outcome or end results of hunting) and the rates of birds to shotgun shells expended (efficiency).

While in his last year of medical school, Codman interned at Massachusetts General Hospital (MGH). At the time, medical students at MGH gave anesthesia during surgery. Codman bet his classmate and best friend, Harvey Williams Cushing, who later became a renowned neurosurgeon, to see whose patients would have better outcomes under their care. The result was the first use of anesthesia charts—graphing such data as the medicine administered to the patient and the patients’ pulse and respiration rate—a significant advance in anesthesiology.

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In 1899 Codman briefly served as the first radiologist at the Boston Children’s Hospital. He ran the fluoroscope for the landmark physiological experiments of Walter Bradford Cannon showing a goose swallowing a radiologically opaque button. Codman became a junior surgeon at MGH and began to publish many papers, including those on the shoulder, duodenal ulcers, and “end results.”. He followed up on the outcomes of all patients he cared for and urged others to do the same. Unsatisfied with the willingness of that hospital to adopt his ideas, he created his own proprietary “End Result Hospital” nearby, where he could pursue his ideas about hospital efficiency. His hospital existed from 1911 until 1918. All patients treated at the hospital were followed up after discharge, with the results reported, patient by patient, and published at Codman’s own expense for all to read. In 1910 Codman helped start the American College of Surgeons. He chaired its Committee for Hospital Standardization, which studied hospital outcomes (end results) and how they could be improved. Eventually the committee led to the creation of the Joint Commission.

In January 1915 Codman unveiled a large cartoon at a local surgical society meeting that depicted his colleagues as being more interested in money than end results. That was the peak of his undiplomatic outspokenness in advocacy of his end results beliefs. His colleagues were offended; his medical income fell; and his hospital was closed in 1918 when he entered military service. Codman would eventually create end-result cards for all the soldiers he treated in World War I. After the war Codman returned to surgical practice in Boston. He started a registry of bone sarcoma, the forerunner of all cancer registries. In 1934 he wrote the first book ever written solely on the shoulder, which is considered a classic work in orthopedic surgery.

In spite of his considerable accomplishments, Codman received little appreciation during his lifetime. He was ostracized by many of his peers and had few patients and little income. When he died, he was too poor to afford a headstone and was buried in an unmarked grave.

In 1996 the Joint Commission established an award in his honour. The Codman Award is awarded to recognize the achievements of individuals and organizations in the use of process-and-outcome measures to improve the quality and safety of health care.

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