A Study in Hospital Efficiency, As Demonstrated by the Case Report of the First Five Years of a Private Hospital  by E A Codman, MD. The Classics of Medicine Library, 1992, 179 pages $47.95

Review by Del Meyer, MD

In 1983, Sherwin B. Nuland, M.D., described a new medical publishing venture which created a privately printed, numbered and registered set of the classic books in medicine, bound in genuine leather. The first volume was a facsimile of Osler's landmark work, The Principles and Practice of Medicine, first published in 1892. It was followed by one of the rarest books in the history of medicine, William Harvey's De Motu Cordis, published in the exact facsimile the first 1628 Latin edition and the Keynes English translation of 192, in the same binding. One of my early favorites was Rene' Theophile Laennec's "A Treatise on the Diseases of the Chest." The recent library selection by E.A. Codman speaks to our subject this month on hospital physician issues.  

Ernest Amory Codman, M.D. (1869-1940), published his first edition in 1916. This facsimile is dedicated to Richard C. Cabot of Massachusetts General Hospital. Codman graduated from Harvard Medical School in 1891, after a year abroad, and practiced Surgery with a keen interest in muscles and bones. He was convinced that Roentgen's recent discovery would play a major role in surgery and spent five years in the Intensive study of x-rays. His monumental monograph, "The Use of X-ray in the Diagnosis of Bone Diseases" was submitted for the Gross Prize given every five years in Philadelphia. When he did not win, he realized that busy surgeons of his day failed to grasp the practical value of X-rays in the diagnosis of disease, and his monograph was probably unintelligible to them. When, five years later, Dr. Keen, who was on the committee that rejected his monograph, asked him to write a chapter on the use of X-rays in surgery, Codman submitted his unpublished paper that was published in Keen's Surgery. Codman also diagnosed and operated on the first case of perforated peptic ulcer at Massachusetts General.  

About the turn of the century, Codman conceived of a concept which he named the "End Result Idea," which was merely the common sense notion that every hospital should follow every patient it treats long enough to determine whether or not the treatment was successful, and to inquire "if not, why not," with a view a preventing similar failures in the future. Codman felt all results of surgical treatment which lack perfection may be explained by one or more of the following causes: errors due to lack of technical knowledge or skill, errors due to lack of surgical judgment, errors due to lack of care or equipment, errors due to lack of diagnostic skill, the patient's unconquerable disease, the patient's refusal of treatment, the calamities of surgery or those accidents and complications over which we lave no known control.  

Codman introduced the "End Result Card" which is kept for each patient and on which is recorded in the briefest possible terms: the symptoms, the diagnosis, the general treatment plan, the complications, the final diagnosis, and the results each year thereafter. It was a volcanic idea according to Anthony F. DePalma, M.D. in Clinical Orthopedics. On May 14,1913, Codman spoke In "The Product of a Hospital" in the Philadelphia Academy of Medicine and posed such questions as "For whose primary interest is it to have the hospital efficient: the patient who seeks relief, the public who supports the hospital?"  

The End Result Idea obviously would not tolerate the seniority system, which operated in all major hospitals of the country. In protest to impress the board o trustees, Codman resigned from the staff of Massachusetts General and applied for the position of Chief of Surgery on the grounds that his results in the past 10 years had been better than those of other surgeons. Despite his documentation, his application was ignored. When he enlisted community support, the board of trustees still could not risk losing their "golden egg" of support. He was even asked to resign as chairman of the local medical society. His friends refused to speak to him. He was avoided at social gatherings. This did not deflect Codman from his work, which he continued by establishing his own hospital. In 1916, he published, at his own expense, the above work, which he sent to hospitals across the country.  

To provide the finest in medical care is an ongoing struggle for every age and generation. Codman's focus on what is best for the patient ultimately succeeded as hospital after hospital eventually adopted his End Result Idea. It came full circle when Massachusetts General also implemented it and honored him in 1929 with the appointment of Consulting Surgeon. It may actually be the exception to be recognized in one's own lifetime for such an accomplishment.