Intended for healthcare professionals

Feature Christmas 2013: Medical Histories

A prophet to modern medicine: Ernest Amory Codman

BMJ 2013; 347 doi: (Published 18 December 2013) Cite this as: BMJ 2013;347:f7368
  1. Caitlin W Hicks, surgery resident, Johns Hopkins University School of Medicine,
  2. Martin A Makary, director of surgical quality and safety, Johns Hopkins Hospital
  1. 1Halsted 610, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
  1. Correspondence to: M A Makary mmakary1{at}

Caitlin Hicks and Martin Makary describe the life of the pioneer of healthcare registries

Remarkably, the outcomes of medical procedures are rarely tracked today. As a result, establishing the best medical treatment can be difficult. Trials to establish best practices are often isolated, underpowered, and lag behind widespread adoption. Moreover, standardized methods to capture complications are lacking for most interventions.

This problem is as old as medicine itself. But one man boldly sought to challenge the status quo and tackle the problem—Ernest Amory Codman (fig 1). Codman was a surgeon who believed that by prospectively tracking outcomes we can learn from our patients and advance the field of medicine quickly. Codman was a scientist of quality. He helped usher in the concept of the regular morbidity and mortality conference and started the first national registry in American healthcare. Given the challenges of medicine today—endemic rates of medical errors, wide variations in quality, and an expanding cost crisis—many physicians are calling for Codman’s basic tenants to be re-visited and applied.


Fig 1 Ernest Amory Codman, reproduced with permission from Boston Medical Library in the Francis A Countway Library of Medicine

Born in 1869, Ernest Amory Codman was a natural academic. He won the prestigious founder’s medal at St Mark’s School as a high school senior and graduated with honors from Harvard College in 1891.1 He undertook his medical education at Harvard Medical School, where he met Harvey Cushing. In 1895, Codman graduated from medical school and joined the staff at Massachusetts General Hospital as an assistant in anatomy, where he became the apprentice of the chief of surgical services, Dr Francis Harrington. In 1900, he was appointed assistant in clinical operative surgery. Through his work with Dr Walter Bradford Cannon, among others, Codman developed strong x ray imaging skills, which led to a career in orthopedic surgery. He developed an interest in shoulder surgery and pioneered a rotator cuff operation. His case based textbook of shoulder surgery, The Shoulder, is still considered one of the pre-eminent textbooks on shoulder disease.

Although Codman was an extraordinary surgeon, his true passion surrounded the science of quality improvement. He proposed that, “If some arrangement could be made by which the house officer should see these late results, it would be very instructive for them, for I feel sure that the house officer in graduating from this institution gets a very much more favorable idea of the results of surgical operations than he is really justified in having.”2 Codman was not afraid to challenge the status quo, and he developed the idea of tracking patient outcomes further to form the concept of the “end result system.” He described this concept in a publicly disseminated pamphlet in 1914: “Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future.”1

Codman believed that by understanding the results of patient care, doctors could change their practice to improve future care. He also pushed for transparency of results, so that physicians could learn from each other’s mistakes and patients could make informed decisions about where to obtain medical care.

Unfortunately, the administration at Massachusetts General Hospital did not entirely support Codman’s push to implement the end result system. But that wasn’t the only thing that frustrated Codman. He disparaged the hospital’s paternalistic approach to hiring; he believed in meritocracy and advocated vehemently for adjusting the hospital’s hiring and promotion policies. He eventually resigned from his full time position in 1911 because of disagreements about the hospital administration’s lack of action regarding his ideas on both topics.

Codman then started his own hospital, called the End Result Hospital, which required all physicians who practiced there to follow his system.1 Codman kept “end result cards” for each patient he treated, on which he recorded demographic, disease, treatment, and outcome data (box). From 1911 to 1916, he meticulously recorded the results for all 337 patients treated, during which time 123 errors were recorded. Ironically, this error rate is close to the 25.1% rate described in a 2010 Harvard study.3

Content of Ernest Codman’s end result cards

  • Symptoms or conditions for which the patient seeks relief

  • The diagnosis that the treating doctor believes to be the cause of symptoms and on which treatment is based

  • The general plan or important points of the treatment given

  • Complications before the patient left the hospital

  • The diagnosis that proved correct or final at discharge

  • The result each year afterwards

In keeping with his call for transparency, Codman paid to publish the results of each of the cases in his landmark book, A Study in Hospital Efficiency: As Demonstrated by the Case Report of First Five Years of Private Hospital.4 He thought that sharing mistakes and experiences in a public forum would improve quality and advance the science of medicine.

In 1912, Codman helped develop what is known today as the Joint Commission for Accreditation of Hospital Organizations (JCAHO).5 Together with Dr Edward Martin, a Philadelphia based gynecologist, Codman formed and then chaired the Committee on the Standardization of Hospitals.6 The committee’s stated purpose was to raise “the standard of American hospitals” through “the establishment in each hospital of a follow-up system of tracing the outcome of treatment given to each individual patient.”2 To start, the committee asked that all hospitals adhere to a standardized set of basic guidelines7:

  • Each hospital should have a medical staff

  • The members of the medical staff should be chosen on the basis of graduation from medical school, competency, and character

  • There should be regular staff meetings to review cases

  • Medical records should be written and filed for all cases

  • Each hospital should have a clinical laboratory and radiology section.

These standards were based on Codman’s belief in the value of meritocracy and embodied his end result system, including the concept of morbidity and mortality conferences and patient tracking. Only 89 of the 692 existing hospitals met these basic standards, and Codman’s efforts were widely rebuffed at the time.8 But others saw the value of Codman’s insights, and eventually his ideas were endorsed.

Codman’s attempts to promote his system were also opposed in the Boston community. To raise awareness of his cause, Codman presented the “Back Bay golden goose ostrich” cartoon at a meeting of the Suffolk District Medical Society in Boston in 1915 (fig 2).8 The controversial cartoon depicted an ostrich (representing the public/patients, labeled by a section of Boston known as Back Bay) laying golden eggs with its head buried in the sand. A caricature of the Harvard president, A Lawrence Lowell, contemplated whether his employees could continue making money if the truth about the outcomes of their clinical services was known publicly. The cartoon highlighted how the fee-for-service system made doctors rich through poor quality medical care and encouraged overtreatment. It noted how Harvard’s leaders oversaw ethical actions and suggested that this broken healthcare marketplace created a moral dilemma. One trustee was depicted scratching his head and questioning the system. The cartoon caused much indignation. Codman was quickly asked to resign as chairman of the society. Today, recognizing Codman’s achievements and prophetic vision, Harvard has come full circle; the ostrich cartoon currently hangs in the Harvard medical school library, and the Massachusetts General Hospital’s quality and safety department is named the Codman Center.


Fig 2 “Back Bay golden goose ostrich” cartoon, reproduced with permission from Boston Medical Library in the Francis A Countway Library of Medicine

Despite these setbacks, Codman pushed on with his cause. In 1920, he developed the first national registry to track bone sarcoma cases 9 after receiving a $1000 gift from a patient’s family (fig 3).1 The American College of Surgeons (ACS) soon followed with an additional $8000 in support. However, the implementation of patient tracking proved more difficult than anticipated; despite multiple solicitations to the 7000 members of the ACS, Codman collected only 17 cases to add to his database.10 Nonetheless, the concept of the national healthcare registry was born and has since been adopted throughout the world.


Fig 3 Dr Codman’s national registry of patient outcomes, reproduced with permission from Boston Medical Library in the Francis A Countway Library of Medicine

Codman died in 1940 in Ponkapog, Massachusetts, but his legacy lives on. Codman’s end result system is now the foundation for many quality improvement efforts, and medical transparency is emerging as a priority for many healthcare systems. In addition, transparency is a first step in current endeavors to tackle dangerous and costly variations in care. The problem of overtreatment, which Codman also warned about, is also the subject of many new efforts. Most recently, in a major 2012 report, the Institute of Medicine concluded that as much as a third of all US healthcare costs may be unnecessary and may not improve health outcomes.

Recent studies have shown how patient outcome registries can lead to scientific discovery and sustained improvements in quality. Despite these benefits, however, their adoption has been limited. Registries are expensive and they require auditing, outcome definitions, and sound data collection for outcomes to be measured in a standardized manner, as well as risk adjustment to make benchmarking fair. In a recent review, we found that only 19 of 117 medical specialties recognized by the American Medical Association house a clinical registry or are affiliated to a registry (H Lyu and colleagues, unpublished data, 2013). The new transparency movement to make healthcare registries more common and more robust should credit the man who pioneered the cause—Dr Ernest Amory Codman.


Cite this as: BMJ 2013;347:f7368


  • Thanks to Scott H Podolsky, director of the Center for the History of Medicine at Harvard University’s Countway Medical Library; Jack Eckert, public services librarian at Harvard University’s Countway Library of Medicine; and Wen T Shen, assistant professor in residence, Department of Surgery, University of California San Francisco for their help in obtaining invaluable biographical information and figures related to Ernest A Codman’s life.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: MAM receives publisher royalties for medical books.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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