Looking forward – September 2014

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Dr. Mallon

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“It may take a hundred years for my ideas to be accepted.” —Ernest Amory Codman, MD, FACS

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Dr. Codman’s great-nieces, Elizabeth Snyder (left) and Virginia Harlan

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From left: Dr. Polack, Dr. Hendren, Dr. Hoyt, Dr. McGinnis, Dr. Warshaw, Mr. Altshuler, and Dr. DuPree

David B. Hoyt, MD, FACS

Few surgeons in the early 20th century could have predicted that outcomes measurement, public reporting, and patient-centered care would be hallmarks of the 21st century U.S. health care delivery system. One surgeon, however, did have this prescient vision: Ernest Amory Codman, MD, FACS, who first promoted these practices in his “end result idea.” Though much reviled at the time, this concept—which called for monitoring patient outcomes after discharge to determine which treatments worked and which didn’t and then sharing this information to improve patient care—now guides the quality improvement programs that the American College of Surgeons (ACS), other organizations, and government agencies have implemented.

To recognize the valiant contributions that Dr. Codman has made to American surgery and to patient care, the ACS and other groups that have benefited from his wisdom agreed to place a headstone at his previously unmarked interment site in Mount Auburn Cemetery, Cambridge, MA. Leaders of these organizations gathered at a dedication ceremony on July 22 to pay homage to the maverick surgeon from Boston.

Efforts to have a headstone placed at Dr. Codman’s gravesite were initiated soon after publication of a Bulletin article by ACS Past-President LaMar S. McGinnis, Jr., MD, FACS. In that article, Dr. McGinnis noted that when Dr. Codman died in 1940 of melanoma, he had limited financial means and asked his wife not to have a marker placed on her family’s burial lot, where his ashes were to be stored. Dr. McGinnis added, “I believe that The Joint Commission, the American Cancer Society, the American College of Surgeons, and the American Academy of Orthopaedic Surgeons should erect a headstone at the gravesite to properly acknowledge this visionary and our debt to him.”*

All of these organizations, as well as the West Virginia Chapter of the ACS; Massachusetts General Hospital (MGH), where Dr. Codman practiced for much of his career; the American Shoulder and Elbow Society; and the American Orthopaedic Association, contributed to the cause financially and/or sent representatives to the memorial service. (For a list of donors, visit the ACS website.)

Celebration of an extraordinary life

At the dedication ceremony, Dr. McGinnis and other champions of Dr. Codman’s work described his life and enumerated “the improper Bostonian’s” legendary contributions to surgery and medicine. Other speakers included Andrew L. Warshaw, MD, FACS, ACS President-Elect, and, like Dr. Codman, a “Preparation H” surgeon, meaning he studied, trained, and taught at Harvard Medical School; William J. (Bill) Mallon, MD, FACS, author of the definitive biography on Dr. Codman; E. Philip S. Polack, MD, FACS, who led the charge in West Virginia to raise money for a headstone; Erin S. DuPree, MD, chief medical officer and vice-president of The Joint Commission Center for Transforming Healthcare; and Boston pediatric surgeon W. Hardy Hendren III, MD, FACS, former Second Vice-President of the ACS (see Order of Service).

Order of Service

Ernest Amory Codman, MD, FACS

Memorial of His Life

Gathering at Grave Site

Opening Comments
David B. Hoyt, MD, FACS, ACS Executive Director

Memories of Dr. Codman and His Importance
LaMar S. McGinnis, Jr., MD, FACS, ACS Past-President

Anecdotes from His Life in Boston
Andrew L. Warshaw, MD, FACS, ACS President-Elect

Historical Personal Comments
W. Hardy Hendren, MD, FACS, ACS Past Second Vice-President

Comments on Dr. Codman’s Life in Medicine
William J. (Bill) Mallon, MD, FACS, author of Ernest Amory Codman: The End Result of a Life in Medicine, and editor-in-chief, Journal of Shoulder & Elbow Surgery

Comments—West Virginia Chapter
E. Phillip S. Polack, MD, FACS, Past-President, West Virginia Chapter

Comments—The Joint Commission
Erin S. DuPree, MD, chief medical officer and vice-president, The Joint Commission Center for Transforming Healthcare

Closing Comments
Dr. Hoyt

Bigelow Chapel

The other speakers and I described Dr. Codman’s influential career. We spoke of the “ether chart” that he and Harvey Cushing, MD, FACS, devised to document and demonstrate the safety of surgical anesthesia and of his role in presenting the first morbidity and mortality conference at MGH.

We acknowledged his pioneering work in diagnostic radiology, the multiple articles he wrote on the management of surgical complications of duodenal ulcer, and his contributions to the treatment of shoulder and wrist conditions.

We noted that the College and its affiliates owe a major debt to Dr. Codman for establishing the College’s first database—the Registry for Bone Sarcoma—and for his role in developing the ACS “Minimum Standards for Hospitals.”

Most of all, however, we thanked Dr. Codman for fighting to overcome the suboptimal conditions at many hospitals of the time, for fearlessly seeking solutions, and for being a crusader for the end result idea. We expressed our gratitude for his willingness to stand up for what he knew was right, even when the Boston medical establishment shunned him for his renegade ways. When the MGH establishment refused to embrace his recommendation that faculty earn promotions based on their outcomes rather than seniority, Dr. Codman started his own 12-bed hospital, which focused on implementation of the end result concept. He closed the faltering facility to tend to the needs of individuals who survived but were severely injured in the “Halifax explosion,” which occurred in December 1917 when a French cargo ship carrying wartime explosives collided with a Norwegian vessel off the coast ofNova Scotia. He then went on to contribute his expertise to caring for the troops fighting in World War I.

We spoke of his rebellious—some would say abrasive—streak, perhaps most apparent when, at a 1915 meeting of the Suffolk District Surgical Society, he unveiled the infamous cartoon of an ostrich with its head buried in the sand kicking golden eggs to Back Bay physicians. In his remarks, Dr. Hendren noted that for many years the only known copy of that illustration was smudged and difficult to read when reproduced. I am delighted to report that Dr. Hendren has procured a clean copy and presented it to the ACS at the dedication ceremony. (Watch a video of the dedication ceremony.)

In addition, two of Dr. Codman’s great-nieces attended the service. They recalled their visits with an uncle who was caring and gentle, enjoyed fishing and hunting, and loved his dog, who apparently suffered from a case of chronic canine halitosis.

Classic design for a timeless figure

The headstone we dedicated that sunny day in Cambridge pays fitting respect to this brilliant, enigmatic man. We selected classical sculptor, Daniel Altshuler of Gloucester, MA, to create the Codman memorial headstone based on his past experience in crafting similar works of art, including portrait heads of Nobel Prize Laureates Francis Harry Compton Crick and James Dewey Watson.

Dr. Warshaw and I selected some photos of Dr. Codman that Mr. Altshuler used to develop the bas-relief portrait on the headstone. Creating the headstone involved a painstaking process. He initially developed a drawing that he used to develop a clay model and finally the bronze cast of Dr. Codman with a caduceus on each side. Mr. Altshuler said that in crafting the portrait he sought to “capture this man’s seriousness and gentleness.” As the photo on page 9 reveals, he succeeded.

The bronze figure is set in the Quincy Granite used in most headstones at the historic cemetery. Complicating matters, the quarry that provided this stone in the past closed years ago. As a result, the artist worked closely with the cemetery to locate repurposed granite. In total, it took more than a year to complete the memorial headstone, but we were determined that this lasting tribute would reflect the exacting standards that Dr. Codman would have demanded.

It truly was an honor to participate in this long-overdue celebration of Dr. Codman’s life and enduring contributions to surgical patient care. But our salute to Dr. Codman cannot end with a memorial service. We must channel his spirit every day in our never-ending efforts to set the highest standards and to achieve better patient outcomes.

*McGinnis LS Jr. Common origins: The two ACSs—100 years of collaboration to improve the lives of cancer patients. Bull Am Coll Surg. 2012;97(4):6-15.

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