Not the Last Word: Codman Was Right--Spread The Word.

S econd only to the discovery of insulin by Sir Frederick G. Banting, the development of an ‘‘End Result System’’ by Ernest A. Codman MD was the greatest contribution to general medicine by an orthopaedic surgeon. You may know Codman more for his eponymous Codman’s Triangle (made by the elevated periosteum adjacent to a long bone tumor) or for his classification of proximal humeral fractures (which is the basis of the current practice of defining such fractures in terms of ‘‘parts’’), but the End Result System outweighs them both, by far. The End Result System is based on a simple idea, radical in its day—that we can determine how well a treatment works by assessing how well a treatment works. (The pre-Codman approach was to consider how close a treatment aligned with the reigning theories of disease. For example, if depression is caused by excess black bile (melancholia, literally), a good treatment would be one that drains it, independent of the actual clinical costs and benefits). Codman stressed recording patient treatment outcomes—‘‘end results’’—as a means of discerning clinical effectiveness from clinical futility. For taking his theories to their logical conclusion, that surgeons should be evaluated by their outcomes, Codman lost his staff position at the Massachusetts General Hospital. Nonetheless, Codman’s approach has taken root. We may disagree regarding the nuances of evidence-based medicine, but few of us would ever employ a treatment without any empirical evidence in hand. That is Codman’s legacy, and countless patients have benefited accordingly. It may come as a surprise, then, that Dr. Donald Berwick recently suggested in the Journal of the American Medical Association (JAMA) [2] that maybe Codman was wrong. Dr. Berwick was dismayed by two studies [5, 11] that reported on complication and inpatient mortality rates by comparing hospitals that participated in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to those that did not. To Dr. Berwick, the observation that the improvements in complication and inpatient mortality rates at NSQIP hospitals were no better than that seen at nonparticipants somehow undermines the Codman approach. I disagree. A non-NSQIP hospital may show improvement without an explicit monitoring program of its own because good practices can be contagious. Take note: The JAMA studies that vex Dr. Berwick did not demonstrate a failure of improvement at those hospitals that collect data; rather, what was shown that the NSQIP hospitals’ improvement was manifest at nonparticipants as well. The simple explanation for this is that the good ideas, generated at NSQIP hospitals, travel to other institutions. After all, Landon and colleagues [10] have Not the Last Word Published online: 5 June 2015 The Association of Bone and Joint Surgeons1 2015