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Healthcare Org 1, 1.19 (V) [FUN] Video - Topic 4 - E.A. Codman, An MGH Legend (2)

from having been discovered in Germany and he was one of the first people to study x-rays in in 1895 and thereafter and he particularly used them looking at obviously bones as you'll hear from his his orthopedic career but also looking at GI function and it may be that exposure to x-rays at that time in his life may have sterilized them and may ultimately have led to his his terminal illness although maybe not because people really didn't understand the risk of x-rays at all unfortunately for Codman he didn't study them for a long long time otherwise he probably would have been more impaired I published multiple articles on general surgery which was one of the principal functions of the department at the time that he practiced he wrote a seminal series of cases about bone mass sarcoma and with several colleagues presented a way of naming and classifying bone cancers which are rare and it takes a lot of digging to put a series of cases together he wrote a classic text on on the shoulder and I'll talk a little bit about that later on there's a cover a picture of the cover that purple picture there on the poster and and then the end results idea which is what I'll talk about mostly so the end result system and his words in the box on the left here is it's the common sense idea that every hospital should follow every patient at treats long enough to whether the treatment was successful and if not inquire why not so that you can successfully successively improve the results of what you're doing the end result system required keeping a record and he I'll show you a few pictures of how he kept records and it requires also some level of self-assessment and you could see on the right that every misadventure every case that lacked perfection I should be explained under his system by either a lack of knowledge or skill a problem with surgical judgment lack of care equipment lack of diagnostic skill unconquered bull disease and patient refusal and these terms were actually still in active use I can't attest to whether they're in active use today but when I was training every case that we reviewed in our surgical morbidity and mortality conference was ascribed to one of these categories and the most sort of painful one to accept was was an error in judgment that was the biggest condemnation I think that you could make of a of a surgeon and a surgical misadventure he also acknowledged that calamities of surgery mistakes actually technical mistakes in the operating room occur and need to be studied to be prevented sort of a premonition about what ultimately became the patient safety movement many years later so these are his cards the cards have a little hole punched at the bottom so they can fit in a file drawer of the way cards do in a library in the old-fashioned card catalogs and you can see that they're typed and they have data around the hospital number and the demographics a small amount the date of operation the description and then the complications and these are kept in a file these are actually the end results cards from from Cadman's hospital which I'll talk about a little bit more in the minute minute but you can see what was on them and and the results that are then compiled subsequently this was not easy for people to accept and Codman in his usual forthright way had a retort for every objection that came up so the first objection is it's too complicated to keep all this information and his response was try it and see too expensive try it and see if it doesn't save money too difficult for the House staff so let the senior surgeon do it and doesn't give the sex or age but it also doesn't give the color of hair and I so who cares is the message there this activity that he did led to quite a bit of national notoriety and when the American College of Surgeons was formed in 1912 so now he's been on the staff at MGH for ten years the committee that was established to sort of carry on his work was called the committee of standardization of hospitals and he was appointed his chair and there were some other very famous and very much more senior and more renowned surgeons on that committee and just to state briefly what then happened to that committee and I'll come back to this a little bit later on but they began doing inspections in sort of a haphazard way they started doing on-site Hospital inspections in 1918 failed almost 90% of the hospitals that they evaluated using just a one-page list of requirements and then within ten years came out with a standards manual which was a bit more expanded over the original page now the importance of this can't be overstated because there literally were no standards for surgery prior to this committee and the work of the committee and one of his very exalted colleagues whose name is Edward Martin who was one of the principals in the forming of the American College of Surgeons had the following quote that the end results idea the tale is more important than the dog which is the American College of Surgeons but we have to have the dog too detail so this was his how he was assessed by one of his very esteemed colleagues now in 1911 for a variety of reasons and I'll get into them a little more subsequently Kahneman decided to open his own hospital because he had these very strong ideas and strong beliefs as to how surgery could be best conducted and how it could be best broadcast to the public and he really couldn't get that done at an institution like MGH where he was still relatively junior so he opened his own private hospital again on Beacon Hill on Pinkney Street and what he did at that hospital which is sort of incredible to think that this was a hundred years ago is he not only measured the end results for every patient but he also published them and in the publication that has the results the the the preamble cites that the object of having standards is to raise them and then he made this amazing guarantee which is a patient who comes to the Codman hospital will get a refund if the result is is unsatisfactory a year later and we will acknowledge the error publicly in our hospital report and the doctors were reappointed annually at this time he wrote this book about the Codman hospital which he entitled the study and hospital efficiency and you're going to start to get a flavor of his his sort of barbed personality here Richard Cabot was his good friend Richard Cabot was was a MGH leader and trustee and a very important figure in the history of MGH his sister actually founded the field of Social Work and and so Godman dedicated this book with a backhanded compliment to Richard Cabot which says I respect his motives admire his courage and energy but heartily disapprove of some of his opinions and methods he wants to reform from the bottom of the I think the blame belongs at the top he then around the same time 1914 the same year as the the Committee on standards was formed he decided to resign from the MGH staff so the Codman Hospital had been open and running he resigned from the staff and protests against the seniority system he subsequently sent the board a letter suggesting if they so choose he'd be happy to be reappointed if they wanted to make him the surgeon in chief because his results were better than the rest of the staff and he would resolve to improve things overall in his comments about this later on he said trustees cannot understand this attitude that a man should give up a comfortable position and be take the same position again even though the position is very comfortable and and have to hold on to it by merit and his comment is such a man they distrust and this reminds me and this is where I start getting a little more off on a tangent this reminds me of a great quote from Shakespeare this is from Julius Caesar and this is Julius Caesar commenting on Cassius and says let me have men about me that are fat sleep sleek headed men the kind that sleep at night Cassius has a lean and hungry look he thinks too much such men are dangerous so that was a the way Codman thinks the board felt about him so the cartoon meeting was really the culmination of the early Codman story he was the chairman of the Suffolk district medical society they had intermittent public meetings for the physicians they met I believe it was at the Boston Public Library and and he had convened the meeting and the topic of the meeting to discuss his favorite subject hospital efficiency which is what he describes as measuring outcomes and ensuring that the hospital care delivers value from the resources expended for the patient that are cared for he invited the president of Harvard and the MGH General Director they declined to attend which as you'll see was probably a good thing but he did get mayor Curley who is famous for having spent part of his time as mayor in prison in Boston but at this point he was very popular and very flamboyant and actually attracted quite a significant crowd that evening there were six speakers the program went on for about two hours one of the first speakers was a guy named Gilbreth who is probably known to many here in the room for a completely different reason this is the guy that Cheaper by the Dozen was written about so the guy the efficiency time and motion expert who had 12 kids and had all sorts of ways of finagling the world via having 12 kids was one of one of Kahneman's disciples and he spoke about the importance of accurate measurement and termed a hospital happiness factory which i think is probably not exactly a correct description and then another one Dickinson made the statement below which I've heard many times in many other forms and over the course of my career is that there's nothing that can't be standardized basically being done being done right now in hospitals the cartoon you can see it over on the wall I'm going to put it up here and describe it in some detail but the actual size of the cartoon is it's about six feet long it was written on drawn on Brown construction paper sort of wrapping paper and it was done by a friend of his who was an artist he didn't do it himself and it's not in color most of the reproductions you see of it are in black and white the original is in the in the count well Conway library and it's quite frail because it's folded into three segments so where it's folded it it has has cracked a little bit and he put up the cartoon and then basically went on a diatribe while the cartoon was up basically telling the audience they were about of fools who were not paying attention to what was going on around him and he subsequently resigned and sort of a flurry of adverse publicity so here's the cartoon and as I said I'll talk a little bit in detail about this but before I talk about what's on it I want to point out that this picture and that picture there were a product of the intrepid spirit of Hardy hendren and Hardy Hendren is another ham g.h legend pediatric surgeon who finished his career as chief over at Children's and Hardy is the most determined person I think I've ever met those of you who know him he is a in unstoppable force and he decided he wanted a copy of his own a quality digital photograph of the Codman cartoon and I would love to have watched the scene as they people in Conway library tried to tell him that it couldn't be photographed and it was too frail because Hardy literally isn't unstoppable so he took this fantastic picture it's a 38 megabyte file so it used to actually be really hard to pass around but if anybody wants it I've got it and I'm happy to share it with you so if you've got plenty of room in your inbox send me an email and I'll email too it's a it's a wonderful picture and actually sits in the center for quality and safety at MGH and about that size up on the wall and I won't go over every facet of it but the basic idea behind the picture is there's a an ostrich with its head in the sand as as is the classic ostrich pose and these are golden eggs so the the ostrich is kicking golden eggs out to the doctors to sort of fuel the economics of their practices and then there's three other elements of the picture so there is the bullfinch building and the MGH trustees there's the massive bridge with president Lowell of Harvard standing on it and then over here there's Harvard Medical School and I think the writing on it some of its a little fuzzier than others but I think the the most pithy part of the writing is if we let her know the truth about our patients do you suppose she would still be willing to lay so the implication is is that people are getting rich practicing medicine but they're not doing much for the well-being of their patients and a little detail down here he referred to humbug several times in his critique of the of the medical audience and that's a little humbug drawn there next to that where the ostrich has its head in the sand so I looked up the word humbug and we all know this word from The Wizard of Oz so it has kind of an innocent child lachemann of goofy feel in modern days but in ancient times as in when Godman was practicing it was a pretty severe insult to be told that you were a practitioner of humbug willful false deceptive insincere pretence deception it was really a pretty nasty thing to call somebody and I'd well also was a piece of mint flavored candy - which is not not relevant so the reactions to the cartoon these are in balance book I think they're phenomenal and I put them up in the same order as he did so Shattuck who was a good friend said can no one differ with you without being a neighbor a fool you retarded rather than advancing your cause last night this is in reference to the cartoon meeting a Southwick said your determination to separate yourself from your friends but of course which strikes me is too radical in some points a to now even others seems quite Teutonic so you have to remember this was right around the time of Prussia and Kaiser Wilhelm in the start of World War one so I I thought the term Teutonic was pretty great in this context and then the last one which was unsigned is ends with wondering if you are mentally deranged because how could anyone have made such a stupid blunder so I I attribute this and this is another sort of little foray into classics attribute this to the hubris that that that that Codman had had built up and he was very confident that he knew what was right he had his hospital he had his reporting system it was absolutely self-evident to him that this was a better way of caring for patients and that anyone who could not see that and who could not adapt to it was it was a fool and you know a lot of times the person with great hubris is also correct so the two are not mutually exclusive but hubris is sort of the great tragedy of mankind hubris is what brings great people of either gender down from the mountaintop and it's been around forever it was sort of the heart of Greek tragedy every great Greek tragedy the the hero is confounded by by his or her own hubris and it also I think in in in a lot of ways is you see it in in day to day life I have to say that the biggest mistakes I've ever made in my life were when I was totally confident that I was right and knew exactly what I was doing so hubris is there in the back of our mind all the time and I think for for for Codman his hubris got the better of him he was sitting on top of his profession he was headed for leadership and everything and and greatness but he was too impatient and too arrogant to wait and and work the system to get what he wanted accomplished so as a result he basically descended into insignificance and one of the things that I'd like to show you is is a little habit from ancient Greece that some of you may know about which is called ostracism and this was an Athenian custom during Athenian democracy where the people of Athens the voting people of Athens could annually decide that they wanted to besides one of their own and it's called ostracism the word ostracism arises because these little shards of pottery are called a Stratos and they were basically like scratch paper they were all over the place because people are always breaking pots they were of no value and you could scratch him and you could write a name on them and so once a year the Athenians would get together and they would have a vote and if the lead candidate made it to a certain number of votes that person would be ostracized from Athens and forced to live the next ten years in exile and it was sort of a merciful custom in some ways and that his possessions were not confiscated and and moreover he could come back as a citizen in good standing after ten years and in fact sometimes the Athenians by invited people back early from their ostracism because they decided maybe the guy wasn't so bad after all and I show a couple of these just to give you an idea what they look like this one here that's Pericles maybe the greatest leader in early democracy anywhere so even he got his name on a on a shard of pottery he never got ostracized but sometimes people would actually take the time to write a message and I put this one up because I thought it was good this was a more typical ostracism he's cursed for being a rascal too long as he abused our hospitality and that individual actually did get ostracized so what happened Codman was in essence an ostracism he resigned from MGH he resigned from his chairmanship of this Society and he basically then vanished for about ten years and now what happened was obviously World War one was in full swing and when the great explosion occurred in the Halifax harbor cogman volunteered to go and help give aid to the people and Halifax because the city had been devastated when that work was concluded he joined the army and went to a camp learn in Kentucky and of course applied the end results system to the treatment of soldiers there and then when he came back after the war he practiced from his home and he kept working on bone sarcoma and then eventually came back into the fold and MGH after about a ten-year exile and was reappointed on the staff began to see patients and conduct clinical research he received some honors later in his life I think almost surely a fraction of what he would have received if he had persevered and and sort of worked within the system with a little bit more patience I mentioned his great book in 1934 the shoulder book it was self financed he was elected an honorary member of the Young Society for a radiologists and also received a gold medal from the American Academy of Orthopaedic for his bone sarcomas work in 1940 so he died in November of 1940 he was about at that point just seventy years old he died of melanoma most likely for him all is outdoor time possibly because of his radiation exposure and he's buried in Mount Auburn cemetery and I put up a list of some kind of an eclectic list of some of the famous people that are buried in Mount Auburn cemetery it is one fabulous place to visit for those of you who have never walked through pond Auburn cemetery it's very easily accessible and there's people who are as varied as buckminster fuller and Oliver Wendell Holmes Edwin land from Polaroid Fame Longfellow the author of the natural Bernard Malamud and and others so it's really quite a cemetery it has incredible trees and and grounds and has actually if you go up to the top of the hill there it has a fabulous view of Boston he did not repent at any time over this this return from ostracism and in his book the shoulder there's this little cartoon that basically says the shoulder book is what sort of floated the the vessel here but again it was in order to give him a chance to broadcast the end results idea and a good piece of the shoulder book is an epilogue and prologue that are basically on the concept of end results and this is his own epitaph in some ways that some persons honor is honest the man with tact enough to make no enemies and a values the love of this generation others regard that man is unselfish who seeks truth so sternly he will not permit a lie to exist even among his friends and clearly that's what Codman considered his his pathway to have been in the final sort of wrap up of this the committee of State on standards as many of you know was divested by the American College not until the 1950s and became the Joint Commission which is the leading authority for accrediting hospitals today it's actually not active right now but the ACS for excuse me the JCT for many years gave a quality award named after a Codman and then very importantly he'd been buried in the Bowditch family plot at at Mount Auburn cemetery but with no grave marker and do I think largely to dr. war shows efforts within the American College of Surgeons and sort of some inspiration that a number of other members of both the orthopaedic academies and the American College of surgery a marker was placed in the bowdish family plot remembering him and that ceremony as you've heard was this summer and at the bottom of the of the copper plaque which will obviously whether to a beautiful green over the decades it says it may take a hundred years for my ideas to be accepted which is is another one of Kahneman's quotes so thanks very much for your attention I hope you hearing about this incredibly



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from having been discovered in Germany and he was one of the first people to study x-rays in in 1895 and thereafter and he particularly used them looking at obviously bones as you'll hear from his his orthopedic career but also looking at GI function and it may be that exposure to x-rays at that time in his life may have sterilized them and may ultimately have led to his his terminal illness although maybe not because people really didn't understand the risk of x-rays at all unfortunately for Codman he didn't study them for a long long time otherwise he probably would have been more impaired I published multiple articles on general surgery which was one of the principal functions of the department at the time that he practiced he wrote a seminal series of cases about bone mass sarcoma and with several colleagues presented a way of naming and classifying bone cancers which are rare and it takes a lot of digging to put a series of cases together he wrote a classic text on on the shoulder and I'll talk a little bit about that later on there's a cover a picture of the cover that purple picture there on the poster and and then the end results idea which is what I'll talk about mostly so the end result system and his words in the box on the left here is it's the common sense idea that every hospital should follow every patient at treats long enough to whether the treatment was successful and if not inquire why not so that you can successfully successively improve the results of what you're doing the end result system required keeping a record and he I'll show you a few pictures of how he kept records and it requires also some level of self-assessment and you could see on the right that every misadventure every case that lacked perfection I should be explained under his system by either a lack of knowledge or skill a problem with surgical judgment lack of care equipment lack of diagnostic skill unconquered bull disease and patient refusal and these terms were actually still in active use I can't attest to whether they're in active use today but when I was training every case that we reviewed in our surgical morbidity and mortality conference was ascribed to one of these categories and the most sort of painful one to accept was was an error in judgment that was the biggest condemnation I think that you could make of a of a surgeon and a surgical misadventure he also acknowledged that calamities of surgery mistakes actually technical mistakes in the operating room occur and need to be studied to be prevented sort of a premonition about what ultimately became the patient safety movement many years later so these are his cards the cards have a little hole punched at the bottom so they can fit in a file drawer of the way cards do in a library in the old-fashioned card catalogs and you can see that they're typed and they have data around the hospital number and the demographics a small amount the date of operation the description and then the complications and these are kept in a file these are actually the end results cards from from Cadman's hospital which I'll talk about a little bit more in the minute minute but you can see what was on them and and the results that are then compiled subsequently this was not easy for people to accept and Codman in his usual forthright way had a retort for every objection that came up so the first objection is it's too complicated to keep all this information and his response was try it and see too expensive try it and see if it doesn't save money too difficult for the House staff so let the senior surgeon do it and doesn't give the sex or age but it also doesn't give the color of hair and I so who cares is the message there this activity that he did led to quite a bit of national notoriety and when the American College of Surgeons was formed in 1912 so now he's been on the staff at MGH for ten years the committee that was established to sort of carry on his work was called the committee of standardization of hospitals and he was appointed his chair and there were some other very famous and very much more senior and more renowned surgeons on that committee and just to state briefly what then happened to that committee and I'll come back to this a little bit later on but they began doing inspections in sort of a haphazard way they started doing on-site Hospital inspections in 1918 failed almost 90% of the hospitals that they evaluated using just a one-page list of requirements and then within ten years came out with a standards manual which was a bit more expanded over the original page now the importance of this can't be overstated because there literally were no standards for surgery prior to this committee and the work of the committee and one of his very exalted colleagues whose name is Edward Martin who was one of the principals in the forming of the American College of Surgeons had the following quote that the end results idea the tale is more important than the dog which is the American College of Surgeons but we have to have the dog too detail so this was his how he was assessed by one of his very esteemed colleagues now in 1911 for a variety of reasons and I'll get into them a little more subsequently Kahneman decided to open his own hospital because he had these very strong ideas and strong beliefs as to how surgery could be best conducted and how it could be best broadcast to the public and he really couldn't get that done at an institution like MGH where he was still relatively junior so he opened his own private hospital again on Beacon Hill on Pinkney Street and what he did at that hospital which is sort of incredible to think that this was a hundred years ago is he not only measured the end results for every patient but he also published them and in the publication that has the results the the the preamble cites that the object of having standards is to raise them and then he made this amazing guarantee which is a patient who comes to the Codman hospital will get a refund if the result is is unsatisfactory a year later and we will acknowledge the error publicly in our hospital report and the doctors were reappointed annually at this time he wrote this book about the Codman hospital which he entitled the study and hospital efficiency and you're going to start to get a flavor of his his sort of barbed personality here Richard Cabot was his good friend Richard Cabot was was a MGH leader and trustee and a very important figure in the history of MGH his sister actually founded the field of Social Work and and so Godman dedicated this book with a backhanded compliment to Richard Cabot which says I respect his motives admire his courage and energy but heartily disapprove of some of his opinions and methods he wants to reform from the bottom of the I think the blame belongs at the top he then around the same time 1914 the same year as the the Committee on standards was formed he decided to resign from the MGH staff so the Codman Hospital had been open and running he resigned from the staff and protests against the seniority system he subsequently sent the board a letter suggesting if they so choose he'd be happy to be reappointed if they wanted to make him the surgeon in chief because his results were better than the rest of the staff and he would resolve to improve things overall in his comments about this later on he said trustees cannot understand this attitude that a man should give up a comfortable position and be take the same position again even though the position is very comfortable and and have to hold on to it by merit and his comment is such a man they distrust and this reminds me and this is where I start getting a little more off on a tangent this reminds me of a great quote from Shakespeare this is from Julius Caesar and this is Julius Caesar commenting on Cassius and says let me have men about me that are fat sleep sleek headed men the kind that sleep at night Cassius has a lean and hungry look he thinks too much such men are dangerous so that was a the way Codman thinks the board felt about him so the cartoon meeting was really the culmination of the early Codman story he was the chairman of the Suffolk district medical society they had intermittent public meetings for the physicians they met I believe it was at the Boston Public Library and and he had convened the meeting and the topic of the meeting to discuss his favorite subject hospital efficiency which is what he describes as measuring outcomes and ensuring that the hospital care delivers value from the resources expended for the patient that are cared for he invited the president of Harvard and the MGH General Director they declined to attend which as you'll see was probably a good thing but he did get mayor Curley who is famous for having spent part of his time as mayor in prison in Boston but at this point he was very popular and very flamboyant and actually attracted quite a significant crowd that evening there were six speakers the program went on for about two hours one of the first speakers was a guy named Gilbreth who is probably known to many here in the room for a completely different reason this is the guy that Cheaper by the Dozen was written about so the guy the efficiency time and motion expert who had 12 kids and had all sorts of ways of finagling the world via having 12 kids was one of one of Kahneman's disciples and he spoke about the importance of accurate measurement and termed a hospital happiness factory which i think is probably not exactly a correct description and then another one Dickinson made the statement below which I've heard many times in many other forms and over the course of my career is that there's nothing that can't be standardized basically being done being done right now in hospitals the cartoon you can see it over on the wall I'm going to put it up here and describe it in some detail but the actual size of the cartoon is it's about six feet long it was written on drawn on Brown construction paper sort of wrapping paper and it was done by a friend of his who was an artist he didn't do it himself and it's not in color most of the reproductions you see of it are in black and white the original is in the in the count well Conway library and it's quite frail because it's folded into three segments so where it's folded it it has has cracked a little bit and he put up the cartoon and then basically went on a diatribe while the cartoon was up basically telling the audience they were about of fools who were not paying attention to what was going on around him and he subsequently resigned and sort of a flurry of adverse publicity so here's the cartoon and as I said I'll talk a little bit in detail about this but before I talk about what's on it I want to point out that this picture and that picture there were a product of the intrepid spirit of Hardy hendren and Hardy Hendren is another ham g.h legend pediatric surgeon who finished his career as chief over at Children's and Hardy is the most determined person I think I've ever met those of you who know him he is a in unstoppable force and he decided he wanted a copy of his own a quality digital photograph of the Codman cartoon and I would love to have watched the scene as they people in Conway library tried to tell him that it couldn't be photographed and it was too frail because Hardy literally isn't unstoppable so he took this fantastic picture it's a 38 megabyte file so it used to actually be really hard to pass around but if anybody wants it I've got it and I'm happy to share it with you so if you've got plenty of room in your inbox send me an email and I'll email too it's a it's a wonderful picture and actually sits in the center for quality and safety at MGH and about that size up on the wall and I won't go over every facet of it but the basic idea behind the picture is there's a an ostrich with its head in the sand as as is the classic ostrich pose and these are golden eggs so the the ostrich is kicking golden eggs out to the doctors to sort of fuel the economics of their practices and then there's three other elements of the picture so there is the bullfinch building and the MGH trustees there's the massive bridge with president Lowell of Harvard standing on it and then over here there's Harvard Medical School and I think the writing on it some of its a little fuzzier than others but I think the the most pithy part of the writing is if we let her know the truth about our patients do you suppose she would still be willing to lay so the implication is is that people are getting rich practicing medicine but they're not doing much for the well-being of their patients and a little detail down here he referred to humbug several times in his critique of the of the medical audience and that's a little humbug drawn there next to that where the ostrich has its head in the sand so I looked up the word humbug and we all know this word from The Wizard of Oz so it has kind of an innocent child lachemann of goofy feel in modern days but in ancient times as in when Godman was practicing it was a pretty severe insult to be told that you were a practitioner of humbug willful false deceptive insincere pretence deception it was really a pretty nasty thing to call somebody and I'd well also was a piece of mint flavored candy - which is not not relevant so the reactions to the cartoon these are in balance book I think they're phenomenal and I put them up in the same order as he did so Shattuck who was a good friend said can no one differ with you without being a neighbor a fool you retarded rather than advancing your cause last night this is in reference to the cartoon meeting a Southwick said your determination to separate yourself from your friends but of course which strikes me is too radical in some points a to now even others seems quite Teutonic so you have to remember this was right around the time of Prussia and Kaiser Wilhelm in the start of World War one so I I thought the term Teutonic was pretty great in this context and then the last one which was unsigned is ends with wondering if you are mentally deranged because how could anyone have made such a stupid blunder so I I attribute this and this is another sort of little foray into classics attribute this to the hubris that that that that Codman had had built up and he was very confident that he knew what was right he had his hospital he had his reporting system it was absolutely self-evident to him that this was a better way of caring for patients and that anyone who could not see that and who could not adapt to it was it was a fool and you know a lot of times the person with great hubris is also correct so the two are not mutually exclusive but hubris is sort of the great tragedy of mankind hubris is what brings great people of either gender down from the mountaintop and it's been around forever it was sort of the heart of Greek tragedy every great Greek tragedy the the hero is confounded by by his or her own hubris and it also I think in in in a lot of ways is you see it in in day to day life I have to say that the biggest mistakes I've ever made in my life were when I was totally confident that I was right and knew exactly what I was doing so hubris is there in the back of our mind all the time and I think for for for Codman his hubris got the better of him he was sitting on top of his profession he was headed for leadership and everything and and greatness but he was too impatient and too arrogant to wait and and work the system to get what he wanted accomplished so as a result he basically descended into insignificance and one of the things that I'd like to show you is is a little habit from ancient Greece that some of you may know about which is called ostracism and this was an Athenian custom during Athenian democracy where the people of Athens the voting people of Athens could annually decide that they wanted to besides one of their own and it's called ostracism the word ostracism arises because these little shards of pottery are called a Stratos and they were basically like scratch paper they were all over the place because people are always breaking pots they were of no value and you could scratch him and you could write a name on them and so once a year the Athenians would get together and they would have a vote and if the lead candidate made it to a certain number of votes that person would be ostracized from Athens and forced to live the next ten years in exile and it was sort of a merciful custom in some ways and that his possessions were not confiscated and and moreover he could come back as a citizen in good standing after ten years and in fact sometimes the Athenians by invited people back early from their ostracism because they decided maybe the guy wasn't so bad after all and I show a couple of these just to give you an idea what they look like this one here that's Pericles maybe the greatest leader in early democracy anywhere so even he got his name on a on a shard of pottery he never got ostracized but sometimes people would actually take the time to write a message and I put this one up because I thought it was good this was a more typical ostracism he's cursed for being a rascal too long as he abused our hospitality and that individual actually did get ostracized so what happened Codman was in essence an ostracism he resigned from MGH he resigned from his chairmanship of this Society and he basically then vanished for about ten years and now what happened was obviously World War one was in full swing and when the great explosion occurred in the Halifax harbor cogman volunteered to go and help give aid to the people and Halifax because the city had been devastated when that work was concluded he joined the army and went to a camp learn in Kentucky and of course applied the end results system to the treatment of soldiers there and then when he came back after the war he practiced from his home and he kept working on bone sarcoma and then eventually came back into the fold and MGH after about a ten-year exile and was reappointed on the staff began to see patients and conduct clinical research he received some honors later in his life I think almost surely a fraction of what he would have received if he had persevered and and sort of worked within the system with a little bit more patience I mentioned his great book in 1934 the shoulder book it was self financed he was elected an honorary member of the Young Society for a radiologists and also received a gold medal from the American Academy of Orthopaedic for his bone sarcomas work in 1940 so he died in November of 1940 he was about at that point just seventy years old he died of melanoma most likely for him all is outdoor time possibly because of his radiation exposure and he's buried in Mount Auburn cemetery and I put up a list of some kind of an eclectic list of some of the famous people that are buried in Mount Auburn cemetery it is one fabulous place to visit for those of you who have never walked through pond Auburn cemetery it's very easily accessible and there's people who are as varied as buckminster fuller and Oliver Wendell Holmes Edwin land from Polaroid Fame Longfellow the author of the natural Bernard Malamud and and others so it's really quite a cemetery it has incredible trees and and grounds and has actually if you go up to the top of the hill there it has a fabulous view of Boston he did not repent at any time over this this return from ostracism and in his book the shoulder there's this little cartoon that basically says the shoulder book is what sort of floated the the vessel here but again it was in order to give him a chance to broadcast the end results idea and a good piece of the shoulder book is an epilogue and prologue that are basically on the concept of end results and this is his own epitaph in some ways that some persons honor is honest the man with tact enough to make no enemies and a values the love of this generation others regard that man is unselfish who seeks truth so sternly he will not permit a lie to exist even among his friends and clearly that's what Codman considered his his pathway to have been in the final sort of wrap up of this the committee of State on standards as many of you know was divested by the American College not until the 1950s and became the Joint Commission which is the leading authority for accrediting hospitals today it's actually not active right now but the ACS for excuse me the JCT for many years gave a quality award named after a Codman and then very importantly he'd been buried in the Bowditch family plot at at Mount Auburn cemetery but with no grave marker and do I think largely to dr. war shows efforts within the American College of Surgeons and sort of some inspiration that a number of other members of both the orthopaedic academies and the American College of surgery a marker was placed in the bowdish family plot remembering him and that ceremony as you've heard was this summer and at the bottom of the of the copper plaque which will obviously whether to a beautiful green over the decades it says it may take a hundred years for my ideas to be accepted which is is another one of Kahneman's quotes so thanks very much for your attention I hope you hearing about this incredibly


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