E.A. Codman and the Rhetoric of Battle: A Commentary

XWX T7HY HAVE WE NOT PURSUED ERNEST CODMAN'S vision to determine the end results of patient care? What he asks is simple-ineluctable. We intend to help out patients, he says, so let us find out how we are doing. Habit is not enough, he says, nor is impression, nor is seniority, nor is oath, nor is good intention. The key, he says, is learning-learning from our own well-intentioned experience. In uncharted terrain, he asks that we build compasses, simple ones of paper and pencil, checklists, tallies, counting, measuring, learning. He does not, in the main, doubt our sincerity; he doubts only our intuition. In darkness, an airplane can be upside down and the pilot unaware of it except for what his instruments tell him. Codman recommends instruments. Why not? What stops us? I could perhaps negate my own question by citing Avedis Donabedian's own career and achievements. Or I could avoid it by listing counterexamples: the vision of Wennberg (1984), the discipline of Brook et al. (1977), the exhortation of Williamson (1971), the precision of Palmer et al. (1985), and Ellwood's resonant call for outcomes management (1988). I could speak of modern bioscience filling our journals with clinical investigations of increasingly correct design. That part of our post-Codman history, the