Codman, Ernest Amory (30 Dec. 1869-23 Nov. 1930), or Amory Codman, orthopedic surgeon and medical reformer, was born in Boston, the son of Elizabeth Hurd Codman and William Coombs Codman, a wealthy businessman. Codman spent his life in Boston as the talented son of one of the city's elite families. He received his early education at a private boarding school and entered high school at the scientifically oriented St. Marks's School, where in his senior year he won the prestigious Founder's Medal. Upon graduation in June 1887 Codman entered Harvard College, graduating with honors in June 1891 and moving on to Harvard Medical School. In medical school, Codman met Harvey Williams Cushing, a classmate who later became a pioneering neurosurgeon. Codman received his MD degree in June 1895 and went into surgical practice.

Codman's first medical post in 1895 was assistant surgeon to outpatients at Massachusetts General Hospital, where he began early investigation into the use of the X-ray. Working with Cushing, and later with the Harvard physiologist Walter Bradford Cannon, Codman developed considerable skill in X-ray photography. He compiled an encyclopedic collection of X-rays of the human skeleton, creating an early example of the X-ray atlas. Codman demonstrated a passion for thorough, systematic medical recordkeeping that would remain a hallmark of his scholarship.

While continuing working on X-rays in the laboratory of the Harvard physiologist Henry P. Bowditch, Codman met his future wife, Bowditch's niece, Katherine Bowditch. The two wed on 16 November 1899 and remained married for life. They had no children and seemed to pursue their separate, busy lives independently. Katherine Bowditch Codman became a prominent activist for social reform, involved with the effort to promote birth control and the women's suffrage movement.

At Massachusetts General Hospital, Codman developed skill and reputation as a surgeon. He rose through the ranks of the medical staff, advancing from assistant surgeon to surgeon to outpatients. Meanwhile, he developed a special expertise in orthopedic disorders of the shoulder, publishing a series of articles on the subject between 1906 and 1908, and in 1909 he devised an influential operative repair of the torn shoulder rotator cuff. His comprehensive textbook, The Shoulder, drew on data from 1,151 cases of shoulder disease and was still in use by physicians sixty years after publication.

During his early surgical career, Codman observed that surgeons paid little attention to the long-term outcomes from their operations. He promoted what he later termed the "End Results System." The idea was simple: Hospitals and surgeons would be required to collect long-term results of all surgical operations to show their accumulated effect on the patient. Codman never wrestled with the question of how to define these effects. He always referred in a general way to the results or outcomes of treatment, and proved most concerned with medical errors that might prevent good long-term results, at one point proposing a classification system distinguishing errors that were attributed to 1) lack of technical skill, 2) surgical judgment, 3) lack of diagnostic skill, or 4) failures in equipment. These ideas met with strong ambivalence among his surgical colleagues, especially when linked to Codman's notion that such tallies be used to publicly rank surgeons (A Study in Hospital Efficiency: The First Five Years [1918], p. 59).

Codman's efforts fit well with contemporary movements for medical reform. Codman allied himself briefly with reformers interested in the application to medical practice of scientific management and Taylorism, sharing their concern for the measurement of results to improve processes in industry, or surgery. He also took a hand in the successful efforts of his surgical colleagues to gain influence over the standardization of hospitals. Codman hoped that his End Results System would become a mechanism for regulating hospital practice. The formation of the influential American College of Surgeons in 1912 marked the creation of a Committee on the Standardization of Hospitals. Codman was named as the first chair and turned the Committee's work to the promotion of his system. From this national vantage, Codman was able to spread his ideas widely and witnessed their widespread rebuff. Codman became more vehement in his cause.

Codman's promotion for the End Results System peaked in January 1915 in Boston at a public meeting of the Suffolk District Medical Society. Codman, as chairman of the surgical section, surreptitiously arranged to use the meeting to expose the hypocrisy that he saw behind resistance to his reforms. Codman invited city politicians and hospital trustees, including President A. Lawrence Lowell of Harvard University (who declined to attend) and Boston's mayor, James Michael Curley, who accepted and opened the meeting. At the conclusion of the program, Codman took the stage with a surprise performance. The next day, Boston daily newspapers reported the outrage of his audience with headlines referring to the "ire" and "wrath" of the local response (Mallo, p. 77). Codman unrolled an eight-foot-long cartoon that caricatured the residents of Boston's elite Back Bay neighborhood as an ostrich with its head stuck in the sand. The scene suggested a cozy arrangement among Boston's academic physicians and the city's prominent university and hospitals. The wealthy ostrich laid the "golden eggs" of high medical fees but never looked up to assess the value of its medical services. Only the End Results System could provide such an assessment. President Lowell was shown in caricature musing on whether his medical professors could earn their incomes without such fraud. Codman asked his audience for a show of hands for those who believed in fraud.

Codman sacrificed his academic career in surgery to the cause of an increasingly radical-seeming reform. He continued to practice surgery in private practice using his own small hospital as a base, but he lost his affiliations with Harvard Medical School and with Massachusetts General Hospital and never regained similar standing in academic medicine. He traveled to Halifax, Nova Scotia, in 1917 to organize emergency surgical care for the thousands of victims of a catastrophic explosion of military munitions in Halifax harbor. He died 23 November 1940 in Ponkapog, Massachusetts.

Codman's efforts at reform derailed a conventionally successful academic surgical career and secured his reputation as an important gadfly in American medicine. A century after his first work on End Results, Codman continues to be cited by health-care reformers who note the commonsense appeal of his system and decry the continued absence from medicine of anything like it.

Codman's papers are found in the Rare Books and Special Collections of the Francis A. Countway Library of Medicine (Boston, Mass.). A bibliography of his published works appears in William J. Mallon, Ernest Amory Codman: The End Result of a Life in Medicine (2000), which also provides a comprehensive biography. The lengthy introduction to Ernest Amory Codman's The Shoulder: The Rupture of the Supraspinatus Tendon and Other Lesions in and About the Subacromial Bursa (1934) is autobiographical. Susan Reverby, "Stealing the Golden Eggs: Ernest Amory Codman and the Science and Management of Medicine," Bulletin of the History of Medicine 55 (1981): 156-171, entertainingly recounts Codman's unconventional assault on Boston's medical elite. Christopher Crenner, "Organizational Reform and Professional Dissent in the Careers of Richard Cabot and Ernest Amory Codman, 1900-1920," Journal of the History of Medicine and Allied Sciences 56 (2001): 211-237, argues that Codman was ostracized from Boston's medical community because of his determined support for top-down, administrative control over a profession that increasingly favored internal reform.