Patient care, not the marketplace, should guide stroke center certification standards.

In 1895 a promising young surgeon graduated from Harvard Medical School. An iconoclast with strong opinions, he would end up “one of the most important surgeons of the twentieth century.1” His name was Ernest A Codman. Dr Codman had a career to which almost any physician, at the dawn of the 20th century or otherwise, would aspire. He trained at a famous medical school; became a faculty member at a premier medical institution (Massachusetts General Hospital); and participated in founding the American College of Surgeons (ACS). However, academic pedigree did not matter to him. In fact, he eventually left Massachusetts General Hospital in disgust at its leadership’s lack of commitment to honestly and transparently evaluating patient outcomes.2 Dr Codman spent his life advocating something called the ‘End Results System’ (ERS). At its core, the ERS proposed an honest reckoning of every patient’s outcome, with frank recording of complications, commitment to long-term follow-up, and, perhaps most importantly, clear and transparent communication of those data to the public. How else was the public to choose where to get its care, unless each and every hospital published a clear account of complications and long-term outcomes? After leaving the Massachusetts General Hospital, Dr Codman founded the End Results Hospital and published the hospital’s data annually, using his own money. He felt that hospitals’ obligations were “for the interest of no one—except for the patients and for the community.2” Dr Codman was not afraid of controversy. He is reported as having said that most clinical research …