Context.—

The first major project of the American College of Surgeons (Chicago, Illinois), founded in 1913, was implementing Minimum Standards for Hospitals. The 1918 standard (1) established medical staff organizations in hospitals; (2) restricted membership to licensed practitioners in good standing; (3) mandated that the medical staff work with hospital administration to develop and adopt regulations and policies governing their professional work; (4) required standardized, accessible medical records; and (5) required availability of diagnostic and therapeutic facilities. One hundred years ago, these were radical expectations.

Objectives.—

To describe the origin, “marketing,” and voluntary adoption of the 1918 standards, and to describe how the evolution of those standards profoundly affected laboratory medicine after 1926.

Design.—

Available primary and secondary historical sources were reviewed.

Results.—

The college had no legal mandate, so it used a highly consultative approach, funded by its membership and the Carnegie Foundation (New York, New York), to establish the Minimum Standards, followed by a nonthreatening mechanism to determine which hospitals met them. Simultaneously, the college educated the public to fuel their expectations. Compliance by more than 100-bed hospitals in the United States and Canada, although entirely voluntary, rose from negligible when first implemented in 1918 to more than 90% in only a few years. From 1922 to 1926, the American Society for Clinical Pathology (Chicago, Illinois) worked creatively with the college to establish Minimum Standards for “adequate” laboratory services.

Conclusions.—

The birth and implementation of this program exemplifies how a consultative approach with full engagement of grassroots stakeholders facilitated a voluntary, rapid, sweeping North America–wide change-management process. This program eventually evolved into the Joint Commission (Oakbrook Terrace, Illinois).

Conditions of surgical practice and hospital services in North America at the beginning of the 20th Century were abysmal.1  However, the wheels were in motion to fix this. There was a vast oversupply of medical practitioners and many were poorly trained. Furthermore, the distinction between medical practice and surgical practice was not yet formalized, so some of these incompetent physicians also practiced surgery. In the early 20th century, better-trained physicians began to group together, forming speciality organizations. Membership was dependent upon demonstrating an appropriate minimum level of competence. Specialists naturally assumed that patients requiring medical or surgical treatment would flock to members of these elite guilds, benefiting both the patients and the financial interests of the practitioners.2,3  The American College of Surgeons (ACS, Chicago, Illinois) was established in 1913, with bold plans to standardize not only surgeons but also the surgeons' workplace—the hospital.4,5  One year before the formation of the ACS, 2 committees were formed at the 1912 Clinical Congress of Surgeons of North America (CCSNA): (1) chaired by Chicago, Illinois, gynecologic surgeon Franklin H. Martin, MD (Figure 1), was to oversee arrangements to establish the ACS; and (2) chaired by Boston surgeon Ernest Amory Codman, MD (Figure 2), was to oversee hospital reform.5  Recognizing that neither the CCSNA nor the ACS would have a legal mandate to reform hospitals, the reforms would have to be accomplished with great diplomacy, with efforts not to alienate other physicians or the American Medical Association (AMA, Chicago, Illinois) and would require voluntary participation by hospitals. Unfortunately, diplomacy had never been Dr Codman's strong suit.

Figure 1.

The 1919 American College of Surgeons board of regents. Franklin H. Martin, MD, is on the far right; John G. Bowman, MA, LittD is second from the far right; Charles H. Mayo, MD is fourth from the far left; George W. Crile, MD is sixth from the far left. Credit: Archives of the American College of Surgeons.

Figure 1.

The 1919 American College of Surgeons board of regents. Franklin H. Martin, MD, is on the far right; John G. Bowman, MA, LittD is second from the far right; Charles H. Mayo, MD is fourth from the far left; George W. Crile, MD is sixth from the far left. Credit: Archives of the American College of Surgeons.

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Figure 2. 

Photograph of Ernest Amory Codman by the Notman Studio of Boston (circa 1911). Credit: This is a reproduction held by the Boston Medical Library in the Francis A. Countway Library of Medicine (Boston, Massachusetts).

Figure 2. 

Photograph of Ernest Amory Codman by the Notman Studio of Boston (circa 1911). Credit: This is a reproduction held by the Boston Medical Library in the Francis A. Countway Library of Medicine (Boston, Massachusetts).

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Dr Codman was fascinated by time-motion studies, efficiency, scientific management of the railroad industry, and the standardization movement that characterized the mid- to late- 19th century American industrial revolution. When he was working as an assistant surgeon at Massachusetts General Hospital (Boston, Massachusetts) in 1900, he developed a special interest in hospital efficiency and standardization, and those interests soon became his lifelong passion.6,7  Dr Codman developed and relentlessly pushed a visionary “end-results system” of hospital organization, which he explained in its simplest terms as follows8(p315):

This system is perfectly simple, the only difficulty with it being its revolutionary simplicity. It requires straight forward truthful answers to these questions: What was the matter with the patient? What did the doctor do to him? What was the result? If the result was not good, what was the reason? Was it the fault of the doctor, the patient, the disease, or the hospital organization or equipment? Heretofore, in hospital organization there has never been a bona fide attempt systematically to fix the responsibility for the success or failure of each case treated. I claim our record system should enable us to fix responsibility, and that it should be used for this purpose.

Dr Codman supported the idea of keeping detailed hospital records with results (based upon follow-up 1 year after discharge) for every admission, generating outcome scores for hospitals and for practitioners for each type of disease or procedure, allowing practitioners to perform only surgical procedures for which they had high enough outcome scores, promotion of surgeons based on their outcome scores rather than seniority or popularity, and, importantly, oversight of each hospital's end-result program by the hospital trustees, which he believed should accept responsibility for “the quality of the Product which their Hospital factories give to the Public.9(p76) Dr Codman was adamant that the results of individual hospitals and surgeons should be published because that would allow potential patients to make informed decisions related to future surgical and hospital care. Dr Codman felt so strongly about his ideas that he resigned from the staff of the Massachusetts General Hospital, started his own small hospital in which he implemented his full system on a small scale, and then he published his results.10  Dr Codman, once all but forgotten, has been rediscovered in the past few decades and much has recently been written about him68,11,12 ; therefore, this essay will not focus on him but, rather, on a movement he helped start. Although Dr Codman's full model proved to be too radical to be implemented in the 1910s, or even today,12  Dr Codman is now correctly recognized as a pioneer of “outcome research,” and he and his model had important roles in the formulation of the ACS hospital standardization program. Because Dr Codman was brash, outspoken, and lacked tact and diplomacy, he was not able to personally see this program to fruition, and some of the more controversial elements he held most dear were abandoned. Two years after the ACS was formed, one of Dr Codman's publicity stunts, which embarrassed Massachusetts General Hospital, its surgeons, and the Harvard University (Boston, Massachusetts), forced him to relinquish the chair of CCSNA's hospital reform committee.5  Nahrwold and Kernahan5(p33) summarized Dr Codman's accomplishments as follows:

He argued forcefully if not always tactfully, for his “end result system.”… Unfortunately, Codman lacked Franklin Martin's executive abilities. His committee produced two reports that confirmed the need for hospital improvement, but left any action for the AMA or the Carnegie Foundation. The AMA had no interest in taking on a project that might lead to conflict with local members. Codman's attempts to interest the Carnegie Foundation in a survey of hospitals were unsuccessful.… With his own political troubles mounting, Codman resigned from the committee in late 1915. With that, the CCSNA's committee disbanded and the College took up the task of hospital standardization.

The development and implementation of the ACS hospital standardization program will be the focus of the remainder of this essay; it is a topic that, surprisingly has been, at best, superficially addressed in the context of Dr Codman and hospital efficiency,1315  or it has been addressed in a piecemeal fashion2,9  in standard sources dealing with the history of American hospitals. In fact, one source states outright in a footnote that “there is no adequate work on the standardization movement.…”14(p148,footnote 34) However, the readers should be aware, although not a history per se, that there is a fascinating article arguing that hospital standardization was “closely linked” to the American pragmatist philosophic movement, which began in the late 19th century and that it “represents a major milestone in the history of American regulation, perhaps the first self-regulatory system steeped in pragmatist principles of social ordering, a Progressive-era model of governance that long foreshadowed some of today's most significant regulatory innovations.”16(p9) However, regardless of its philosophic origins, the ACS hospital standardization program was an important regulatory framework for hospitals for 32 years before evolving into the Joint Commission on Accreditation of Hospitals in 1951, which was renamed the Joint Commission on Accreditation of Healthcare Organizations in 1987 and the Joint Commission (Oakbrook Terrace, Illinois) in 2007.17  Toward the end of this article, I will analyze how Minimum Standards for hospitals affected hospital laboratories, a perspective that has not, to my knowledge, been addressed in the limited literature on hospital standardization.

The first meeting of the ACS was held in Washington, DC, on the evening of Monday, May 5, 1913. It was attended by 450 American and Canadian surgeons, both generalists and specialists. This meeting was planned by an organizing committee of 12 prominent surgeons appointed by the CCSNA at its November 1912 meeting. Members of the CCSNA Organizing Committee canvassed the United States and Canada through a series of regional meetings. Essentially, in “each large university city,” a meeting was organized by 3 local surgeons, and 1 of the 12 organizing committee members. From these regional meetings, 500 surgeons were invited, 450 attended, and the ACS was born.4,5  The ACS had lofty goals to improve the quality of care for surgical patients by elevating surgical training and practice.

By 1914, ACS leadership, while still “perfecting the organization of the College and… obtaining a sound financial basis,”18(p114) determined that hospital standardization was its first big initiative and so it “began to acquire first-hand information about hospital conditions in Canada and the United States. It conferred with doctors, hospital trustees, and hospital superintendents about the work; with medical societies and with hospital organizations, asking their help and co-operation in formulating a plan of action.”18(p114) Although it is not clear that this hospital standardization began as an educational initiative, it quickly took on that flavor because this helped to justify why hospital standardization fell clearly within the college's mandate. There were potential reasons why hospital standardization, if overseen by the ACS, could financially benefit ACS fellows (nb, according to sociologist Paul Starr, controlling the hospital workplace was a long-term goal of physician guilds so that they could “avoid the fate of the tool-less wage worker”).15(p165) On June 22, 1914, the fellows approved a plan to raise a permanent endowment fund and agreed that the income from that fund would be used to advance the purposes of the ACS. Behind the scene, several prominent ACS surgeons, such as George W. Crile, MD (Figure 1) (chair of surgery at the University Hospitals Case Medical Center [Cleveland, Ohio] and, soon, cofounder of the Cleveland Clinic [Cleveland, Ohio]), Charles H. Mayo, MD (Figure 1), and William J. Mayo, MD (ie, the Mayo brothers who transformed St. Mary's Hospital into the Mayo Clinic [Rochester, Minnesota]), were not initially supportive because it would create a significant financial burden for the college,5  precipitating unsuccessful discussions with the AMA asking them to take on this role instead.2  In February 1915, John G. Bowman, MA, LittD (Figure 1), president of the University of Iowa (Iowa City, Iowa) and former secretary of the Carnegie Foundation for the Advancement of Teaching (Stanford, California), was appointed the ACS director of education.5  Dr Martin continued as the powerful college secretary.

By December 1, 1915, Dr Martin had already raised $526 000 from the approximately 3400 surgeon members.19  In January 1916, the ACS officially announced that it had an endowment fund of $500 000. That same announcement stated, “[i]nasmuch as proper training in surgery is inseparably involved with the conduct and efficiency of hospital, the College will seek accurate data on all matters which relate to hospitals.”20(pp116–117) By the end of the month, Drs Martin and Bowman, relying upon the latter's personal connections, had also raised an additional $30 000 from the Carnegie Foundation, specifically for hospital standardization.2,5 

At the annual meeting of fellows in Philadelphia, Pennsylvania, on October 27, 1916, the Bowman21  Report of the Director provided even clearer direction. The address given by Dr Bowman focused on only 2 topics: admission to fellowship and investigation of hospital conditions. Because the latter was a new public direction, and he needed to “educate” the fellows, that comprised most of his talk. Dr Bowman justified the new direction entirely within the context of surgical education21(p745):

This work is not merely something which we may do; it is something which we must do. It is our business to know what real training in surgery means. That has been obvious to all of us from the start. And it is a true estimate, I believe, to say that eighty per cent of what a surgeon uses in practice he acquires during his interneship [sic] and hospital training. In other words, the particular training ground for the surgeon is the hospital. Forced upon us, then, is the obligation to know what this training ground is, and what kind of standard we should hold up to ourselves as the proper training of a surgeon in a hospital. Further, the problem of the training of a surgeon in a hospital cannot be isolated as a separate factor of the hospital's program.… There are specific divisions, however, in every hospital which we may investigate, and having accurate data, we may point the way of progress.

Dr Bowman then addressed a series of specific topics, including hospital record keeping (are case records complete and “accessible for study and future guidance?”), the state of laboratory services, the relationship of hospital medical staff to its hospital board of trustees and the hospital superintendent, hospital credentialing, the relationship of the hospital to the county or local medical society, and relationship of the hospital with the public. Related to the latter, Dr Bowman had strong words21(p746):

Why shouldn't the trustees… be able honestly to guarantee to their communities honest, competent services? Such a condition is one of the things which the American College of Surgeons proposes to bring about. It proposes to deal with these problems in no uncertain or half-hearted fashion. The central part of its effort will be a series of pamphlets written so simply that the man who moves his lips when he reads can understand. These pamphlets will deal one after another with the things which make hospitals the right sort of institutions for the care of sick people. Sometimes it may be necessary to call meetings of the local commercial clubs, or of other bodies of laymen, in order to waken the community as to the actual conditions in their hospitals. If this course is necessary, it will be followed. The day has gone by when any sort of indifferent or incompetent practice can be shielded in a hospital. The day has gone by when hospital trustees may rest in an irresponsible attitude toward the trust imposed in them.

Although now fully embedded within the college's educational mandate, what was actually being proposed could easily have been interpreted by outsiders as an all-out war on the status quo in North American hospital care, and, even the powerful AMA, although fully recognizing the need for hospital reform, was unwilling to take this problem on, a decision the AMA would later regret.1,4,5  Each area of reform held potential landmines for one or more stakeholders. For instance, in the realm of medical record keeping, it was not even entirely clear hospitals had the right. According to medical historian and sociologist Rosemary A. Stevens, PhD9(p60):

A doctor admitting his own patients had no incentive to create records that others might use or that served the hospital as a whole…. Doctors could claim that they owned their own records, and that the hospital as the physician's workshop, had no separate, legitimate interest in recording or monitoring patient care.

Intuitively, the risk associated with a single medical specialty, even a powerful one, addressing hospital reform was high. After all, the ACS represented only a few North American physicians (at best, about 5%). On the other hand, most hospital patients were surgical patients, and hospital numbers had expanded exponentially in a matter of only a few decades1 ; therefore, hospitals could not afford to alienate surgeons. Although the presence of their endowment fund positioned the college to move quickly, there was clearly a need for the ACS to tread lightly, which it achieved by using an open, consultative process, which, importantly, included other physician specialties.

Also at the 1916 annual meeting in Philadelphia, Pennsylvania, “Fellows were asked to create in each province in Canada and each state in the Union a standards committee, the purpose of the committees being to advise with regard to a sound and constructive program of action.”18(p114) In accordance with that vote, such standards committees were created all around North America, but the committees could not be brought together for a group meeting until October 19–20, 1917, because of World War I.19  At that 2-day meeting in Chicago, Illinois, approximately 330 committee members and 50 to 60 leading hospital superintendents from throughout North America discussed “three fundamental questions”: “What conditions exist in hospitals? What do we want in hospitals and [w]hat is to be done?”18(p114) According to the college18(p114):

The immediate outcome of the meeting was the appointment of a committee of twenty-one, upon which were represented physicians, surgeons, hospital administrators, laboratory workers, statisticians, etc., the purpose being to outline a questionnaire through which the College might obtain hospital data essential in its further work and to consider a “minimum standard of efficiency.” The committee of twenty-one met for two days in Washington, in December, 1917, formulated the questionnaire, and discussed the “minimum standard.” Early in 1918 the questionnaire was sent to the hospitals, together with a letter asking the co-operation of the hospitals in the standardization program. The response of the hospitals to this questionnaire exceeded the most optimistic hope of those concerned with the work. Hundreds of letters came from all parts of the continent, pledging co-operation. …In March, 1918, a complete statement of the hospital standardization program of the College and of the minimum standard was sent to the hospitals and to the Fellows. …In March, 1918, the work of personal investigations of hospitals was taken up. The College employed visitors or inspectors to make reports of conditions at the various hospitals. An important part of the work of the visitors was also to explain the details of the program more fully than can be done by pamphlets or letters, and to make clear the spirit of all of the undertaking.

Although a rapid and forceful process like that being suggested had the potential to be intimidating, the brilliant way the ACS marketed the whole process essentially precluded that. The college defined hospital standardization as follows18(p113):

It is not an effort to make hospitals alike in form of government, of administration, or of equipment; it does not seek to enforce conformity to any given mold nor to limit originality in any phase of hospital work. Hospital standardization means thinking alike on the part of doctors, hospital trustees, hospital superintendents, laboratory workers, nurses, and the public upon the aims and utility of hospitals. It means that every patient in a hospital is entitled to the most efficient care known to the medical profession…

Defined by such “motherhood” statements, how could any reasonable person or organization take a public stance in opposition to cooperating to achieve better patient care? This sentiment was also in keeping with the American progressivism movement and, increasingly, all health care providers recognized that hospitals, which in the late 19th century existed as “hotels” for poor patients and primarily for the convenience of physicians and surgeons, now needed to focus on the quality of patient care and patient experience.16  Hospitals even recognized that reform was necessary from a business perspective because the reputation of hospitals in the United States had been so dismal throughout the 19th century that wealthy patients had avoided them and instead were usually cared for at home.

The college considered how to approach this issue, noting that “there are two methods by which hospital standardization may proceed. The first is scientific; the second, human.”18(p113) The college's description of the “scientific method” can be paraphrased in current day parlance as top-down, using blunt force to implement its own analysis. A contemporary example of this type of standardization approach that the ACS leadership would have been extremely aware of was the 1910 Flexner Report, also funded by the Carnegie Foundation, which pushed a standardized medical school with minimum academic requirements for admission and a curriculum based on the principles of “scientific medicine” using a teaching-hospital setting.22  Clearly, the dynamics were entirely different (nb, there were too many proprietary medical schools and one of the objectives of Abraham Flexner, MD, OD, PhD, was to put hopeless medical schools out of business; in stark contrast, there were not excessive numbers of hospitals, and the ACS simply wanted to improve them)! There is another, even more fundamental reason that such an approach could not have worked. The leadership of the ACS, although recognizing that hospital standardization was desirable and that they should be leading it, did not have a clear idea of what they wanted it to look like and, because participation would be voluntary, had no idea what would be acceptable to the diverse stakeholders. Furthermore, the ACS leaders recognized that whatever model was implemented should change and improve constantly.16  The complexity of those goals must have seemed obvious to Dr Bowman, who was the ACS director of education, and was not even a physician. So instead, the college wisely took the “human method” approach as described below18(p113):

The human method never forgets the point of view of others. In fact, that is the only point of view which it knows. It assumes that men are intelligent and open-minded. But it is not sentimental or merely “sugar and spice and everything nice.” It values straight thinking and accurate data quite as much as does the scientific method. Under the human method hospital standardization says to hospitals: “here is a plan for the betterment of hospital service. It is a plan which grew out of our own heads and hearts after conscientious and long effort on the part of all of us to devise such a plan. Will you please consider whether or not you will accept it?”

The college's highly consultative approach was labor intensive and costly. After mailing the Minimum Standard (Figure 3) to all 697 hospitals in the United States and Canada with 100 or more beds, in March 1918, 7 college staff members, called visitors, divided the task of personally visiting each hospital. The visitors simply presented the standard and explained what it meant23(pp469,473):

The College did not assume authority to enforce the standard. At all times the College depend[ed] upon the sheer merit and soundness of its proposals to win and to hold the co-operation of those concerned with the work.… These men, all graduates in medicine, went to the hospitals… as engineers, discovering first what the shortcomings of the institution were in relation to the minimum standard and then indicating how such shortcomings might best be overcome. The council meetings held at the various hospitals by these inspectors proved to be an important element in the success of the work.

These visitors collected data, which were collated at college headquarters, for each hospital using standardized “visitor cards”23  (Figure 4). The personal visit approach worked, and hospitals cooperated and strove to achieve the standard. The ACS leadership may have adapted this personal-visit method from the one they had successfully used to rapidly bring surgeons together in 1912–1913 to form the ACS.

Figure 3.

The Minimum Standard document was created sometime between December 8–9, 1917, and March 1, 1918, when it was mailed to the fellows and hospitals. It was used as the gold standard for the data collected during site visits starting in 1918. Credit: Archives of the American College of Surgeons.

Figure 3.

The Minimum Standard document was created sometime between December 8–9, 1917, and March 1, 1918, when it was mailed to the fellows and hospitals. It was used as the gold standard for the data collected during site visits starting in 1918. Credit: Archives of the American College of Surgeons.

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Figure 4.

The front side of an American College of Surgeons visitors card (nb, the back of the card included IV. autopsies, V. general notes, and VI. persons interviewed and their positions). Related to autopsies, there were 2 questions to answer: (1) Number of deaths and autopsies in the last year, and (2) Does the pathologist meet with staff to review clinical history in relation to autopsy findings? Reprinted with permission from the Journal of the American College of Surgeons, formerly Surgery Gynecology & Obstetrics 1920;30:543.

Figure 4.

The front side of an American College of Surgeons visitors card (nb, the back of the card included IV. autopsies, V. general notes, and VI. persons interviewed and their positions). Related to autopsies, there were 2 questions to answer: (1) Number of deaths and autopsies in the last year, and (2) Does the pathologist meet with staff to review clinical history in relation to autopsy findings? Reprinted with permission from the Journal of the American College of Surgeons, formerly Surgery Gynecology & Obstetrics 1920;30:543.

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The college also lined up powerful allies who supported and endorsed the Minimum Standards. These included the American Hospital Association (Chicago, Illinois), the Canadian Medical Association (Ottawa, Ontario), the Catholic Hospital Association (CHA; Washington, DC), the Conference Board of Hospitals and Homes of the Methodist Church (Chicago, Illinois), the Medical and Surgical Section of the American Railway Association (Cary, North Carolina), the American Protestant Hospital Association (Chicago, Illinois), and numerous state, provincial, and local organizations.24(p582) Gaining the support of Father Charles B. Moulinier, SJ, who was both the regent of the Jesuit Marquette University School of Medicine (Milwaukee, Wisconsin) and the Director of the newly formed CHA, was critical because this association represented about one-half of all hospital beds in North America5  (nb, gaining CHA support was actually not an onerous task because Father Moulinier, who was made aware of the ACS hospital standardization program in 1914, actually spearheaded the formation of the CHA in 1915, specifically to facilitate organized Catholic hospital participation and, by serving on the ACS Standardization Committee, he simultaneously served as “a useful safeguard for Catholic hospitals against any strong external control.”).9(p115),25  The college also obtained another $75 000 in financial support from the Carnegie Foundation in 1920, which, as mentioned, had donated $30 000 in 1916.26 

Although compliance with the Minimum Standards was entirely voluntary, realistically, hospitals, hospital superintendents, and hospital trustees probably had little choice but to come into compliance because the requirements sounded so reasonable, they had an opportunity to help formulate them, and their competitors were doing so (see below). As explained matter-of-factly 5 years into the process by Secretary-General Martin27(p133):

Is there anything that a hospital can leave out of the standard and be a hospital? First, records; second, staffs, with staff meetings; third, a competent and honest staff; fourth, laboratories. That is practically the minimum standard of the American College of Surgeons. Any hospital that cannot furnish this minimum standard is not a hospital.

Nevertheless, as reasonable as all this sounded, loss of autonomy and putting trust into the hands of the ACS was scary. According to Dr Stevens9(p115):

The ACS had a “selling” job to do. John Bowman… traveled all over the country between 1918 and 1920, speaking to surgical and hospital groups about standardization. He presented the program as one designed to bring a sense of responsibility to hospitals so that they might seek the goodwill and support of their communities and thus, in turn, attract private patients and community donations. But even appealing to enlightened self-interest, his message ruffled feathers at the local level, where any form of outside intervention was suspect. Community standards were assumed to be a local responsibility, not a matter for national pacesetters.

The actual survey work was begun in 1918. Data were initially collected only for hospitals in the United States and Canada with 100 or more beds. In 1918, only 89 of the 692 hospitals with 100 beds (12.9%) met the standard and several of North America's most prestigious hospitals had failed. A detailed report had been generated for distribution at the October 1919 CCSNA meeting in New York, New York; however, the ACS regents (Figure 1), who were meeting at the Waldorf Astoria (New York, New York) immediately before the CCSNA congress, were so horrified with the results that it was decided not to distribute the report because it might adversely affect further cooperation. Dr Bowman explained to the regents that almost 200 of the hospitals were in the process of implementing corrections and suggested that, if released at that time, many of the hospitals would likely blame their poor showings on “wartime conditions.” Every copy of the report was carried to the hotel furnace room and “solemnly cremated.”5(p34)

Giving all hospitals a stay of execution for the first year (and especially those that should have been “too good to fail”) was likely a prudent decision that promoted the survival and continuance of this voluntary program. Had a report been released showing that a number of the top hospitals had failed, it would have given lesser hospitals an excuse that the standards were unattainable. Instead, however, there was immediate improvement. In 1919, 198 of 692 (28.6%); in 1920, 407 of 692 (58.8%); in 1921, 573 of 761 (75.3%); in 1922, 677 of 812 (83.4%); in 1923, 751 of 870 (86.3%); and in 1924, 831 of 961 (86.5%) 100-bed hospitals met the standard.28  Once a year, the ACS published a state-by-state and province-by-province list of these large hospitals meeting the standard as well as a scatter-plot diagram of compliant and noncompliant large hospitals attached to a map of North America, undoubtedly providing positive reinforcement for the former and negative reinforcement for the latter. One by one, community hospitals were able to hang proudly “their certificates in visible positions and announce their success through local newspapers.”9(p116) This, from a marketing perspective, likely made the whole ordeal worthwhile (Figure 5). Starting in 1922, the surveys included an additional category for hospitals with 50 to 100 beds; compliance in these medium-sized hospitals was lower but exceeded 50% by year 3.28  By 1929, 93% of large, 63% of medium, and 20% of small (a new category, with 25–49 beds) hospitals met the standard.5  The work of the ACS hospital standardization program continued until the early 1950s, when it was turned over to the new Joint Commission on Accreditation of Hospitals, and ceased to be voluntary.17 

Figure 5.

American College of Surgeons minimum standards wall certificate given to hospitals having met the standard. Credit: Archives of The American College of Surgeons.

Figure 5.

American College of Surgeons minimum standards wall certificate given to hospitals having met the standard. Credit: Archives of The American College of Surgeons.

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During the early years of the ACS hospital standardization program, Dr Bowman was the director and Dr Martin was the ACS secretary, a part-time position. In 1917, the regents appointed Dr Martin to a fulltime position, secretary-general, which created a lack of clarity related to ACS governance, and, by 1920, Dr Bowman was considering his other options. In November 1920, Dr Bowman accepted the position of chancellor of the University of Pittsburgh (Pittsburgh, Pennsylvania). After a brief interim replacement, the positions were consolidated and Dr Martin became the director-general. After Dr Bowman's resignation, the ACS hired Malcolm MacEachern, MD, CM,29  a Vancouver, British Columbia–based surgeon and superintendent of the Vancouver General Hospital (Vancouver, British Columbia, Canada), to direct the ACS hospital standardization program, which he handled superbly for the next 27 years.5 

In the 1920s, the ACS director-general, Dr Martin, curiously invoked the college's ability to “rewrite” history and, while still taking credit, distance the college from having unilaterally initiated the process of hospital standardization. According to Dr Martin, speaking in 192127(p133):

The American College of Surgeons is responsible for the standardization of hospitals, because in its early days it found it necessary to standardize its own environments. For instance, in making a standard for admission to fellowship, it was necessary that we ask the candidates to furnish us the reports of fifty major operations and fifty minor operations, in lieu of an examination. These reports began to come in. They were on all kinds of forms. There was absolutely no standard record on which they could give us the evidence of their own ability to practise surgery. Soon we were asked from every direction to furnish a standardized system of records, to suggest a form upon which these records could be given to the College. We attempted to do that. A committee was formed for the purpose, and we furnished, wherever required, a set of standardized records. Then what happened? The hospitals—a great many of them—began to ask us if we could not in some way furnish these same standardized records or forms to them, which, of course, we were very glad to do. That was the first step in the standardization of hospitals.

Although maintaining appropriate records clearly became a shared common interest for the ACS and hospitals, it is difficult to conceive how that could be the “first step” in the hospital standardization movement because that began with Dr Codman and his CCSNA committee, even before the ACS was formed. Regardless, records became a common ground for both the ACS and hospitals, and the ACS was correct in noting that “a hospital in which a candidate for Fellowship prepares these records, if not already keeping adequate records, is usually induced to do so.”18(p116)

The minimum standards were exactly that, rudimentary requirements for an adequate hospital. The first component of the standard was the organized medical staff (Figure 3), which was pivotal. Because the ACS planners did not know exactly what a standardized hospital should look like, the expectation was that, once the Minimum Standards were met, the organized medical staff would take an active sense of personal responsibility that would facilitate continuous improvement in all arenas in every standardized hospital,16  which was the ACS master plan for the future, and it had a side bonus of ensuring that physicians would control their workplace, through the auspices of the ACS.

The AMA had considered taking on hospital reform in both 1913 and 1914 and had unsuccessfully approached the Carnegie Foundation for grant funding to pursue that. Even the ACS leadership, who were worried about their fledgling guild's finances, had tried to convince the AMA Board of Trustees to take over that role in 1914, but the “AMA declined on the basis of expense.”2(p91) Dr Stevens concluded that “the relative poverty of the College in 1914… suggested to the AMA no great competition to its own activities in hospital standardization. But as a result, the AMA lost the initiative in the hospital standardization movement. The American College of Surgeons became the dominant force behind hospital reform.”2(p119) By 1917, the AMA leadership recognized that they had made a serious tactical error and had been outmaneuvered by the ACS, who had hired the former secretary of the Carnegie Foundation to be its director. In 1918, the powerful AMA Council on Medical Education announced it would broaden its mandate to include hospital standardization and in June 1920 was renamed the Council of Medical Education and Hospitals, but the AMA had already lost the battle for control of the physician's workplace. After that, as noted by Dr Stevens, “in many areas… the College had become a strong potential competitive force.”2(p125) The relationship between these 2 powerful organizations became increasingly strained thereafter.

Before the 20th century, most pathologists were academicians practicing in medical schools and were not normally involved in patient care; laboratory tests were typically simple enough that a clinician could perform these in the ward. In the first 2 decades of the 1900s, the numbers and complexity of laboratory tests increased exponentially, creating a niche for someone to provide these new services. There were 2 competitive models: private commercial laboratories versus hospital-based clinical laboratories. If laboratory tests were viewed simply as a commodity, the economy of scale permitted by high test volumes and batching strongly favored the private commercial laboratories, and by the early 1920s, it seemed likely to many clinical pathologists, who were feeling the economic pinch, that the private laboratory model would prevail and the hospital-based laboratories were on their way toward extinction.30,31  At the same time, tissues removed during operations were generally discarded and were rarely examined by pathologists; in the rare instances in which histopathologic diagnoses were required, these could be provided for free by state public health laboratories but with very slow turnaround times.32 

The ACS leadership intuitively knew that the clinical laboratory was important to facilitate scientific practice in a standardized hospital, but had only vague ideas as to what this might look like. Hence, when the 1918 Minimum Standard document was generated, details related to laboratory services were vague. As shown in Figure 3, the Minimum Standard was that diagnostic facilities “under competent supervision be available for the study, diagnosis, and treatment of patients, these to include, at least, (a) a clinical laboratory providing chemical, bacteriological, serological, and pathological services; (b) an X-ray department…” There was no requirement that the supervision be by a physician, let alone a trained clinical pathologist, and there is no explicit statement requiring staffing. The 1918 Minimum Standard did not require in-house pathology services provided by a pathologist; it simply required the existence of a hospital laboratory (nb, there was an educational need for interns to have an opportunity to perform basic laboratory tests).

Two important events rapidly affected on the evolution of laboratory services after the 1918 Minimum Standard document had been created; the first of these was the 19-month involvement by the United States in World War I. After that, thousands of American physicians and surgeons who had enlisted and served with the American Expeditionary Forces in Europe returned. Many of them had little or no contact with pathologists or pathology services before enlisting. In France, however, they had been exposed to the first-rate laboratory services implemented by Louis B. Wilson, MD, director of laboratories at the Mayo Clinic.33  When they returned home, most had much greater expectations for laboratory services; therefore, the college invoked Dr Wilson's services when fleshing out the laboratory component of its hospital standards.34  There were other learnings from World War I that influenced other aspects of hospital standardization.9,16 

In 1922, the college established the ACS's Standardization of Clinical Laboratories Committee with RADM Edgar R. Stitt, MD, MC, USN, chief medical officer, as chair. Col Wilson, who had been awarded a Distinguished Service Medal by the president of the United States for his excellent organization of the laboratory services of the American Expeditionary Forces in the war, was 1 of 4 other clinical pathologists (unfortunately they were described in the Bulletin of the ACS as “eminent laboratory technicians”) on the committee; these members were Francis Carter Wood, MD, of Columbia University (New York, New York); Ludvig Hektoen, MD, of University of Chicago (Chicago, Illinois) (nb, he would soon become the founding editor of the Archives35); and Milton J. Rosenau, MD, of Harvard University. This committee was tasked with recommending an “acceptable” (nb, this adjective was used to recognize that the ACS was establishing Minimum Standards) hospital clinical laboratory “which will not entail prohibitive expense.”36(p14) Dr Wood was selected to be a member of the committee because he had previously worked with the ACS and had published an article on laboratories for an efficient hospital in the ACS Bulletin,37  and Dr Rosenau provided an article on the topic for the American College of Surgeons 10th Yearbook.38 

The second major event occurred in 1921–1922, when 2 Denver, Colorado, pathologists—Ward Burdick, MD39  (Figure 6), and Philip Hilkowitz, MD (Figure 7)—organized the American Society of Clinical Pathologists (nb, the organization later changed its name to American Society for Clinical Pathology [ASCP]).31  The ASCP was created as quickly as the ACS, and one of the precipitating factors had been a battle between clinical pathologists and the AMA over commercial laboratory advertisements in the Journal of the American Medical Association.30,31  The ASCP leadership surveyed the environment and observed the ACS's hospital standardization movement was much more compatible with the “in-house” laboratory services model they supported than the private commercial laboratory model that they had been fighting against; they quickly worked with the ACS to determine how its membership could help plan laboratory services for the “standardized” or “modern” hospital. The timing was perfect! What could have been more fortuitous for both specialties? The ACS wanted “adequate” clinical laboratories in their standardized hospitals, but they did not know exactly what that meant, whereas the ASCP, representing laboratory physicians who were experts in the realm of clinical pathology and who wanted to be hospital based, were happy to provide their advice—the making of a truly symbiotic relationship. Although high-quality “chemical, bacteriological, serological, and pathological services” could mostly be provided by commercial laboratories or state public health laboratories, it became clear to the leadership of the ASCP that what the college really needed was in-house surgical pathology and autopsy pathology.31  These, in addition to allowing improved diagnoses, quality assurance, and patient care, supported the ACS financial incentives harkening back to one of the initial reasons for forming their specialist guild. As noted earlier, there was an oversupply of surgeons, and the ACS fellows wanted to establish themselves at a higher standard than the competition, expecting that would enhance the economic value of their services.30  The public at that time was generally suspicious of surgeons for good reason.1  According to Dr Stevens, there was a need “to police avaricious and inappropriate behavior by hospitals' surgeons. This was to be done by having pathologists check unnecessary surgery through analysis of tissue removed at operation….9(p114) Health economist William D. White, PhD, noted that the ACS wanted to establish pathologists in hospitals “to impose a minimum check on the quality of care being provided in hospitals” because “these checks… provide[d] a potential way to cut down on competition from nonspecialists, who presumably were practicing lower-quality surgery than specialists.”40(p55)

Figure 6.

Ward Burdick, MD. Credit: Journal of Laboratory & Clinical Medicine 1925;10:678–690.

Figure 6.

Ward Burdick, MD. Credit: Journal of Laboratory & Clinical Medicine 1925;10:678–690.

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Figure 7.

Philip Hilkowitz, MD. Courtesy of Beck Archives Special Collections, University Libraries, University of Denver (Denver, Colorado).

Figure 7.

Philip Hilkowitz, MD. Courtesy of Beck Archives Special Collections, University Libraries, University of Denver (Denver, Colorado).

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Obviously, performing autopsies on patients who died would further identify incompetent and unsafe, nonspecialist surgeons, who could then be culled from practicing surgery in standardized hospitals by corrective action of their new medical staff organizations.

Establishing surgical pathologists in hospitals provided another economic benefit to the ACS fellows because it negated the need for state public health laboratories to continue to provide free histopathology services for physicians.31  This service, present in more than one-half of all states,32  had threatened the separation of surgery and medicine because it had allowed physicians and nonspecialist surgeons access to free tumor-diagnosis services, thus, facilitating their practice of “scientific surgery,” which ACS fellows considered their private domain.

The ASCP leadership recognized that neither surgical pathology nor autopsy pathology could be efficiently supplied by private commercial laboratories outside of the hospital walls; however, these low-volume, anatomic pathology services would not sustain a livable income, but anatomic pathology services combined with the higher-volume, clinical laboratory testing made the hospital-based practice package highly attractive.31  Anatomic pathology also offered state-of-the-art, newer diagnostic modalities, such as intraoperative frozen-section diagnosis,30  and prognostic modalities, such as tumor grading.41  It was immediately clear that the ASCP and ACS had important common ground that could be exploited, as reported to the ASCP membership by its Secretary-Treasurer Ward Burdick, MD: “The American College of Surgeons, recognizing in this organization its logical collaborator in establishing adequate laboratory services in modern hospitals, very graciously solicited our views before their last convention and some of the suggestions presented have because been adopted.”42(p874) In fact, in 1925, the ASCP executive reported to its membership43(p207):

It has become a tradition with the American College of Surgeons to invite a representative of the American Society of Clinical Pathologists to read a paper at their annual meeting. The interests of the two organizations are closely interwoven; both are intensely desirous of elevating the scientific standards in hospitals. The proper conduct of the clinical laboratory involving important aids to diagnosis is an indispensible factor in the structure of hospital standardization. Dr. Spitz, who is a member of our Executive Committee, was delegated to address the Congress at the Philadelphia meeting, his article being “Pathological Conferences in Standardized Hospitals.” The paper was received with hearty commendation and liberal discussion and will appear in the transactions of the Congress.

As indicated, the Spitz44  article was published in the ACS Bulletin. The ACS Standardization of Clinical Laboratories Committee, which the ASCP leadership sometimes called Wilson's Committee, worked in conjunction with the ASCP. In fact, on June 7, 1924, at the third annual ASCP meeting held at the Mayo Clinic, the ACS had asked the ASCP to pass a resolution indicating its support for their standardization initiative, and that passed unanimously.45(p71) Dr Burdick46  also published a timely article in the ACS Bulletin, entitled “Adequate Laboratory Services in the Modern Hospital.”

In 1926, the college published A Manual of Hospital Standardization.47  There were now 6 explicit standards related to clinical laboratories in hospitals47(p10–11):

  • 1.

    That the clinical laboratory shall be under the direction of a graduate in medicine, especially trained in clinical pathology.…

  • 2.

    That the clinical laboratory shall be prepared to perform satisfactory work in (a) histopathology; (b) bacteriology and parasitology; (c) serology; (d) haematology; and (e) chemical and morphologic examinations of other body fluids, exudates, transudates, and excreta.…

  • 3.

    That all tissue removed at operations shall be examined in the laboratory and reports rendered thereon.…

  • 4.

    That an easily available copy of all reports shall be filed in the laboratory and one with the patient's record. In histopathology there shall be, in the laboratory, a cross index of, at least, the name of the patient, of the hospital or laboratory number of the patient, and of the lesion or organ. There shall be preserved also for at least three years either section, embedded tissue, or gross tissue from each case from which tissue is removed.…

  • 5.

    That a uniform system of charges for laboratory work shall be enforced.…

  • 6.

    That the clinical pathologist shall attend the monthly staff conferences of the hospital.…

This 1926 document provided more explicit clarification to each of the standards listed above. A 1-page long hospital standards document in 1918 (Figure 3) had now become 18 pages long. Related specifically to clinical laboratories, a single vague sentence (ie, 5 in Figure 3) in the 1918 standards became 1.5 pages of detailed text in 1926. That level of detail and the explicit requirements laid out above tipped the balance strongly in favor of service being provided by hospital-based clinical pathologists. As previously discussed, physicians were sometimes not cooperative with hospitals regarding the “ownership” of their patients' records. If testing was done offsite in private commercial laboratories, results were sent to the ordering physician or patient rather than to the hospital. The new explicit requirement that standardized hospitals must have a clinical laboratory staffed by a clinical pathologist and must keep records of test results in 2 places within the hospital resolved that ownership issue without the need to start a turf war, solving a potentially thorny issue for the ACS and hospital administrators. Having “the clinical pathologist… attend the monthly staff conferences”47(p11) reinforced the policing and quality functions alluded to by both Stevens and White. The ASCP benefited as well because hospital standardization almost put private commercial laboratories out of business.31  Although compliance with the ACS Minimum Standards continued to be voluntary, there was actually little option, especially for large hospitals. Hospital-based clinical pathology practice, which was not a widely accepted model in 1922 when the ASCP formed, became a fully viable specialty after 1926, when it became a requirement “that all tissue removed at operations shall be examined in the laboratory and reports rendered thereon.”47(p10) This phrase established routine surgical pathology for both diagnostic and quality-assurance purposes. The immediate availability of intraoperative frozen-section diagnoses also became an expectation; in fact, within a few years, there was a movement to prevent cancer surgery from occurring in hospitals without that capability.30 

The 1926 standard stressed the importance of autopsies, but it did not establish a minimum autopsy rate requirement. The standard said47(p11):

The number of post mortems in the majority of standardized hospitals is far too low. Much has been said and written of late in this regard.… The American College of Surgeons urges all standardized hospitals to give this matter serious attention during the coming year. Careful inquiry will be made in regard to this feature in all subsequent surveys.

The ACS Minimum Standard drafters wanted hospitals to meet the minimum standards as rapidly as possible and likely did not think it prudent to hold hospitals fully accountable for their autopsy rates because consent under normal circumstances could only be provided by the next-of-kin. However, the ACS surveys monitored hospital autopsy rates, and hospitals striving to exceed “adequate” knew that a high autopsy rate was an expectation. However, this became a bit of a moot point as on March 12, 1927, when the AMA Council on Medical Education and Hospitals announced48(p817):

Because of their importance in every progressive hospital, the Council's policy is to increase gradually the requirements in regard to necropsies. A ruling has recently been adopted that after Jan. 1, 1928, no hospital will be continued as approved for the training of interns unless necropsies are held on at least 10 per cent of the deaths occurring in the hospital, and, after January 1, 1929, this requirement will be further increased to 15 per cent.

In this same article, the AMA provided a table showing ratios of autopsies to deaths in hospitals currently approved to train interns showing that at least 36% would not meet the 10% autopsy rate standard and at least 55% would not meet the 15% standard. This new requirement immediately increased autopsy rates in many hospitals that had low rates.49  Ironically, the AMA, having earlier abdicated the ability to provide oversight for laboratory services related to patient care, invoked its educational role to insinuate itself into hospital standardization—just as the ACS had done in 1914. For educational reasons, the AMA now required that “there must be a clinical laboratory in charge of a pathologist of attainments and standing at least equal to those of other staff members, who shall be in charge of the laboratory, supervise the work of, and give instruction to the interns.”48(p826)

Before the 1926 standards, there had been no way to pay for autopsies without billing the family. Now, performance of autopsies could be fully subsidized by the more lucrative, higher-volume clinical pathology testing. However, how the clinical pathologist should be compensated for services rendered (see above—“that a uniform system of charges for laboratory work shall be enforced”47(p11)) was an ongoing, controversial issue for decades because many hospital administrators preferred a salaried model, whereas many laboratory physicians preferred a fee-for-service model.2 

The ACS deservedly took credit for this revolutionary movement to minimum hospital standards. For instance, Malcolm T. MacEachern, MD, CM, associate director of ACS Hospital Activities, summarized it 5 years into the program as follows50(p137):

A need was discovered by the College; a remedy was found to meet that need; the remedy was applied in a practical manner through this movement, which is ever increasing in momentum and permanency. The hospitals have willingly and in a solicitous manner taken to the program because “its requirements are reasonable, its methods of presentation acceptable, and the work of the hospital investigators, because of the personal visits and the impartial manner of making reports, appeals to the hospitals as an honest, unprejudiced, disinterested effort to arrive at facts. Without ostentation this movement for hospital betterment has been its only propagandist. It has convinced the medical profession that a great event has been transpiring; that when two or more individuals get together in harmony, even in the profession of medicine, and pursue a course of self-betterment, the results are stupendous, the effect inspiring. Every hospital trustee, every superintendent, and every nurse of the North American continent have been drawn into the vortex of this movement and each one prides himself on his part in it. Business men of large and small communities have learned that the profession of medicine can conduct its affairs in a business-like manner as well as wield the scalpel and administer drugs. One of the conservative philanthropic foundations, the Carnegie Corporation, after a thorough investigation of this program, for five years contributed toward is financial support to a sum aggregating $105,000. In addition to this a sum of $220,283.09, contributed by the College, represents a total expenditure during the five years of $325,285.09.”

Dr MacEachern spoke at the banquet of the annual ASCP meeting on May 14, 1927, on the topic of the relations and responsibilities of the clinical pathologist to the hospital standardization movement.51  Another ACS self-congratulatory analysis reinforced Dr MacEachern's thoughts and further noted that “it encourages and even compels research.”52(p322)

These self-congratulatory statements, although mostly correct, somewhat exaggerate the result, which was not exactly what the ACS wanted. Although the ACS had accomplished all of this against considerable odds, the founders like Drs Martin, Bowman, and MacEachern were disappointed that, in general, hospital medical staff organizations did not share their enlightened vision; the founders had fully expected that the medical staff organizations would want to use their power to continually improve the hospital, but many were simply satisfied to have met the Minimum Standard and be on the list of standardized hospitals.16  Nevertheless, the ACS minimum standards for hospitals did improve patient care, and its rapid implementation—the first major accomplishment of the ACS—stands as a glowing example of a massive successful continent-wide change management project that has benefited patients for almost 100 years. The manner in which the new profession of clinical pathology rapidly adapted to this movement, insinuated itself into the movement by creating a symbiotic relationship with the ACS, and then used that relationship to establish hospital-based laboratories on firm footing is a credit to the creativity of the founders of the ASCP. Patient care, from the perspectives of diagnostic certainty, prognostication, and quality assurance, benefited from this as well. Modern-day teachers of change-management strategy should study the ACS hospital standardization program and use it as case study material for their students.

The results of the hospital-standardization initiative were not at all what Ernest Amory Codman, MD, had envisaged, but there was never any real possibility that his vision would have been acceptable to many of the stakeholders, including the ACS, doctors in general, hospital administration, or trustees. However, Dr Codman rebounded to make another innovative contribution that forever improved the care of patients with cancer and facilitated outcomes research. He conceived of the first tumor pathology registry and established the ACS Bone Sarcoma Registry in 1921.5,8  Noting that bone sarcomas were rare and generally misdiagnosed until very late into the clinical course, Dr Codman convinced the ACS to allow him to chair its first subcommittee, and then he wrote the entire ACS membership asking fellows to send cases with histories, slides, and x-rays for his surgical pathologist committee members James Ewing, MD, of Cornell (New York, New York) and Joseph Colt Bloodgood, MD, of Johns Hopkins (Baltimore, Maryland) to review. This showed there was no uniformity in histopathologic diagnostic terminology used by pathologists, including those who were experts in the pathology of bone cancers. One quick win was that the committee met with the ASCP and agreed to standardized nomenclature in 1923. Although the Bone Sarcoma Registry continued to thrive, it soon had new leadership because Dr Codman, true to his nature, “resigned amid controversy in 1925.”5(p54)

I thank Peter J. Kernahan, MD, PhD, for reviewing an early version of this manuscript and for helpful suggestions; I also thank Kristin Rodgers, MLIS (collections curator), Medical Heritage Center, Ohio State University Health Sciences Library, for archival assistance; the staff who maintain the ACS Archives electronic database (https://www.facs.org/about-acs/archives); Dolores J. Barber, MSLIS (ACS assistant archivist); Thyria Wilson, MLIS, JD, and Jeanne Abrams, PhD, Special Collections and Archives, University of Denver, for providing images; Thomas Kryton, BFA, for assistance with digital images; and Charlotte Monroe, Sherry Mount, and the staff of the Interlibrary Loan services of the University of Calgary and Alberta Health Services for assistance with obtaining articles.

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Author notes

The author has no relevant financial interest in the products or companies described in this article.