In 1850, there was a brief attempt to organize some aspects of healthcare delivery in California through a society called the Medical Faculty of Los Angeles. However, not until the birth of the California Medical Association in 1856 was there a functioning organized medicine group, a potent political influence in California.

Barbara Gray's book, 120 Years of Medicine, provides insights into the difficulty. She writes: "Why did mid-century physicians fail to effectively organize? They were faced with enormous problems: Quackery, encouraged by the gold rush, put more emphasis on fee schedules than on the exchange of medical information; quack hunting created animosities within the early organizations, and physician nomadism--caused by the economic uncertainty within the cities of California--created an unreliable membership roll."

Nonetheless, on Jan. 31, 1871, some solo medical practitioners in Los Angeles formed a common interest group and began holding regular monthly meetings. Seven years later, on June 7, 1878, with Articles of Incorporation approved, physician members elected corporate officers and chose a corporate name, the Los Angeles County Medical Association.

LACMA hoped to prove a concept antithetical to capitalistic business true: that the sharing of expertise by individuals would enhance the business practices of the group as a whole as well as each individual. The commonality would also foster the development of new and profitable business innovations, which would perpetuate the organization.

One of the first issues LACMA grappled with was the troubling nature of medical education: There was no uniform standard. Curriculum content and teaching practices in what were termed as "medical schools" varied from esoteric to incompetent. All sorts of educational and apprenticeship organizations produced a motley spectrum of "doctors," from ritualistic voodoo-type healers to professorial pontificators. Marginal, yet profitable, physician-run proprietary training programs, some by mail order, enlisted any and all who desired entrance into the medical profession.

At the very top of the practitioner heap were homeopathic, osteopathic and allopathic physicians. The idea of having some scientific method to determine treatments was novel for the time, but encouraged by all three types of physicians.

The University of Southern California operated a College of Medicine since 1885, but due to debt, the college was transferred to the regents of the University of California in early 1909. With help from LACMA, a College of Physicians and Surgeons was established at USC in the fall of 1909.

The American Medical Association was also a burgeoning influence, having been formed by allopathic physicians. The AMA and LACMA were instrumental in developing and setting standards for medical education and in approving standards for medical schools. Although the groups continually lobbied for standardization of medical education and physician regulation of the profession of medicine, their opposition favored a laissez-faire, multiply independent system that held the hearts and minds of the American public. Cultural attitudes always drive the nature of healthcare delivery. In response, the AMA formed a Council on Medical Education, but lacked sufficient funding and political influence to make the council effective.

In 1901, John D. Rockefeller extended his philanthropic interest to medical education and founded the Rockefeller Institute for Medical Research. An allopathic pathologist on the institute's board of directors, Simon Flexner, had a brother on the staff of the Carnegie Foundation for the Advancement of Teaching--Abraham Flexner.

Abraham Flexner (1866-1959) was steeped in the field of education. He had attended graduate school at Harvard after a 19-year career of teaching in high school. After additional training in educational systems at the University of Berlin, he sought a position at the Carnegie Foundation. Flexner championed academic preparedness for higher education and was determined to raise the standards of high school education in the United States with a dual system of education--literacy training for all and rigorous higher education for the gifted. Steeped in German traditional learning, he advocated a strong background in the sciences as a prerequisite for a higher level of experimental-derived education that would replace didactic learning at that higher level.

So the stage was set for organized medicine and the Flexners to change the future of healthcare delivery. Simon Flexner nominated Abraham to lead a study of medical education. With $10,000 in Carnegie financing, Abraham set out on an amazing adventure in 1908. By the time he published his report in 1910, he had reportedly visited and evaluated 155 graduate and a dozen postgraduate centers of medical education in the United States and Canada.

This first detailed and authenticated medical education quality study, "The Flexner Report," became a watershed event for healthcare delivery. With ample financial and political backing, the report gained wide acceptance and drove future economic considerations in healthcare.

Flexner Report recommendations included consolidating the number of medical schools, reducing the number of graduates, increasing entrance standards with a prerequisite basic science curriculum, and increasing the quality of medical care. Other concepts included increasing the study and use of pharmaceuticals and scientific research to enhance learning in medical schools.

So far reaching was Flexner's impact, that modern day critics still opine about his work. A 2000 article in The Medical Sentinel criticized: "Abraham Flexner's evaluation of education on the North American continent in the early 20th century proceeded at a rapid pace. The itinerary emerges from the footnotes Flexner left in his report reveals periods during which he would have had only a fraction of a day to travel to and visit a school. Either Flexner was strikingly efficient or his efforts lacked thoroughness. In any event, a report of such repercussions warrants further study of the methods used in its creation. Certainly Flexner, allegedly the promoter of the scientific method in medical education, would have approved of such perusal."

Only 80 of 160 medical schools survived in the intervening years after the release of the Flexner Report. Further, the report clearly evolved dominant forms of healthkeepers. "Real" doctors were reduced to three types--allopathic, homeopathic and osteopathic.

Eventually the allopathic ranks became the new dominant healthkeeper set. The MD became entrenched in a medical ecolo-nomic environment that was willing and able to accept Carnegie Foundation financing along with AMA influence and control.

MDs applauded the consolidation movement as a reaffirmation of the Oath of Hippocrates to teach to "disciples bound by a stipulation and oath according to the law of medicine, but to none others." And MDs had authority over healthcare delivery during the first quarter of the 20th century. No nonMD competitive healthcare delivery system barked or whined any significant threat to MD power and control.

The report also generated an intolerant attitude among physicians for any type of healthcare practitioner not trained according to the new standardized curriculum. MDs were awarded with diplomas stamped "Flexner-approved" and were allowed to promote themselves as the only "real" doctors. The public embraced that perception.

Patients openly praised and demonstrated gratitude for the care they received. The cost of care was not excessive, as expensive medical technology remained limited. Doctors were few in number, and their role was revered. The MD of that time was accepted as a true professional who held a public trust to perform medical work and do no harm in a spirit of fairness, respect and generosity.

Ethical values of justice, autonomy, non-malfeasance and beneficence became a standard strictly demanded of fellow physicians. Doctors naturally expected other doctors to treat every patient fairly, not to interfere with a patient's life plan and to help the needy. Philanthropic physician endeavors became numerous and stemmed from the traditional philanthropic funding of the greater part of a physician's education.

An altruistic hunger to satisfy the public good and a propensity to serve people resided in the gut of most physicians. All doctors felt they were, in part, public servants. During this "iatrogenic era" of healthcare delivery, physicians were in control. Any doctor who was willing to work hard made a comfortable living, but was by no means considered wealthy. Physicians were often from well-to-do families, and they often depended on their affluent family structure for financial support. Their driving forces consisted of pride in work and honor in society.

Although presumptively prejudicial and surely shortsighted, physicians judged their own and others' professional value and worth by the "skill" with which they were able to diagnose illnesses or perform procedures, rather than by the patient outcomes achieved. A specialist, therefore, was more highly respected; and there arose a great dichotomy in payments for surgical vs. diagnostic services.

This dichotomy fostered the downgrading of cognitive services, which persists in healthcare delivery to this day. The once-honored general practitioners were the brunt of jokes among medical and surgical specialists. Backed by a system that praised and financially rewarded technical skills more than cognitive skills, some know-it-all surgeons foolishly fell victim to their own propaganda and cut themselves off from the humble nature of their profession. That vanity sometimes became their undoing.