“Does each and every patient receive the very best the clinic has to offer? If not, why not?” 

— Joseph W. Jackson, first chairman, National Association of Clinic Managers, 1926

On the first morning of November 1926, in a room at the Madison Club in Madison, Wisconsin, a man stood up before 32 men and women, greeted them as “fellow sufferers,” and reached into his pocket for a deck of playing cards.

The man was Colonel Joseph W. “Bud” Jackson, and what he did with that deck is the reason the meeting still matters a hundred years later. One card at a time, he laid out everything a person needed to know to run a medical practice. Played for laughs and delivered off the cuff, it was the first body of knowledge the profession of practice management ever had.¹

Jackson was an unlikely author for it. Before Madison he had punched cattle in the Little Missouri badlands of the Dakotas and commanded a U.S. Army remount depot in the First World War^2,3 — a fuller life described in a companion The Roots of the Profession article, “What He Planted.” What matters here is that in 1920 his family brought him into the Jackson Clinic, one of Madison’s first multispecialty groups created by his father and three of his brothers,^3,4 to run the business side of the practice. He was the rare Jackson who hadn’t gone to medical school, and he turned out to be exactly what a clinic full of doctors needed.

By the mid-1920s, a scattering of people were doing that same job in other clinics — a role with no name, no training and no literature to guide them. Jackson decided they should compare notes. He wrote to the 37 medical groups he knew of, proposed his hometown and set the dates for a meeting; 32 administrators from 21 practices answered the call. When the meeting opened, he was elected chairman on the spot — and he had the group hire a stenographer, which is why we can still read every word and share it with you today.

He knew he was convening something that didn’t yet exist. “There are a mighty few of us in the whole country who can really be called old-timers in this work,” he told them, “because … the clinic is the outgrowth of the war to a large extent. Clinic managers have only existed for a few years.”

On that first day, Jackson put the question at the center of everything: What, exactly, is this job? Harry Harwick — the Mayo Clinic’s legendary first administrator — gave a wry short answer. A business manager, he said, needs to know “how to keep out of trouble.” Then Jackson turned to his own brother, Dr. James Jackson Jr., the clinic’s surgeon, who answered without hesitation: “Everything. A physician shouldn’t know anything except how to operate.”

Then Jackson pulled out the cards.

Working through the deck, he built the job description in the open. The jack of clubs meant a manager must know “the general duties of each member of the staff and every member of the clinic organization.” The king of clubs: the “transportation facilities, railroads, highways and traveling schedules” that brought patients in. The queen of hearts demanded “a practical working knowledge of ordinary medical terms and especially of operations regularly performed.”

The financial cards alone read like a modern competency list: know the accounting system inside out; track income by department; watch overhead; analyze the per-patient cost of care; keep billing and collections tight; benchmark compensation against peers; prepare and defend tax reports; even know how to finance a new building.

The operational cards ran just as long — every step of the patient’s path from registration to discharge, the referral network, hospital relationships, medical terminology, inventory and purchasing, the physical plant down to the heating and the landscaping. Still more covered insurance, law and workplace safety.

He dealt the last cards for a laugh. A manager, he said, must know how to “make happy temperamental prima donnas, some of whom are 99% temper and 1% mental,” and must serve “365 days of each year as the clinic CHEERUPADIST.” Then the seven of hearts, “which says, lastly, as firstly, if he is to be successful and satisfactory, he must know everything.”

For all that breadth, the thing Jackson placed first wasn’t on a card. It was people. The greatest single challenge, he said, was “building up and moulding together a thoroughly capable, well-balanced, smooth-running, energetic organization of men and women who will co-operate with each other.” And he distilled the whole enterprise into a single test question — “Does each and every patient receive the very best the clinic has to offer? If not, why not?” — that no dashboard has since improved upon.

The meeting attendees were so new to the work that, before the two days were out, they stopped to argue over what to call themselves. “Business Manager is objectionable,” one delegate complained. “What should we call ourselves?” Alfred Stasel, of Minneapolis’ Nicollet Clinic, offered “Business Director.” The title would keep changing for decades. The job would not.

That is why Jackson’s hour with a deck of cards earns the name body of knowledge, and not as a figure of speech. When the American College of Medical Practice Executives set down the formal Body of Knowledge for Medical Practice Management — the credentialing standard administrators study toward today — it was published in 2003: 77 years after Madison,⁵ and nearly half a century after ACMPE itself was founded in 1956.⁶ Its competency domains are, almost card for card, the categories Jackson dealt out at the Madison Club. 

• His financial cards are Financial Management.
• His prima donnas and personnel are Human Resource Management.
• The patient’s path and the physical plant are Operations.
• The insurance and law cards are Risk Management. 

He didn’t gesture at the modern body of knowledge. He enumerated it, one card at a time, 77 years early.

The founders did one more thing that first week that would outlast them all: They agreed to survey one another — costs, staffing, overhead, collection rates — and share what they found.⁷ That handful of clinics trading numbers is the acorn of the benchmarking enterprise MGMA now runs across thousands of organizations. The conviction that the work should be measured, compared and improved was there at the creation.

The tools have turned over completely. Jackson’s ledgers are now databases; his card index is an analytics platform. But set his list beside a job posting for a practice administrator today and the overlap is uncanny: Align the people, guard the finances, master the operations, manage the risk and keep every patient at the center of all of it. A former cowboy described this profession whole before it had a name, a credential or a single textbook — and a hundred years on, practice managers are still, in his words, expected to know everything. 

Notes

1. Proceedings of the First Conference of Clinic Managers, The Madison Club, Madison, Wisconsin, November 1–2, 1926 (verbatim stenographic transcript, Vol. I).
2. J.W. Jackson to Mrs. C.M. Russell, January 14, 1918, Auxiliary Remount Depot No. 331, Camp Lewis, American Lake, Washington. Gilcrease Museum, Charles M. Russell Research Collection (Britzman), Tulsa, Oklahoma, TU2009.39.1379. https://collections.gilcrease.org/object/tu2009391379
3. Jackson-Stevens-Morris Family Papers, 1773–1968. Wisconsin Historical Society, Division of Library, Archives, and Museum Collections, Madison, Mss 919.
4. “Jackson, James Albert 1840–1921,” Dictionary of Wisconsin History, Wisconsin Historical Society. https://www.wisconsinhistory.org/Records/Article/CS9064
5. ACMPE Guide to the Body of Knowledge for Medical Practice Management, American College of Medical Practice Executives, first published October 2003; soon to be in its fifth edition.
6. The American College of Medical Practice Executives was founded in 1956 as the American College of Medical Group Administrators. The National Association of Clinic Managers was renamed the Medical Group Management Association in 1963. https://www.mgma.com/american-college-of-medical-practice-executives-acmpe
7. Gans DN, “Data Mine: A Century of Progress?” MGMA. April 1, 2026. https://www.mgma.com/articles/data-mine-a-century-of-progress