Of my patients
I am a physician.
Most of my patients are Mexican.
Of course, we stop and scrutinize everything that mentions
another culture or country, and parse the phrases for their political
correctness, so let’s, for a second. It
is politically alright to call my patients Mexicans, I’d say, for they are from
Mexico. Most are not in any sense not
Mexican-Americans; excepting a brief continuation of their stay in the United
States, they are here illegally, awaiting deportation to Mexico. The few I see who have lived since childhood
in the US are a whole different sort. I
treat them in English; they are completely from a different universe. My patients are from Sonora, and Durango;
from Baja California Norte, and Oaxaca.
Mostly, their “business enterprises” have brought them here; I do not
discuss their “business” background.
They come from a broad range of cultures, abilities,
education and origins. Here, in the US
bubble, we sketch our pictures of Mexicans with the broadest strokes. Our image of Mexicans is really a cartoon;
our amigo bueno, Gustavo Arellano
will tell you that in “Ask
a Mexican®” in the Orange County
Register, and in the local Alibi.
For those bothered by the
logo on his column (right), one can
click on it and take it up with Mr. Arellano and Mark Dancey.
I shall not dwell overmuch on political correctness in
terms. Political correctness is often
called upon to fill up time in the absence of real thought, and to generate
purposeless dispute and bickering, in the empty echo-chamber of modern thought.
We think of the campesino – the fieldworker – most of the
time when we speak of Mexicans. We do
not think of the Museo Soumaya, a museum which
contains
a preponderance of the works of Rodin and other Impressionist artists
in a boldly modernistic structure in Mexico City. The picture is an actual photograph of the
museum, although it appears so crisp and stylized as to seem like an artist’s
sketch.
This amazing building was constructed by Mr. Carlos Slim,
a Lebanese-Mexican businessman, in memory of his wife, Soumaya, who collected
many of the artworks in her personal holdings that now reside in the museum. She was a Mexican, like her husband. Those artworks, like the museum, were paid
for by the family out of their personal wealth.
Lest anyone cringe at the term “Mexican Businessman,” and
consider the PRI and institutionalized corruption, this family’s wealth largely
derived from introducing the digital age to Mexico and beyond. One could call him the “Bill Gates of
Mexico.” However, his wealth exceeds
that of Mr. Gates, so really Microsoft was founded by the “Carlos Slim of America.”
Of Campesinos that I have met
What we see here in America is largely the campesinos –
the rural fieldworkers, who are simply the Okies of the Dust Bowl from a different
place, from a different time.
America struggles to understand and handle the presence of
illegal Mexicans. I do not understand
why, as they are the model residence in the eyes of government. They work in an economic paradise, from the
government’s perspective. They often pay
Social Security taxes through withholding, using bogus numbers; but they do not
collect Social Security earnings, nor Medicare nor Medicaid. They pay millions, but are not entitled to
any benefits – any government’s ideal citizen.
In America, the campesinos do not annoy the government
with entitled demands and expectations; they usually hide from any contact with
authorities. They flee. They cannot argue for their Fourth Amendment
rights, or other Bill-of-Rights stuff; that is not their America.
Unlike the farm and orchard, the Mexicans I see come from
a broader swath of background and culture than the pickers and stoopers of the
Central Valley in California.
My interest is not in what makes pickers pick – our
civilization has spent many millennia gathering food from the earth, and it is
not a valuable enterprise, regarding wealth and prosperity. It will keep you alive; the gleanings of
windfall can be eaten from the orchards, the bruised apples and wormy pears.
In actuality, the term “Mexican” can mean picker, or
entrepreneur, when applied to the whole spectrum of the country’s people. Here in the US, we simply mean campesinos,
and for some reason fear and despise them.
What Mexicans do to us does not concern me as much as what we are doing
to ourselves.
Campesino Medicine
Somehow, the recruiters have gotten my email address. I am offered a position in Virginia.
“Are you available in December to pick up hospitalist work? We have a new facility in Virginia looking to
fill their schedule and need your help!” And in California: “CA Puzzle Piece Solutions 1Hr to Bay
Area, California - $300,000+ Real Potential - 100% Outpatient - No Call.” Or Las Vegas (NV) “See a show or try your luck in Las Vegas for 6 months!~ ANY State License
Gets You Here” And East Coast: “we
have an opportunity just minutes form Philly and the Jersey Shore in our rehab
facility.”
This is depressing.
How does a former profession go from providing care, to eMigrant labor
in the 21st century? Of all
the business models for healthcare in the future, why the campesino model?
I have no particular contempt for the campesinos from
Mexico. One side of my family came to
the factory town of Lawrence, Massachusetts to work in the mills doing
handwork; the other side fled north Texas to high water and survival in Magdalena,
New Mexico. I think no less of
pieceworkers, or pickers and stoopers; I only ask why that means of producing
things is still used beyond Neolithic agriculture.
Of ideas old and discarded.
Somehow, we have harvested the chaff in management planning,
at least in medicine. All of the
terrible ideas in management that were energetically discarded years ago have
gone underground, and survive still in the HR departments and general
occupational consciousness in America.
Early in the Journal of the Harvard Business School,
Whiting Williams criticized and scrutinized some of these terrible old ideas
and suggested a reformation of them.
To-day the majority of us find ourselves in such
contact with the general public that we are likely to accept as final for
us-the measurement of the particular tape-line which that public, rather than any
smaller and probably more discerning group, currently, employs. Here in the United States, that is apt to
mean the pursuit of one thing - wealth. For,
at the present time at least, the dollar furnishes ·the yardstick by which the
great body our fellow citizens habitually endeavors to determine the exact degree
of each member’s accomplishment.
…
Too long we have thought of work as a curse. The
truth is that every one of us plays a part in making it whatever it is; it
becomes a curse only when we withhold from the performer of any useful service
our proportionate economic and social recognition. Because we have so long
failed to see men's wish for worth through work, we have failed too often to
keep our promises of reward. Indeed, we have too generally based our whole
program of the management of our industrial personnel less upon the hope of
reward than upon the fear of punishment. That fear is the fear of discharge the
fear of joblessness and all of those attendant stigmas and miseries which not
management but society has erected.[1]
No campesino would speak well of any of the current
management ideas. They would agree with
Williams – for what other purpose would drive a family to uproot themselves in
the old country and flee to a new land without any guarantee of success, other
than the hopes that Williams writes about.
They may be proud of being campesinos – of working
hard with dignity. They are not proud to
be campesinos. Their children are
intended to be Americans. Every culture
that has come to America has hoped to make their children Americans, not
second-class Americans. Although they
may derive honor for feeding their children, they would be embarrassed if their
children only follow in their footsteps.
The awful idea remaining is that if a certain enterprise
is considered too expensive, one should fracture it into constituent elements,
rote behavior and piecework; and measure the productivity of the “pieces” scientifically,
in order to maximize profit and throughput.
Then one can offer “best practices” that maximize the productivity of
the workers’ hands.
Nowadays, Williams sounds uncomfortably Euro-socialist,
and Frederick Taylor more familiar, at least in the concepts currently used for
management in medicine, in his assertion:
As has been pointed out, however, the underlying
principles of the management of "initiative and incentive," that is,
the underlying philosophy of this management, necessarily leaves the solution
of all of these problems in the hands of each individual workman, while the
philosophy of scientific management places their solution in the hands of the
management… Under scientific management, on the other hand, it becomes the duty
and also the pleasure of those who are engaged in the management not only to
develop laws to replace rule of thumb, but also to teach impartially all of the
workmen who are under them the quickest ways of working.
All that is needed is to include the assumption, in medicine,
that management is the thing learned in a business school with an MBA,
and that MBA’s should direct the business of medicine, and there you have it –
the history of medicine over the last few decades. Taylor long ago invented “management” as a class
of people, as well as a duty; he implicitly accepts the division of the “management”
class from the “proletariat,” as Marx sketched out decades before. The inherent assumption is that those who
‘do’ cannot possibly see the forest for the trees, and it takes a special,
remote class to govern the strategic interests of the enterprise.
We have decided that we no longer have the money to pay
for medicine, and our response is to revert to Taylorism. To make it work in America, we must denigrate
the status of the ‘do-ers’ to pieceworkers, and the ‘leaders’ as the management
class – a concept credible only to Marxists and scientific managers.
In order to dissolve the old model of healthcare, we have
needed to disparage the professions, which we have done so admirably with
nursing. Now, it is the doctor’s
profession that is being reconstructed as the shifting, migrant pieceworker,
here in the Central California valley for a few months, then up to Oregon for a
few more – the locum tenens and the
campesino as all but the same principle.
As picking strawberries is easily measured and paid, why not the
provision of medical care? From a
management perspective, they are all the same.
Where are we going?
So, we continue to
stagnate with management ideas that are a hundred years old and obsolete. Meanwhile, Latin America is becoming
digital. The Mexican GDP exceeds that of
Canada; it rivals and may soon exceed that of the UK and France. Mexico did not really have a firm foundation
for stability until 1929, when it became a stable autarchy of the PRI; it has
only recently had a credible multi-party government in this millennium. Within a much shorter time period of
stability, Mexico is rapidly flourishing.
Like the Ottoman Empire and Roman Egypt, America might
become the Amusing Old Man of the New World over the next few decades.
Do-ers and leaders.
Somehow, after starting with a powerful contempt towards
nobility and class, we have settled into a culture riven with class and status;
while Latin America struggles to jettison its old racism and
discrimination. They, like the Americans
of old, are becoming more interested in those that can do, make and build, over
the old aristocratic days of color and family. Perhaps the legacy of Jefferson
and the founders has spread; it has not taken permanent root at home. We persist in our Puritan certainty of this
land as Divinely Chosen even after nothing recognizable persists from those
days.
