Revisiting
The Spirit Catches You and You Fall Down
, Cultural Competence, and the Human Side of Medicine
I first read Anne Fadiman’s The Spirit Catches You and You Fall Down through anthropology, not medicine.
That seems important now.
I’m returning to the book while moving toward radiologic technology and, eventually, MRI and advanced medical imaging. Same book, different vantage point. Some of the things that stood out to me before still do, but others have shifted. I’m less interested now in extracting a clean lesson from Fadiman than I am in the uncomfortable space the book opens up between technical knowledge, cultural interpretation, and what actually happens when real people encounter medicine.
Part of that change probably has to do with MRI itself.
Inside an MRI scanner, hydrogen nuclei respond to a powerful magnetic field. Radiofrequency pulses perturb their alignment, and as those nuclei return toward equilibrium, the resulting signals can be transformed into images of astonishing detail.
That is not metaphor. It is physics.
You can see tissue that would otherwise be inaccessible. You can distinguish structures, identify pathology, detect changes, compare one region to another. For most of human history, that sort of internal visibility would have been unimaginable.
And yet.
The image still cannot tell you what illness means to the person lying there.
It cannot tell you whether they trust the hospital. It cannot tell you whether their family agrees with what the physician is saying, whether they are frightened, whether they can afford what comes next, whether they have been dismissed by a doctor before, or whether they think of healing in a way that has almost nothing to do with the vocabulary medicine is using.
The image can be extraordinarily precise.
The person is not.
That tension is one of the reasons I came back to Fadiman.
Her book follows Lia Lee, a Hmong child with severe epilepsy, her family, and the American physicians attempting to treat her. It has become almost canonical in medical education because it presents a profound collision of explanatory worlds. Lia’s doctors saw seizures through neurology. Her family saw them through a Hmong framework in which the spiritual and the physical were not cleanly separated.
That difference mattered. So did language. So did medication complexity. So did expectations of authority. So did the fact that everybody involved thought they were helping Lia.
That last part is what bothers me most.
Nobody has to be evil for things to go badly.
Sometimes people care deeply and still miss each other entirely.
One obvious reading of Fadiman is that clinicians need to understand their patients’ cultures better. Fine. I agree with that as far as it goes.
Language matters. Religion matters. Family structure matters. Immigration matters. Trust matters. Historical experience matters. There are countless ways in which a clinician can misunderstand a patient because the clinician does not know enough about the world that person comes from.
But then the phrase cultural competence starts to bother me.
Competence is a useful concept in medicine. It has to be. You either understand anatomy or you don’t. You either know how to perform a procedure safely or you don’t. You can be evaluated in imaging physics, positioning, infection control, pharmacology, technique.
Culture doesn’t behave that way.
What does it mean to be competent in someone else’s culture?
At what point do you get the certificate?
This is where the problem becomes almost embarrassingly obvious. Two people can live in nearly identical houses on the same street, drive similar cars, shop in the same places, speak the same language, and still have radically different beliefs about medicine, family, religion, obligation, authority, pain, death, risk.
We don’t even have to leave one neighborhood to find cultural difference.
The opposite is also true. Two people who appear to come from completely different worlds may enter a hospital with nearly identical assumptions.
So yes, culture matters.
But it’s slippery.
It doesn’t sit still long enough to master.
Janelle Taylor’s critique of Fadiman gets at part of this problem. In attempting to take culture seriously, we can accidentally ask culture to explain too much. That creates its own distortion.
A Hmong patient is not “Hmong culture” in a gown.
A Puerto Rican patient is not a walking bundle of Puerto Rican cultural traits. A Catholic patient is not reducible to Catholicism. A Black patient is not a racial case study. A rural patient is not “rural culture.” A wealthy patient isn’t predictable either, for that matter.
These categories can matter tremendously. Sometimes they may be the key to understanding something that would otherwise make no sense.
But they do not finish the person.
That is why I find cultural humility more useful than cultural competence, even though I’m not entirely satisfied with that term either.
Tervalon and Murray-García developed cultural humility partly as a response to the idea that culture could be mastered as a bounded domain. Humility starts from a different intellectual posture: there may be something here I do not understand.
That sounds modest.
It really isn’t.
Medicine is not built around uncertainty in quite the same way anthropology is. Clinical environments require decisions. They require action. At some point, somebody has to decide what is probably happening and what to do next.
So I don’t mean that every biomedical conclusion should be suspended because a patient offers another explanation.
A bacterial infection remains bacterial.
A malignant tumor does not become nonmalignant because someone understands it through a spiritual system.
Evidence is evidence.
I think there is sometimes a tendency in discussions of culture to become so anxious about hierarchy that we lose the nerve to say that. Not all explanations have the same evidentiary status.
But that is a very different claim from saying that biomedical knowledge gives the clinician complete understanding of the situation.
It does not.
Arthur Kleinman’s work on explanatory models helps here because it makes a simple distinction that is easy to forget.
The clinician may be asking:
What is happening biologically?
The patient may be asking:
Why is this happening to me?
Those are not the same question.
Sometimes they fit together nicely. Sometimes they don’t.
Kleinman’s distinction between disease and illness is useful precisely because disease can be described pathophysiologically while illness is what happens when disease enters an actual human life.
And human lives are not controlled experiments.
My own family gave me an early version of this problem long before I knew enough to call it medical anthropology.
My grandmother was Puerto Rican and deeply Catholic. She also participated in spiritual practices that did not fit neatly inside Catholicism, and certainly not inside a biomedical model.
I never remember her treating these things as mutually exclusive.
That may be the important part.
Religion here. Medicine there. Culture over there. These categories are analytically convenient. Real people often ignore them.
Someone can trust modern medicine and pray for a miracle.
They can agree to surgery and perform a spiritual ritual.
They can understand what the physician is saying biologically and still believe something else is also happening.
That can look irrational if you insist that one explanation must drive the others out.
People don’t necessarily experience it that way.
People mix things.
A lot.
The word noncompliant becomes very strange once you start looking at behavior from that angle.
It sounds clinical. Clean. Efficient.
A recommendation was made. The patient did not follow it.
Noncompliant.
But why?
Maybe they cannot afford the medication.
Maybe the drug makes them feel worse.
Maybe they misunderstood.
Maybe they understood perfectly well and made a different choice.
Maybe they are ashamed.
Maybe they distrust the institution.
Maybe religion is involved. Or a spouse. Or a parent. Or some terrible encounter with medicine twenty years ago that the present clinician had nothing to do with but nevertheless inherits.
Or maybe the patient simply says no.
Medicine tends to dislike that possibility because it complicates the idea of adherence, but adults sometimes make choices professionals think are bad.
That is not automatically confusion.
All of these different situations can wind up looking identical in a chart.
That should make us cautious about what exactly the label is explaining.
This is where work on structural competency becomes useful. Some things that look like individual behavior, or even like cultural difference, are being shaped by institutions, economics, law, access, insurance, geography, transportation, work schedules, family demands. Sometimes the “problem” is not sitting inside the patient at all.
If someone is not taking a medication because they cannot afford it, learning more about that person’s ethnic background probably will not solve very much.
But I’m also wary of replacing one total explanation with another.
Culture cannot explain everything.
Neither can power.
Neither can economics, race, religion, education, institutions, psychology, or personal responsibility.
Human beings are produced by all of these things at once and then, inconveniently, refuse to behave consistently anyway.
A person can distrust medicine generally and trust one physician completely.
Someone can believe something that is centuries old and still be fascinated by an MRI scanner.
The same family can refuse one treatment and accept another.
Two siblings raised in the same household may respond to illness in entirely different ways.
I don’t think those are annoying exceptions sitting around the edge of the real explanation.
They may be the thing we are actually trying to understand.
And eventually all of this theory has to come back down to something practical.
What is a healthcare worker supposed to do with any of it?
Not become an anthropologist.
That would be absurd, and probably not especially useful anyway.
A radiologic technologist, nurse, physician, therapist, whoever happens to be standing in front of the patient, cannot possibly carry detailed ethnographic knowledge of every population they might encounter. And even if they somehow could, the patient could simply turn out not to believe what the textbook says members of that culture are supposed to believe.
What seems more useful is learning to notice when you do not know enough yet.
That can involve surprisingly ordinary questions.
What worries you about this?
What do you think is happening?
Is there something about this treatment that concerns you?
Is there a reason this plan might be difficult to follow?
Who else needs to be involved?
None of these is revolutionary. That may be precisely why they matter.
They do not require the clinician to identify a patient’s culture correctly before speaking to them. They allow the patient to supply information the clinician does not have.
And now I come back to imaging.
My academic background is in anthropology, history and education. I am moving toward radiologic technology, with a particular interest in MRI and the physics underlying imaging. On paper those subjects can look oddly assembled. They feel less strange together the more I study them.
Imaging is, among other things, an extraordinary technology of observation.
Anthropology has spent a long time worrying about observation too—not only what we see, but what we think seeing allows us to know.
That may be why this subject has followed me back into medicine.
Put someone in an MRI scanner and we can produce an extraordinarily precise representation of something inside their body. That image leaves the scanner. Someone reads it. Someone explains it. A physician may make a recommendation because of it. A patient and family may then have to decide what to do with information they did not have the day before.
The machine has done exactly what it was designed to do.
But the human problem is only partly finished.
I don’t come back to The Spirit Catches You and You Fall Down now thinking that it supplied the answer to all of this. If anything, I think I trust it more because it doesn’t.
Fadiman shows how badly people can misunderstand one another even while trying to help. Taylor makes the culture argument less comfortable. Kleinman reminds us that illness and disease are not quite interchangeable. Cultural humility shifts attention from knowing everything about someone else’s world toward recognizing the limits of that knowledge. Structural competency complicates it again by pointing toward forces outside the individual.
I don’t think these ideas line up perfectly.
They probably shouldn’t.
I’m also not sure I want them to.
Medicine can know extraordinary things about the body. There is no reason to diminish that achievement in order to make room for the human side of medicine. The two aren’t opposites.
But knowing the body with increasing precision does not necessarily mean knowing the person with increasing precision.
That may be the distinction I am most interested in now.
An MRI image can reveal structures hidden beneath skin and bone. It can show pathology with an accuracy that would have been almost unimaginable not very long ago.
Leave a Reply