Author: Atlasheld

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.

Revisiting The Spirit Catches You and You Fall Down, Cultural Competence, and the Human Side of Medicine

Revisiting

The Spirit Catches You and You Fall Down

, Cultural Competence, and the Human Side of Medicine

Anne Fadiman’s The Spirit Catches You and You Fall Down has been widely read in medical education for decades. The book follows Lia Lee, a Hmong child with severe epilepsy, her family, and the American physicians who tried to treat her. Its influence is understandable. Fadiman made visible the consequences of profound misunderstanding between a family and a medical system even when, perhaps especially when, both believed they were acting in the child’s best interest.

I first encountered the book through anthropology rather than medicine. Returning to it now, while moving toward radiologic technology and medical imaging, I find that some of its questions look different than they did the first time around.

Part of that may have to do with MRI.

Inside an MRI scanner, a powerful magnetic field causes hydrogen nuclei in the body to align with that field. Radiofrequency energy perturbs that alignment, and signals generated as those nuclei return toward equilibrium can ultimately be reconstructed into remarkably detailed images. The physics is rigorous, and the resulting images can reveal anatomical and physiological information that would otherwise remain inaccessible.

Yet the clarity of an image settles surprisingly little about the person inside the scanner.

It cannot tell us what illness means to that person, what experiences they bring into the examination room, whether they trust the institution treating them, what they fear, what they believe constitutes healing, or what burden a particular treatment may impose on the rest of their life.

That distinction is part of what drew me back to Fadiman.

The book is often described as a story about the collision of two cultures. There is good reason for that description. Lia’s physicians understood her seizures through biomedical neurology. Her family understood them within a Hmong explanatory world in which seizures could possess spiritual meaning alongside their physical consequences. Language barriers, differences in expectation, complicated medication regimens, and very different understandings of illness contributed to a relationship in which both sides could care deeply about Lia and still repeatedly fail to understand one another.

What has become more interesting to me, though, is that the continuing usefulness of the book may lie less in the solution it seems to offer than in the questions it leaves behind.

The Problem With an Easy Lesson

One possible lesson from Fadiman is straightforward enough: clinicians need greater knowledge of the cultures of the patients they treat.

There is obvious value in this. Ignorance can cause harm. Language matters. Religion matters. Family organization matters. Migration history and previous experiences with institutions can matter enormously. Much of what shapes a person’s response to illness will never appear neatly in a medical chart.

The difficulty begins when cultural knowledge starts to look like something that can simply be mastered.

Anthropologist Janelle Taylor examined precisely this problem in her critique of Fadiman’s book and its use in medical education. Taylor was interested not only in the story itself but in what happens when a complex ethnographic narrative becomes a teaching instrument for “cultural competence.” Culture can begin to do too much explanatory work. Instead of helping us understand an individual, it risks becoming another way of classifying the individual in advance.

The problem is that culture rarely exists in the tidy form educational examples sometimes imply.

Two people can live on the same street, work in similar professions, shop at the same stores, speak the same language, and still understand illness, family responsibility, religion, authority, risk, and medical intervention quite differently. At the same time, people whose backgrounds appear radically different may approach healthcare in almost indistinguishable ways.

Culture matters, certainly. It simply does not predict everything.

This makes the word competence itself worth examining.

Medicine depends on competence. There are things a clinician must know and procedures a clinician must be able to perform reliably. Competence in anatomy, pharmacology, imaging physics, infection control, positioning, or clinical procedure has a reasonably concrete meaning.

Culture is not quite like that.

It is difficult to imagine a point at which one could say, in the same sense, that one had become competent in another person’s culture. Even the idea of a single, stable culture becomes less convincing the closer one looks at an actual person.

This does not make cultural knowledge unimportant. It may simply mean that such knowledge is most useful when it tells us what we might need to ask rather than convincing us that we already know the answer.

From Competence to Humility

This concern was already taking shape within medical education by the late 1990s.

In 1998, Melanie Tervalon and Jann Murray-García proposed cultural humility as an alternative to the idea that clinicians could eventually master a finite body of cultural knowledge. Their model placed greater emphasis on continuing self-evaluation, recognition of power differences, and the quality of relationships with patients.

I find that distinction useful, though not because it resolves the problem entirely.

A clinician does not need to become an anthropologist. Nor does openness to another person’s understanding of illness require medicine to suspend scientific judgment whenever the patient’s interpretation differs from the biomedical one.

Evidence still matters.

A bacterial infection does not cease to be bacterial because it is interpreted spiritually. A malignant tumor does not disappear because another explanatory system assigns it a different meaning. Medical science derives much of its extraordinary power from the fact that its claims can be tested, challenged, reproduced, revised, and replaced when better evidence appears.

But accepting the authority of scientific evidence does not mean that scientific knowledge answers every question present in a clinical encounter.

This seems particularly important in highly technical fields. There is something compelling about being able to see more. As technology becomes more precise, it becomes easier to confuse increased visibility with complete understanding.

MRI can make anatomy visible in extraordinary detail.

It cannot make a person transparent.

Illness and Disease Are Not Quite the Same Question

Arthur Kleinman’s work offers another way into this problem.

Kleinman distinguished the biomedical classification of disease from the lived experience of illness. His concept of explanatory models focused attention on the questions patients and clinicians may actually be answering, sometimes without realizing that their questions differ.

What is happening? What caused it? How serious is it? What should be done? What is most frightening about it?

A clinician may be principally asking, What biological process is occurring?

The patient may be asking, Why is this happening to me?

There is no necessary contradiction between the two. But neither are they interchangeable.

Sometimes those ways of understanding illness coexist with very little difficulty. Sometimes they do not.

I saw something of this in my own family long before I had any reason to place it within an academic framework. My Puerto Rican grandmother was deeply Catholic while also participating in spiritual traditions that did not fit neatly within conventional biomedical categories. There was never a particularly clear boundary in her life where religion stopped, culture began, and medicine occupied an entirely separate territory.

It was all present at once.

That has always made neatly separated explanatory systems somewhat difficult for me to accept. People combine things. They borrow from different traditions, sometimes without seeing any contradiction in doing so. Someone may trust a physician and pray simultaneously. A person may accept surgery while continuing to participate in a spiritual practice. It is possible to understand a biological explanation perfectly well and still attach another kind of meaning to what is happening.

From the outside, those combinations may appear inconsistent.

From within an actual life, they may not be.

The Trouble With “Noncompliance”

Few medical terms expose this complexity as quickly as noncompliant.

At first glance, the word seems straightforward. A clinician recommends a course of treatment and the patient does not follow it.

But this tells us very little about why.

A person may not take a medication because they cannot afford it. Someone else may stop because the adverse effects seem worse than the condition being treated. Instructions may not have been understood. Or they may have been understood perfectly, and the patient may simply disagree.

There may be distrust, shame, religion, family obligations, fear, or a previous bad experience with medicine. A patient may decide that the burden of treatment is greater than the benefit they expect to receive.

These situations arrive at a similar clinical outcome through very different routes.

Calling them all noncompliance may describe what happened from the standpoint of the treatment plan while obscuring much of what produced it.

Later work in medical education expanded this discussion beyond culture itself. Jonathan Metzl and Helena Hansen’s concept of structural competency, for example, asks clinicians to consider the institutional, economic, legal, and social conditions that shape clinical encounters. This was, in part, a response to explanations that placed too much interpretive weight on the individual patient or the patient’s culture.

The distinction matters because the same apparent behavior can emerge from very different circumstances.

A patient who does not obtain medication because of cost and one who refuses the same medication because of a religious conviction may look almost identical in a chart.

They are not the same situation.

Nor can either necessarily be understood by knowing the person’s ethnicity.

Culture Is Not the Only Variable

At this point, the discussion becomes more complicated than deciding whether Fadiman was correct or whether her critics were.

If culture is asked to explain everything, individuals begin to disappear inside categories. But replacing culture with power, economics, or institutional structure does not solve the problem if any one of those is then expected to account for human behavior on its own.

People participate in cultures, institutions, families, religions, professions, economic systems, and personal histories at the same time. These things overlap. They do not always pull in the same direction.

The same person may distrust medicine in one situation and trust it almost completely in another. Someone may retain a traditional belief while enthusiastically embracing modern technology. A family can reject one recommendation and accept the next. People living in the same household may disagree profoundly about what an illness means and what ought to be done about it.

That complexity is not necessarily something analysis has failed to solve.

It may simply be what there is to analyze.

What Medicine Can Realistically Ask of Itself

This leaves a practical question.

If clinicians cannot master every culture, and if culture itself is only one of many influences on behavior, what should medical education reasonably attempt to teach?

The answer may be more modest than mastery.

Awareness, perhaps.

Not the expectation that every clinician should know the beliefs of every community, but the habit of recognizing when something important may not yet be understood.

That recognition can begin with fairly ordinary questions.

What worries you most about this?

What do you think is happening?

What concerns do you have about the treatment?

Is there something that would make this difficult for you?

Who else needs to be involved in this decision?

These resemble the explanatory-model questions associated with Kleinman, but their usefulness does not depend on possessing specialized anthropological knowledge. They do not require the clinician to know beforehand what a particular patient believes.

They require curiosity, and some willingness to discover that an initial assumption may have been wrong.

That may ultimately be a more realistic goal than competence understood as mastery.

Returning to the Image

My own interest in this subject now comes from a somewhat unusual intersection.

My academic background is in anthropology, history, and education. I am moving toward radiologic technology, with a particular interest in MRI and advanced medical imaging. On the surface, those fields can appear to belong to very different intellectual worlds.

I am increasingly less convinced that they do.

Medical imaging is one of the most technically sophisticated ways humans have developed to observe the body. Anthropology, among many other things, is concerned with what human beings make of the worlds they observe and inhabit.

Those concerns meet every time an image becomes part of someone’s medical care.

The scanner may produce an extraordinarily precise representation of tissue. What happens afterward is less mechanical. Someone has to explain what has been seen. Someone has to determine its clinical significance. Decisions follow, sometimes straightforwardly and sometimes not.

And someone has to live with those decisions.

None of this diminishes the science. It places the science inside the human circumstances in which it is actually used.

An Ongoing Question

One reason The Spirit Catches You and You Fall Down remains compelling is that it does not allow good intentions to function as an adequate explanation for good outcomes.

Lia Lee’s physicians cared about her. Her parents cared about her. That shared concern did not prevent misunderstanding, conflict, or tragedy.

Taylor’s critique makes the story more difficult by asking what happens when culture itself becomes too coherent an explanatory object. Kleinman gives us a way to examine the different explanatory models patients and practitioners can bring to the same illness. Tervalon and Murray-García shift attention from mastery toward humility. Metzl and Hansen widen the frame again, asking us to consider circumstances that may initially appear cultural but are also being shaped by institutions and larger social structures.

Taken together, these approaches do not produce a particularly neat formula.

That may be one reason they remain useful.

Perhaps the enduring question is not how medicine can become perfectly competent in the enormous variety of human cultures. I am not sure that is even a coherent objective.

A more useful question may be how medicine can remain scientifically rigorous while becoming more attentive to what its tools cannot measure.

An MRI image can reveal extraordinary detail. It can show structures hidden beneath skin, bone, and tissue.

There are still things the image cannot tell us.

For those, medicine has to ask.