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The Spirit Catches You and You Fall Down

By Anne Fadiman

General Discussion Options

1) Reactions to main “characters”

- Does anyone perceive this differently?

- What might be other ways of thinking about this patient/practitioner?

2) Point of view

- How does the world look from ______ perspective?

- What might explain _____ behaviors?

** Attempt to enter the character’s reality and speak in their voice

** Try to practice “speaking in patient’s voice”

3) Clinical implications

- How the physician acted

- Strengths?

- Shortcomings?

- What might be alternative approaches?

- What might happen if _____ were said and done?

- Would greater cultural understanding have helped?

- Knowing the patient more fully

Chapter 1 - Birth

- Compare Hmong birth rituals with our American culture

(laboring in silence, placental care, postpartum care, naming the infant soul

calling ritual, causes of illness, clothing babies)

Chapter 3 – The Spirit Catches You and You Fall Down

- Hmong beliefs about seizures: caused by “soul loss” and fright, illness of distinction,

evidence of the power to perceive things others can’t see, intuitive sympathy for others,

not to be refused or will die, increased social status, marks person as one of high moral

character vs. Western descriptions: disease, satanic, crazy, mostly negative

- Social Worker Jeanine Hilt only Western care provider that had asked the Lees what

they thought was the cause of the illness

- No interpreters with medical knowledge were available

* How does it feel as a medical provider to not be able to communicate in the same

language with patients?

Chapter 4 – Do Doctors Eat Brains?

Txiv neeb (tse neng) VS. Western medicine

Home visit	Office
Polite Immediate feedback/Dx	Rude Tests blood, urine, stool
Clothed	Remove clothes
Respect	Physical invasion
Focus on soul	No concern with soul
Lengthy visits	Short time
No questions	Asks intimate questions
Failure to cure:
Blame on spirits	Blame on doctors

Hmong beliefs:

1) Lab samples blood supply finite, leads to death

2) Unconscious/anesthesia soul at large leads to illness/death

3) Loss of body parts disfigurement leads to imbalance, ill or incomplete in

next incarnation

4) Loss of body parts at death (autopsy/embalming) soul cannot be reborn

- Quote from Dwight Conquergood regarding the relationship with the Hmong: “a

productive and mutually invigorating dialog, with neither side dominating or winning

out.”

Chapter 5: Take as Directed

- Lia – 17 hospitalizations and more than 100 office visits/ER between 8 months and 4 ½

years of age

- When about to seize, run to parents with scared expression (listen to patients)

-seizure aura called angoranimi or soul anguish

- Compliance themes

- Lia overweight and parents thought fat was healthy, but resulted in difficult IV

access

- re: not taking medication, parents lying or confused

- Neil – felt the father was “deliberately deceitful”

- Peggy – felt the mother was “either very stupid or a looney bird”

*What did the doctors try to improve the communication?

(nurse to have Hmong interpreter, stickers on medicine bottles, marked syringes,

taping pills to calendars with suns/moons)

*What else could the doctors/team have done?

(home visit, involve Hmong community leaders, learn about Hmong treatments

and culture, ask the parents)

- Neil Ernst – retrospectively, “Lia 18m to 3 1/2 , too angry to feel sympathy, the best

thing I could have given Lia’s mother was compassion, and I wasn’t giving her any and I

knew I wasn’t giving her any.”

- ER visits, “precipitous peak of anger – quickly followed by fear.” It’s hard to work so

hard and not receive a single word of thanks, in fact, to have your efforts invariably

greeted with resentment.

- Financial aspects – frustration

- Neil – poor parental compliance, neglect, placed in foster care so that medication

compliance can be assured

Chapter 7: Government Property

- Might Neil Philip actually have compromised Lia’s health by being so

uncompromising?

* Which would have been more discriminatory: to deprive Lia of optimal care another

child might have received, or to fail to tailor her treatment in such a way that her family

could comply?

- What is “standard of care”?

- Neil’s attitude: a doctor’s job is to practice good medicine, patient’s job – to comply

* What do you think of this statement?

* What do you think of the statement made by Neil Ernst, (page 79 – “I felt it was

important for Hmong to understand that there were certain elements of medicine that we

understood better than they did and there were certain rules they had to follow with their

kids’ lives.”)

- Principles of autonomy vs beneficence in adults vs. kids

- Page 84 “As long as doctors and parents continue to negotiate, even if they disagree, the

conflict is confined to differences in belief systems.”

- With the change in Lia’s status, differences of belief changed to differences in POWER

* How does it feel to hold power as a doctor? Examples from cases?

* How does it feel to be disempowered? Examples?

- Lia returned to family as they proved ability to give medication as ordered

Chapter 9: A Little Medicine, A Little Neeb

- Foster care for 10 months

- “returned in damaged condition” – was parent’s opinion

- parents believed Lia was taken from them because “the doctors were angry at us” for

noncompliance

- page 111 – traditional methods, culminating in change of name from Lia to Kou

- page 113 – Empathy, Jeanine Hilt, lesbian, rejected by her family

* Do you think that experiencing a similar problem is necessary for empathy?

* Where does empathy stem from?

* Is empathy important to patient care?

- fall at school, lead to hospital stay, status epilepticus, tracheal infection, 3 weeks home,

readmitted with normal Depakene level, “waiting for the big one”

Chapter 11: The Big One

-Ambulance, transfer to Fresno ICU (because of severity or vacationing MDs?)

-spinal tap – “they just sucked her backbone and it makes me disappointed and sad

because that is how Lia was lost” vs medical “knowledge” that Lia was septic with blood

cultures growing pseudonomas.

Chapter 13

- Lia returned from Fresno to MCMC “to die” on December 5

- parents request to take Lia home, even though still having fevers. Peggy Phillips said

“Lia needed to stay at MCMC for a few days of observation. I was sure she was dying,

but that’s the quandary of Western medicine, that you can’t let people die.”

* What do you think about this statement/philosophy?

- Discharged to home on December 9, but father confused and thought told “in two hours

Lia is going to die” so he flees the hospital

- Code X is called

- Resident – “They wanted to take Lia home to let her die and we were willing to do that,

but it had to be in a medically acceptable manner, not by starving her to death.”

* What do you think about this statement?

* Is starving to death a bad way to die?

- Parents took home, washed with herbs, she didn’t die.

Chapter 17

- Lia lives in vegetative state, other Lee kids did well, acculturated successfully

- Jeanine Hilt has asthma attack and dies.

- Neil Ernst wins first “Faculty Teacher of the Year” award

- Peggy Philip becomes Merced County Health officer (their son develops ALL)

- Dan Murphy becomes director of MCMC Family Practice Residency Program

- Arthur Kleinman (psychiatrist/medical anthropologist at Harvard) developed the “Eight

Questions” designed to elicit a patient’s “explanatory model”

1. What do you call the problem?

2. What do you think has caused the problem?

3. Why do you think it started when it did?

4. How does the sickness work? What does it do?

5. How severe is the sickness? Short or long course?

6. What kind of treatment should the patient receive? What are the most

important results you hope to receive from treatment?

7. What are the chief problems the sickness has caused?

8. What do you fear most about the sickness?

* Do you think these questions could be helpful in your care of patients?

Dr. Kleinman’s suggestions retrospectively –

1. Get rid of the term “compliance” (it implies moral hegemony)

2. Look for a model of mediation (requires compromise on both sides, do what is

critical and be willing to compromise on everything else)

3. The culture of biomedicine is equally as powerful as the patient’s cultural

background (you must first accept your own culture’s interests, emotions, and

biases)

* Do you agree that these suggestions could be helpful?

* Are there any other guiding principles that you may find helpful?

Chapter 18

The author states “I have come to believe that her (Lia’s) life was ruined not by septic

shock or noncompliant parents but by cross-cultural misunderstanding.”

* Do you agree?

Successful intercultural medical cases used:

- house calls

- interpreter who also acted as “cultural broker”

- worked within the family belief system

- did not threaten, criticize or patronize

- liked the Hmong

- consider practicing “conjoint treatment” i.e. integrating western medicine with

traditional healing arts. Or Naokao, “a little medicine and a little neeb.”

- Kleinman – “the doctor cures the disease but the indigenous healer heals the

illness”

- Guilt in Western medicine, as a motivator for compliance

- Medicine in US – separates students from emotions

- Stanford approach – “whole doctor-whole patient” model

- MD brings “full humanity” to medicine and approaches patient as “complete

person”

- similar to William Osler, “Ask not what disease the person has, but rather what

person the disease has.”

Chapter 19

- Interesting culturally, provides closure, ritual