One of the strengths of medical education at UCSF is the opportunity to work with a diverse group of patients. Pediatrics residents see families with roots in the hill country of Laos and the villages of El Salvador, families who struggle financially and those of means. Caring effectively for these patients requires finely honed communication skills, and pediatrician and neonatologist Carol A. Miller, MD, helps make sure that students who pass through UCSF Pediatrics acquire them.
Culturally sensitive communication is an essential piece of the core communications competency required of UCSF graduates, and Miller thoroughly enjoys helping residents and medical students build those skills.
“People have differences in their world view and in their past experiences, and providers have their own world-view biases,” says Miller, a soft-spoken woman with a calming presence.
Miller began working with residents on this issue early in her 30–year career as a pediatrician, at a time when the concept of culturally sensitive training was just starting to bubble up in medical training.
“It struck me as important here because of the diversity of the population at UCSF. It opens an opportunity for a more in-depth relationship, and increases how helpful you can be to patients.”
Being Sensitive to What Is and Isn't Said
Miller uses a variety of teaching tools, including lectures, role-playing and clinical observation to help residents hone their communication skills. She builds awareness of the nonverbal ways that can help physicians work more effectively. What is the emotional atmosphere when they first walk into an examining room?
“If you notice what first hits you, it helps you modulate your behavior in a helpful way,” says Miller.
She encourages physicians to explore whether they give an impression of being patient or rushed. Are they making assumptions about the family constellation, such as marital status and sexuality? Do they greet the family? Talk to the child?
Personal space is a consideration. Keeping about three feet from the person you interact with is often a good start, but some patients’ body language may signal that is too close. They also may not be comfortable with direct eye contact.
“People naturally maneuver themselves into a comfortable space. We have to let that happen,” says Miller.
Acceptance for Culturally Sensitive Communication
What was once viewed as a somewhat fringe element in medical education is now widely accepted by students. Compared to their peers of past generations, they have had more exposure to other cultures, often through travel or community service. Many are also fluent in more than one language. They understand how cultural differences impact communication.
Miller’s skill in this arena has extended outside UCSF. She has participated in cultural communications workshops for prenatal caregivers within the SF Department of Public Health. The sessions try to address research that indicates unempowered women feel more stress around prenatal care, which may be associated with poorer perinatal outcomes.
The approach takes time, a precious commodity in today’s medical setting, but the payoff is worth it. According to Miller, good communication is one of the tools that helps build trust with a patient, and that makes a difference in everything from patient compliance in the primary care setting to peace of mind in palliative care.
It’s a two-way street, notes Miller, who says she has learned a great deal from her patients. For example, over the years she has observed how families from Asia, the Indian subcontinent, and South America introduce babies to solid food. If the circumstances seem right, she’ll sometimes share a suggestion from a different culture.
“It’s all about making the patient more comfortable,” says Miller.
by Leslie Lingaas