The Deliberate Practice of Caring

Sallie could not forget her patient, a 10-month-old baby admitted with tetralogy of Fallot. A year later, she presented the case to her classmates, not to unravel the mystery of cardiac anomalies, but to probe a far more complicated mystery: why congenital heart disease is deadlier for Black babies than White babies. I listened quietly, ostensibly the teacher, disturbed by the story but proud of Sallie for telling it. She was becoming an expert in caring. As Sallie’s discussion progressed, reasons for the disparities in mortality rates emerged. There are no errant, race-related genes, just a litany of social hurdles, like the ones this baby’s family confronted. They had recently moved from out of state, so there was a gap in their Medicaid coverage, and they had 2 older children to care for, only 1 car, no gas money, and no family support. The care team members did not know any of this at first. They only knew that the baby was sick and should have had the operation months before. In their minds, her mother and father were “bad” parents—often absent, always adversarial, and oblivious to their daughter’s grave condition. It was Sallie who challenged these toxic misconceptions. I thought about Sallie recently when I learned that Anders Ericsson died. Professor Ericsson was the world’s expert on expertise; his decades of research dispelled the notion that talent is genetically determined. After studying chess masters, athletes, and musicians, he discovered instead that expertise results from countless hours of deliberate practice. Deliberate practice has common features regardless of the endeavor. Well-established representations of ideal performance provide students with models to emulate. Performance is deconstructed into component parts that students can practice separately. Escalating the goals pushes students beyond their comfort zones and skilled teachers provide detailed feedback before guiding their students to new goals. 1 This very tedious process extends the bounds of human possibility, not the genetic jackpot. More recently, Ericsson investigated how doctors maintain expertise throughout their careers. While most of his studies focused on procedural expertise, other aspects of doctoring are just as crucial. We call them soft skills, and a stubborn belief persists that you must be born with them. Unlike everything else Ericsson studied, these skills would depend on our genes. Genuine caring is one of those skills. It derives from the moral nature of caring relationships in which those who give care act intentionally to uplift those who need care, with an aim of helping them flourish. 2 In her writings on the ethics of caring, Joan Tronto deconstructed this kind of caring into 5 elements: attentiveness, responsibility, competence, responsiveness, and citizenship. 3 Dissected in such a way, caring can be modeled, measured, and deliberately practiced. Clearly, Sallie had been practicing. She was keenly attentive—inquiring, listening, and establishing a more compassionate understanding of the parents’ behavior. She was responsible, relating the family’s circumstances to social workers, who then issued meal tickets and gas cards for the parents’ daily visits to the hospital. She was responsive, ensuring that her efforts allayed the parents’ concerns and allowed them to accept the treatment plan. And as an activated citizen, she was honing the skills needed to advocate for equity. She may not yet have the technical competence of the cardiologists who stabilized the baby or the surgeons who repaired her heart. But Sallie’s burgeoning expertise in caring equally saved the baby’s life. Just like technical expertise, expert caring can be taught and deliberately practiced. As educators, we must study it, measure it, and build consensus on an ideal framework. And above all, we must value it, not only in medical students and doctors, but in everyone. Can you imagine how our world might look if every person pursued the deliberate practice of caring? Surely that would expand the bounds of human possibility.

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