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Perspectives

Caring to Care: Applying Noddings’ Philosophy to Medical Education

Balmer, Dorene F. PhD; Hirsh, David A. MD; Monie, Daphne PhD; Weil, Henry MD; Richards, Boyd F. PhD

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doi: 10.1097/ACM.0000000000001207
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Abstract

One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

—Francis W. Peabody, MD1

Francis Weld Peabody’s words emphasize caring as a core value of medical practice. Less certain, however, is the degree to which medical educators deliberately structure and explicitly teach caring. There appears to be a gap in appreciating the act of caring as a formative force in medical education; perhaps caring does not fit well into the predominant, rational–objective mode of biomedical sciences. Specifically, empirical inquiry, the cornerstone of logical positivism, does not naturally accommodate the subjective, internally perceived nature of caring.2,3 This is not to say that caring cannot be assessed, nor to suggest that medical students do not learn to care. Others report that students learn much about being a caring physician from their interactions with faculty.4–12 Nonetheless, a clear understanding of how students learn to be caring is still nascent.

Nel Noddings’ philosophy, “an ethic of caring,”13–16 builds on the work of psychologist and feminist moral philosopher Carol Gilligan.17 By setting a foundation for successful pedagogy, Noddings’ ethic of caring may illuminate how students learn to be caring physicians from their own experiences of caring relations with teaching faculty. Noddings, herself an educator as well as a feminist moral philosopher, argues that caring is more than an attitude of a single moral agent, and more than the behaviors of a “good person.” Instead, caring is our most natural way of being in the world and in relation to others; it is the essence of being human.13,14 In this Perspective, we summarize Noddings’ philosophy, share our supplementary analysis of students’ perceptions of caring in one clinical education setting, and discuss how Noddings’ philosophy might be applied to medical education design and to medical education research going forward.

Noddings’ Philosophy: An Ethic of Caring

The idea that caring is reciprocal, or relation-centered, is central to Noddings’ ethic of caring. A special bond exists between the one-caring (i.e., the initiator of care) and the cared-for (i.e., the recipient of care) that is characterized by receptivity and responsiveness of each.13,14 The one-caring is aware of, and attends to, the other. The one-caring also understands the situation of the other and acts in ways that consider the other’s needs. In turn, the cared-for responds with interest in the support of the one-caring. Even when the cared-for may be dependent on the one-caring, the response of the cared-for motivates the one-caring and sustains the caring relation. In other words, caring must be received to complete the caring relation. According to Noddings, the response of the cared-for manifests in different ways: overt recognition of care, a general attitude of positive regard, or moving toward a learning goal.14,18

Noddings’ ethic of caring does not focus singularly on caring relations; it also attends to contextual conditions that engender and sustain these relations. She identifies two important “contextual continuities” in educational settings that either support or work against caring.16,19,20 The first is duration. To support caring, the one-caring and the cared-for should stay together long enough, and interact frequently enough, to know each other. The second is space. To support caring, the place in which the relation unfolds should seem safe, both physically and emotionally. In Noddings’ terms, it should be more of a dwelling place than merely a place of transaction.16

We believe that Noddings’ ethic of caring may be relevant in undergraduate medical education because it appears to connect directly to a core value in medicine—that is, caring. To comport with Noddings’ philosophy, medical students’ interactions with teaching faculty would be caring encounters if three conditions are met: (1) Teaching faculty understand the situations of students and respond to their needs, (2) students recognize their teachers as caring and respond accordingly, and (3) contextual continuities of duration and space are sufficient. The converse is also informative; encounters fail to be caring if teaching faculty do not attend or respond to students’ needs, if students do not receive the care offered by faculty, or if contextual continuities of space and duration are insufficient to support caring relations.6,14,21

An Ethic of Caring in Longitudinal Integrated Clerkships

Increasingly adopted by medical schools in the United States, Canada, and abroad, longitudinal integrated clerkships (LICs) appear to support the three conditions described above.22–25 The educational continuity that underpins the LIC design creates curricular structures that foster longitudinal, and we would argue, potentially caring, relations with faculty.23,26 Both quantitative and qualitative data suggest that students in LICs develop and maintain a caring, patient-centered stance as health care providers.27–34 However, relatively little attention has been paid to students’ perceptions of caring relations with teaching faculty. One exception is Hauer and colleagues’35 multicenter qualitative interview study, which explored medical students’ successful and unsuccessful relations with teaching faculty. Compared with students in traditional block clerkships, students in the LICs felt more respected by faculty and more comfortable in navigating teaching relations that did not meet their perceived learning needs.35

Our interest in exploring Noddings’ ethic of caring arises in the context of the authors’ (D.F.B. and B.F.R.) research, which focused on understanding students’ lived experience across the four years of medical school.36 In their data analysis, D.F.B. and B.F.R. were struck by differences in how students in an LIC and students in traditional, block clerkships used terms like “feeling cared for” and “being trusted.” The authors saw an opportunity to examine the alignment of Noddings’ philosophy with a subset of the data, a post hoc matter of interest.37

The subset of data examined was derived from interview transcripts from eight students in the Columbia-Bassett Program at Columbia University’s College of Physician and Surgeons; D.F.B. interviewed students midway through their major clinical (third) year and seven to eight months prior to graduation. For these students, representing 80% of the 2012 Columbia-Bassett cohort, the preclinical curriculum took place on Columbia’s New York City campus, but their major clinical year was an LIC based at Bassett Healthcare Network in central New York. As part of the LIC, students followed their own panel of patients in daily outpatient clinics and as part of a longitudinal panel. Consistent with the LIC model, the program assigned clinical preceptors in each discipline to work with students on a one-to-one basis throughout the LIC.

Seeing caring as a formative force in medical education, D.F.B. and B.F.R. reviewed the interview transcripts to identify students’ comments that resonated with Noddings’ ethic of caring. Specifically, they reviewed comments that D.F.B. had coded initially for “trust, “feeling cared for,” “long-term learning relation,” “long-term patient relation,” “one-on-one learning,” and “Bassett culture.” The initial coding provided a basis for supplemental analysis. D.F.B. and B.F.R. convened a team; together, the team iteratively read the selected comments alongside Noddings’ writings to see if, and how, students recognized and responded to being cared for and how contextual continuities contributed to students’ experience.

In the following section, we share our supplementary analysis. Given the small sample size, we do not suggest causality in the theoretical links between Noddings’ work and our analysis of the transcripts. We do not know whether students’ perceptions of being cared for by teaching faculty influenced their own care of patients. Instead, we explore the “goodness of fit” between the three conditions in Noddings’ philosophy—being cared for, acknowledging being cared for, and duration and space continuities—and students’ reported experiences in the Columbia-Bassett LIC.

Students’ perceptions of being cared for

According to Noddings, the first role of the one-caring is to direct attention to the cared-for and to understand his or her situation.13,14 In interviews, students talked about being known. For example, one student was “sought out” by a faculty member who knew the student’s career interest and set up an opportunity for that student to engage in career-specific activities:

I’m going into [subspecialty] and so I think back to those experiences and this is something I’ve thought a lot about during my subinternships but in October, there was a patient who was gonna be undergoing a major [subspecialty] procedure. It’s like a six-hour operation and the one that was on the schedule, one of the [subspecialty] attendings sought me out and said, “You should really try and make this operation.” … I was scrubbed in and basically first assisting with this [subspecialist] throughout the majority of the procedure. His actual assistant was delayed in another OR [operating room] and it was great because, at this point, I had worked with this [subspecialty] attending over the previous eight to nine months and he knew I was interested in this subspecialty. [ID 03]

Noddings’ second role for the one-caring is to direct his or her energy toward meeting the needs of the cared-for.13,14 Some students named “care” specifically when describing teaching encounters in which preceptors met their learning needs:

We have the same preceptors for many of the main rotations for the entire year. By now, we have been with them for a few months. You get to know them; you get to know how they work. You still get a lot of those similar experiences [to Columbia students in traditional clerkships in New York City] but I think it feels like you are almost more taken care of. [ID19]

More often, students spoke in general terms of an attitude that conveyed that the teaching faculty cared:

I was on a first-name basis with a lot of attendings and certainly the residents; they were part of my cohort, and the faculty was incredibly supportive of me.… I felt that they were very personally engaged in what I was doing [ID 09].

Noddings closely connects caring and trust; indeed, she concludes that trust both grounds the caring relation and is an outgrowth of caring.18,19 Students described working with faculty members long enough to develop a trusting relationship: “It was small enough [at Bassett] that as a third-year, I worked with this attending enough that, like, he trusted me enough to go see a really sick patient on my own and report back to him” [ID 02].

Students’ responses to being cared for

Noddings acknowledges that, in teacher–learner relations, the one-caring has the greater responsibility. But the cared-for is not passive: They complete the caring by responding with interest to support offered by the one-caring.14,20 Consistent with Noddings’ philosophy, caring calls forth enthusiasm, action, and responsibility in the cared-for.19,20 In our own analysis, students in the LIC did not mention talking to their preceptors about the “caring” side of their relationship. Rather, they shared stories reflecting enthusiasm, action, and responsibility in their caregiving:

I met [the patient] in the emergency department where she is 35 weeks pregnant and she had a kidney infection. She was in horrible pain, and came into the emergency department. I remember all the nurses thought she was going to deliver but was not in labor; she was in pain. I ended up being the one to sit with her and talk her through the pain. She had a lot of social needs; this was very much an unplanned pregnancy.… I ended up following her at each of her prenatal visits. I’d just go and check in, not from a medical standpoint but from a social standpoint. When she went into labor, she paged me and I came over. It was12 hours of labor and I was there most of the time. I ended up being the one to catch her baby. I sewed up her lacerations. I delivered the placenta. I was very involved.… I went to every one of her postnatal visits. And I was there when she brought the baby in a couple of times for fever, fussiness, and eating poorly. [ID 15]

Students also commented in ways that suggested that their relationship with their preceptor afforded them opportunities for action and responsibility:

I had a particular affinity for the difficult patients, for whatever reason. I really liked them and sometimes when a clinical encounter was going south, I would know enough about my relationship with my preceptor to know I can sort of step in [ID 10].

Contextual continuities of duration and space

Noddings recognizes the importance of establishing and maintaining “climates of care,” which enable students and teachers to stay together long enough to develop trust and a sense of safety.16,18,19 In their interviews, students implied that the longitudinal structure of their LIC facilitated relations with teaching faculty. They described having enough time to develop close relations with clinical preceptors in different disciplines. Continuity with people (i.e., duration) tended to blend with continuity of place (i.e., space), and each seemed to contribute to a supportive learning environment: “Overall it was a very fostering environment. By the end of the year, we had ridiculously strong relationships with our preceptors and we knew everyone. It was a very comfortable space” [ID 19].

Moreover, students often spoke of the space beyond curricular structure and clinical practice. For instance, nearly all students commented on the local context in which their training unfolded, and how the sense of community contributed to relations with teaching faculty: “Everyone knows everyone else.… People’s lives overlap in many ways that it’s not just ‘this is my coworker’ or ‘this is my neighbor’” [ID 19].

Applying Noddings’ Ethic of Caring to Medical Education

In this Perspective, we describe a considered view of Noddings’ ethic of caring that arose from our supplementary analysis of interview transcripts with students in LICs. Because of the close association between Noddings’ philosophy and the core value of caring in professional practice, we believe that Noddings’ philosophy may offer a lens to inform medical education design and medical education research going forward.

Although theoretical links that stemmed from our review of the transcripts do not prove that caring relations “cause” students to care, it did increase our confidence in Noddings’ philosophy as a conceptual framework worth exploring further. For example, it is unclear how well Noddings’ ethic of caring “fits” the experience of medical students beyond the context of an LIC. Future research could examine how students in traditional clerkships develop longitudinal relations with teaching faculty and whether, in non-LIC settings, students can still experience contextual continuities of duration and space.

How well Noddings’ ethic of caring “fits” other trainees’ experiences is also unclear. How do residents experience contextual continuities of duration and space, if at all?6,21,26 It seems reasonable to posit that residents move from a “cared-for” role to a “one-caring” role, and research could explore how, when, and under what influences that transition occurs, and examine the implications of this role transition for the trainee or for the educational design of residencies.

We explored Noddings’ ethic of caring in one context: an LIC wherein faculty, not residents, were the primary teachers. However, her philosophy grounds caring in relations rather than in a single agent. What matters then is not who is the one-caring—even if they say they care or model caring—but whether the cared-for recognizes and responds to caring. Noddings contends that every claim to care is rooted in the response of the cared-for.13,14 Noddings’ ethic of caring further suggests that we might attend not only to the effects of caring on the cared-for but also to how the cared-for treats others as a result of their experience in caring relations. In this vein, Noddings’ philosophy might illuminate a connection between caring in medical education and caring in medical practice. As an ethical ideal, caring springs from a natural impulse to care, such as occurs between a trusted mentor and protégé, or as in the metaphor that Noddings offers, between a mother and child. But in the absence of that natural impulse, caring also springs from a longing to maintain, recapture, or enhance the best memories of caring and being cared for.13 This is an area for future educational research, as it could help to explain why students in LICs seem to construct more patient-centered professional identities compared with students in traditional clerkships.28,30,32–34

It is also interesting to think about the caring relation between students and teaching faculty as an educational alliance.38 Our Noddings-informed speculation that being cared for by teaching faculty could enable students to recognize and respond to patients seems consistent with research on therapeutic alliances in psychotherapy. Those research results demonstrate that the quality of the patient–doctor alliance, as experienced by the patient and not by the therapist, is the best predictor of therapy outcomes.38,39 This comports closely with Noddings’ attention to the experience of the cared-for.

It is encouraging that 15 years ago, Dr. William Branch recognized the educational value of the ethic of caring.15 We hope our work builds on that start and encourages medical educators to concentrate design and research efforts on conditions in medical education that support caring relations.

Acknowledgments: The authors wish to thank the medical students who shared their stories and inspired this work.

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