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On CAML

Conversation with Dr. Tom Graber...on CAML

  • Interview Number: 1
  • Date: May 2, 2006
  • Interviewer: Klara K. Papp, PhD

Interviewer: I’m very privileged to begin the first of what I hope is a series of interviews with Dr. Tom Graber, who is the guiding spirit and the light behind the Center for the Advancement of Medical Learning (CAML).
Our purpose today is to begin a conversation about learning and to discuss some of the motivating factors that brought him to consider supporting this effort at Case Western Reserve University School of Medicine. What motivates you to care so passionately about learning?

Dr. Graber: I really am passionate about my own learning, and about helping others to learn. With respect to my own learning, I am driven by my desire to free myself, as much as possible, from my limitations. That includes not just limitations in the facts I can apply, or the skills I can perform, but in the ways in which I learn. I believe I have succeeded in becoming a better learner, and in learning ways to help others become more effective learners.

I think my background in psychology has taught me skills to help both myself and others. The therapeutic process is, in itself, a form of learning facilitation directed at personal growth and coping strategies. In my psychology training, I learned the value of the learning technique of shifting between focus and perspective. With focus, I can take in specific new knowledge; and perspective requires that I relax my commitment to that same knowledge in order to make new discoveries. I also learned about creating the learning experiment—a mechanism by which individuals try out new behaviors or ways of thinking in a safe environment. I loved having the chance of applying these and other techniques for the benefit of myself and others.

Interviewer: So that’s interesting in making the point which I totally agree with that governments can work to provide freedom for its citizens but it is truly through education, the mind, that one becomes a free human being.

Dr. Graber: Absolutely. But with our learning, we both free ourselves and entangle ourselves. We gain power from knowledge. But we organize our knowledge in mental cubby holes we create with our memories, assumptions, biases and prejudices. It is essential that we make those cubby holes to be able to retain the knowledge, but if we are to have the maximum freedom in the long run to use that knowledge, we need specifically to learn how to let go of those cubby holes—our categorizations and perspectives. It is that balance of taking in information, finding a place for that information by relating it to what we already know and believe, and then throwing it in the air and letting it fall into new significance—that whole balance or learning and, in a sense, “unlearning” is very exciting to me.

Interviewer: So, I think your background in psychology is definitely revealed here in your ideas about cognitive structuring of knowledge and how the facts that one really learns needs to be integrated and reorganized in memory in some real way for it to be learning.

Dr. Graber: My psychology background has been useful. Psychology refers to that “ah ha!” experience—that moment where we find the puzzle piece that gives the whole a significant new meaning. It is a moment of insight resulting in significant behavior change. I think we’ve all had that “ah ha” experience, whether it’s when we first learn to use a computer that we’ve been struggling with, or we learn that something that we’ve been doing on an interpersonal basis is accomplishing the opposite of what it is that we intend. As physicians we may learn that we can benefit a patient we thought we could not help. But we’ve learned some new skill, or some new direction, or have allowed ourselves to drop an interpretation of data that we’ve had before in favor of something that, in fact, gets us towards our goal providing better service. That’s all so exciting. Significant insight is, for me, one of our very most rewarding educational experiences.

Interviewer: Since there are only a handful of centers devoted to medical learning across the country, was there some event or some deciding moment that occurred that made you really recognize and pursue the creation of the Center for the Advancement of Medical Learning (CAML) [at Case Western Reserve University] School of Medicine?

Dr. Graber: I think there were a couple of things that really focused me on CAML. The first I might have included in the answer of what has fed my passion to advance learning. My middle daughter has a learning style which was really not well supported by her elementary, middle and high schools. Whereas, in college, she could pursue learning in the ways that worked best for her, in elementary and middle and high school, she was told basically how she had to do things. The mismatch between the educational approaches and her learning style was such that my wife and I had to serve as advocates for her.

Learning from my daughter about the ways in which she learned and appreciating that it was different from how I learned and how I understood other people learned, was an incredible eye-opener for me. But my eyes were also opened by the advocacy process. I learned that the teachers were very eager to also learn how my daughter could most effectively learn, and some were eager to consider trying new things. They needed and wanted some guidance. They needed a process by which they could listen to their students and convert what they learned from their students into actions that, in fact, improved their ability to facilitate learning.

Then, I had a business opportunity that allowed me to have some funds that I could dedicate to a cause. I thought immediately of the immense gratitude that I had for the education I received at Case Western Reserve University School of Medicine. I thought about some of the reasons why I valued it so highly and created a trust and listed [CWRU] as the recipient of that trust. The alumni office—in particular, Evy Neufeld—really was incredibly helpful in posing the question, “What would you like your gift to do?” She helped to unite me with a group of faculty, including you. I am convinced all of the faculty in the CAML group had a burning desire to improve the ways in which we, as educators, facilitate learning. In addition, I’m sure that everyone in that group was an eager learner themselves and could relate to it not only from a standpoint of professional responsibility but from the wonder of sharing the excitement that each of us has when we learn something of value. When we met over several years and I think each of those participants in that group contributed considerably and showed their passion and eagerness to promote our ability to facilitate learning. All expressed, in some degree, frustration with the lack of a formal structure to advance how it is that we facilitate learning. It was from this group that the CAML found its genesis, its name and its direction.

Interviewer: So building on that excitement, truly there was a lot of energy when that group came together and commitment to identify what the issues are in the School of Medicine for both students and faculty and list a number of areas, priorities, that such a center might truly help and advance both students and faculty in their own journeys of learning. That was a wonderful opportunity to come together with like-minded educators across the school in various departments to talk seriously about how we can create a center, pool our energies, and work together to help meet the needs of both faculty and students.

Dr. Graber: I think that’s true and I think one might characterize that committee as being, as being in fact, in itself, the first iteration of the Center for the Advancement of Medical Learning. The faculty group was, in fact, a learning community dedicated to the advancement of learning in itself and in that whole process we all learned, but we also contributed concretely to our ability to advance learning in the future.

Interviewer: Yes. One becomes, starts to do what one is hoping to achieve truly by becoming transformed in achieving those goals. Yes. That was several years ago. It shows how the process really takes a little time in becoming organized and established and now the timing of it is perfect in terms of the curriculum changes that are now taking place in the School of Medicine and faculty and students alike welcome the institution of the center with open arms in fact. There’s great need for it and truly the center has its work cut out for it at this moment in the school’s history.

Dr. Graber: I agree. I think that when the CAML group started talking, the school was focussed on research—and not quite ready to invest in a learning center. Now we have some real depth in learning leadership and bold new curriculum, so it is a great time in the school’s history to proceed. I think it is also helpful that some other schools have developed learning advancement centers in the past and have done some research. These other centers have demonstrated two things which I think are absolutely at the core of this center. One of those is the belief that through a formal process, through directed energy, you can improve your ability to learn. It is not just that you can learn specific content provided to you, but your whole ability to learn is, in fact, a teachable skill. Secondly, as an educator, through a similar formal process, you can learn how to be a better learning facilitator. If we know that by specific efforts we can improve as learning facilitators and that this improvement is measurable, the CAML becomes a compelling center for the medical school to create.

The group that met to develop the specific concepts of the CAML had, I believe, faith in both our abilities to improve as learners and learning facilitators and had a certain amount of exposure to the literature. I think now we have an opportunity to demonstrate these important abilities at Case Western Reserve in a concrete, visible program that educators can choose to join. Our power to advance medical learning has immensely increased by having the Center for the Advancement of Medical Learning.

Interviewer: There’s an enormous recognition of the need for it. In fact, I think in the information age, where facts and knowledge on the internet everywhere is so accessible, the role of the physician in some ways really changes and we cultivate not just people who are knowledgeable and have all the facts, but truly their ability to think about those more deeply and integrate them and to be able to recognize when certain facts are applicable in certain cases and when they are not. So, it is a journey and it’s a very, truly a very exciting path for the curriculum and the challenges that lie ahead.

Dr. Graber: I agree.

Interviewer: What information about yourself would you like to make known to medical students and faculty who participate in the activities of the Center for the Advancement of Medical Learning?

Dr. Graber: I have a little trouble with that question. I am delighted, more than delighted; I’m honored to be associated with this center. I am thrilled to contribute to the process of becoming, in a new way, a learning community.

I’m not really sure what, what specific knowledge about me would be of use to others. I have been very fortunate to have had the opportunity to do a good deal of field work, experimenting with different approaches. I certainly look forward to sharing what I have observed and to learning from others what they also have learned doing similar work.

Interviewer: So, if I may, just out of curiosity, feel free to say you don’t want to go there, but I’d be very curious about where you grew up and how you came to Cleveland? Just a little bit about yourself so that we have a sense of your geographic origin, your own history of education and how medical school, your experiences at [CWRU] that stand out for you, your residency, just short biosketch.

Dr. Graber: Sure, I’d be happy to. I was actually born in Chicago and grew up for the most part in Evanston, Illinois, a northern suburb of Chicago.My father is an orthodontist but he is also the primary author and developer of the main text in orthodontia. He is certainly a significant international educational leader in his field.

My mother is an international lawyer and political scientist who, likewise, has been at the head of her profession. She is doing a great deal recently in the issue of how people learn the information that instructs their political choices. Our nation is built upon the presumption of an informed electorate. She asks the questions “are we informed and how are we informed? How is it that we learn and develop the ultimate decisions that we make politically?”

I think that’s what we are talking about here. How is it in fact that we learn to do the things that we learn to do, looking at it first not from a prescriptive but from a descriptive standpoint. Let’s just see what really happens. So I think that my parents are a tremendous inspiration to me in this process. The dedication to education has been a familial thing all along.

Interviewer: You’ve confirmed my belief that physicians who are great educators have parents who themselves are great educators in their own professions and fields.

Dr. Graber: I feel very blessed in that regard. It is fun for me to recall my early education. In high school and prior to that, I focused upon doing what I was asked so I would get praise and good grades. I think that is really a fair summary of how I approached education at that point and, of course, despite the limitations of my approach, I learned a great deal. Probably most of what I learned, I really did not learn from any specific school activity. I thought the purpose of an educational institution was to provide me a structure that would allow me to get good grades.

In college, I became a psychology major and I think that reflected right then my true interest in how people learn, think and make decisions. The whole process by which we gather information, draw conclusions and make decisions is critical to psychology. I participated while in college as a teacher of group process. This group process orientation helped me see that learning is not just personal, but also social. Learning is a cooperative group product. And that was a very different view of education than what I had before.

I, for reasons I don’t quite remember, went to a career counselor towards the end of college who asked me what I wanted to be and at that point I think I said maybe, “I want to be a psychiatrist,” and she informed mein my great surprise that meant I needed to go to medical school. So in the last two years of college, I crammed in my premedical training. At the sametimeI pursued training at the Gestalt Institute of Cleveland which was really at the top of its field in that branch of existential psychology.

Interviewer: Okay. So you decided then to go into medical school and took all of your courses in college and it must have been a shock to go from college and a background in psychology where there’s so much personal exploration to then go into medical school where, here you are, here’s the curriculum, it’s all science and factual information and people are less concerned, really, in those early years about how you are feeling, and emotions and all of those things that psychology is so concerned about. So, how did that transition go for you?

Dr. Graber: Well, it seemed to me like more steps on a continuum than a sharp difference.

Interviewer: Really?

Dr. Graber: Certainly. I was the same person encountering the learning process with the same general personal tools. I had the same motivators. The content provided in medical school was really, for me, just an opportunity to be myself in a new place with new friends. The facts were like tools I could use to better do all of the things I had wanted to do in the first place. I felt I was able to use much of the material provided to learn and grow in the way I wanted. I think the process of learning medicine is, at best, very personal for all of us.
For some, there was more focus on specific scores and specific tests, and that was their motivator. And for others, it was looking at it in the larger picture of becoming a physician and the excitement and the anxieties associated with that. I did, concomitant with medical school, take a three-year postgraduate program in Gestalt psychology. The medical school allowed me to teach an elective I called, “Observing and Communicating in Medicine.” That was a truly wonderful opportunity for me to use skills and interests that I had in educational process. Teaching this course also allowed me to gain a better understanding of what my fellow students were going through. So I continued to learn much both related and unrelated to psychology, and that was really not a change for me.

Interviewer: So was this a dual degree or did the Gestalt Institute give you a certificate while you were in?

Dr. Graber: They gave me a certificate. Teaching Gestalt Psychology actually allowed me to pay my rent through medical school.

Interviewer: So you did have the flexibility and the freedom to continue your interest in psychology while you were in medical school?

Dr. Graber: I did, even to the point of setting up the Medical School elective. I have to say that that was, when I think about the things that made me grateful for my education, one important thing was the willingness of the Case Western Reserve University School of Medicine faculty and administration to let me design and teach this course. In doing that, they supported me in my personal goals to grow and foster growth in others.

Interviewer: Uh-huh.

Dr. Graber: I think that was very forward looking. I think there are many schools that would not have permitted that, but [CWRU] did and I’m very grateful for that and I think that principal of fostering some educational experiments is something we should continue.

Interviewer: And at some point you decided that psychiatry was less interesting to you than emergency medicine.

Dr. Graber: Well, psychiatry was much less scary to me than emergency medicine and when I went to medical school, what terrified me most was that someone might one day come to me and need something that I could not provide; need it desperately and yet I could not provide it. My reaction to that was to, above all, at least know how to initially respond to whatever somebody might urgently need. I needed to do that for my own security. Emergency medicine was the way to do it and, as it turns out, emergency medicine and at least psychology as I understood it turned out not to be drastically different in important respects. Both emergency medicine and existential psychology address what is emergent.

Interviewer: What an amazing combination of skills to bring to the persons who truly are in desperate need of emergency help! I can see how you found the best possible combination of educational background to bring to the field of emergency medicine.

Within emergency medicine, you developed educational materials for emergency department heads such as yourself?

Dr. Graber: More recently, I have had much more opportunity to pursue my interest in education and in how people learn. I had some additional training recently from the Weatherhead School of Management in that regard for which I am very grateful, excellent training in areas of leadership and emotional intelligence and worked with a number of educators who were also taking that program and, from there, went on there to develop leadership training courses for emergency department directors.

So much of emergency medicine leadership training is about listening, relating, how you organize, achieve knowledge, how you communicate knowledge to others. It involves normal activities that we have to do all the time but can be done more effectively with training and I was given the opportunity to design educational experiences to facilitate the learning of the medical directors in those areas.

Interviewer: You know, I would love to talk more about that at another interview to learn your journey in structuring that material because you truly took your own experience of your profession and then figured out how people in your position would best learn this. I think there’s a lot to be gleaned there about your own philosophy of education that I would like to explore in a subsequent interview with you.

In your opinion, what projects or activities should the Center for the Advancement Medical Learning have among its highest priorities? There is a list of priorities that the CAML lists among them and I just wanted to hear your perceptions of what you think are most important.

Dr. Graber: There are two overarching messages I hope, whatever vehicle we choose, will be manifest in what we do. Those messages are first that it is possible through a formal, organized approach to improve our ability to learn and second that it is possible through a similar approach to improve our abilities to facilitate learning. The improvement of both learning and learning facilitation should be, in my view, base goals.

In its early years, the center must maintain a relatively narrow focus upon what we can do well with our relatively limited resources. I think we need to consider, with the goal of the long-term survival of this center, the current critical audience whose support is necessary for our success. And I think we need to seek a clear understanding of what our critical audience sees as its major needs. How can we, as a Center for the Advancement of Medical Learning, do something valued by our critical audience that, without the center could not be done? We need to do concrete things to advance learning and learning facilitation that make our supporters want to continue providing us support.

Interviewer: Uh-huh. So, in your response, you’ve indicated that the emphasis should be on the learner. And insofar as we are focusing on being better teachers, we, that’s not enough. The center of the focus should really be to see whether teachers are achieving their goals by bringing about better learning in the students that they are teaching.

Dr. Graber: I believe the primary measure of the success learning facilitation is what the student takes from the room, or from the experience. If that measure demonstrates that we are performing well, then there are other somewhat less centrally important measures that are very much worth pursuing.

Interviewer: Yes. And would you accept as a benchmark, as an indicator of student’s perceptions about their own learning or how do you feel about asking students whether they’re learning and are they in a position to judge those things or do you need more empirical evidence?

Dr. Graber: I think that very question is one of the frontiers of learning facilitation. What is in fact the fair measure? Is the popularity of an educational experience; does that correlate with its true educational value? One of the important aspects of the CAML is, again, that concept of community. One of the exciting things that I think we can do from the outset with respect to the CAML is to foster dialogue about some of the very tough education questions. One of those questions will plumb what kind of outcomes really we are looking for and how those outcomes are best measured. Certainly we want the students to like their education. If for no other reason than that they actually participate in it in a positive way, but is that enough? I don’t know the answer to that, but I’m looking forward to working with others to find out.

Interviewer: That’s certainly some of the early work needs to organize priorities and truly identify what the outcomes that will satisfy both those in the administration of the medical school and those who are benefactors of the center to see whether the center is achieving its goals.

Dr. Graber: I think it is relatively easy to measure student’s feelings about their educational process and that it’s worthy to do that in the beginning. I think we may learn things that will lead us ultimately to other measures. But that’s one measure that we can pursue early and we have the tools already in place to do so.

Interviewer: Is there anything else that I have not asked you about that you would like to add at this point to our interview?

Dr. Graber: I know we’ll answer other questions in other interviews. I’d just like to say that I believe that the CAML is, has been, in some respects, up and running for quite a few years with all the various people who have been involved, progressing in their own thinking and participating and structuring with their own personal growth as learners and as learning facilitators. And I am really excited about the prospectabouthaving a more organized community working on this together. The dialogue, the discoveries, and the opportunities to work together, I’m very much looking forward to that.

Interviewer: So in subsequent interviews, we will perhaps get together a board that is sort of the think tank behind the Center for the Advancement of Medical Learning and have maybe group conversations about this that also merit recording. Because these are so key; I do believe that we forging new ground here and looking at a process that is so incredibly important for human development and so I look forward to having you around the table when those discussions occur.

Dr. Graber: I look forward to being there.

Interviewer: Thank you very much.