On Learning

Conversation with Dr. Tom Graber...on Learning

  • Interview Number: 2
  • Date: May 16, 2006
  • Interviewer: Dr. Klara Papp

Interviewer: In talking about learning, you mentioned in our first interview that you studied Gestalt psychology before you started medical school. I would like to explore Gestalt psychology’s influences on your views of learning medicine, your practice of medicine, and how you perceive your prior training in Gestalt psychology at this point.

Dr. Graber: I started learning about Gestalt psychology during my second year of college. The study and practice of Gestalt psychology helped me to grow personally while providing me ways to help others grow as well. Certainly the practice of Gestalt psychology promotes personally relevant learning. It is not a compendium of facts, techniques, and directions. Instead, it is a set of principles supporting awareness and responsibility in our process of noticing and making choices. Awareness is the ongoing process of noticing. Responsibility is involved in owning—admitting to ourselves—the choices that we make and that it is, in fact, we that make them.

What and how do you notice? What and how do you choose? Gestalt does not focus so much on why people do things as opposed to what they do and how they do them. The concept is that if you know what you are doing and how you are doing it, then you have the option to do something different or to do something differently.More possible choices become apparent. What could be more relevant to learning than awareness and responsibility in our process of noticing and making choices?

One of the wonderful things about just the power of noticing is that we can do so with a minimum of bias. Noticing is not the same as categorizing and judging. We talked a little bit last time about the opportunities and the dangers of factual material. We need factual material. In order to progress, we need concepts and structures. But it is those same concepts and structures with which form the basis of bias and prejudice. We imprison ourselves at times and inhibit ourselves from seeing truth. And so we need to be able to develop a balance between the collection and organization of factual material, and a specific process of maintaining openness in how and what we notice, and how and to what we respond.

Gestalt talks about foreground and background. Foreground is the object of our focus. During a lecture, our foreground might be the lecturer’s picture and words and the notes we take on specific presented facts. Background; a lot happens in the background. Background may, in a lecture situation, include the knowledge we already have about the topic, or the noises we can hear around us or the perfume wafting up from the student in the row ahead of us. Background may be unstructured awareness, such as what we might seek to experience in the depths of meditation. In a lecture, to move from foreground to background is to change from noting and organizing elements of the presentation before us, to a process of simply noticing and being informed by our awareness. Foreground is essential to collect content relevant to the learning goals of the lecture. Background awareness, in part because of its relative lack of structure, gives us greater freedom to re-arrange the facts in a very different way in our own mind. I am eager to learn more about how we use the process of alternating foreground and background awareness in the process of learning.

Gestalt helped me think about and experiment with that process of continuous awareness change. I think it is valuable for anybody to experiment with consciously moving back and forth between foreground and background. But this continuous awareness change process also instructs us about how it is that we engage as learning facilitators. As opposed to giving people an hour of factual material, we need to appreciate that people will vary from foreground to background, and that these continuous changes are absolutely essential. Without them, I believe there would ultimately be no learning.

Interviewer: Yes, so the principles of Gestalt made you very conscious of the fact that it is not simply how we experience the world through our sensations, there is also a lot going on which are calling background that students bring to the classroom so they are not all experiencing this lecture in the same way. As a matter of fact, depending upon that background they could be experiencing the very same stimulus very, very differently depending upon what they are bringing to that situation.

Dr. Graber: I think that is true and one of the exciting things about recognizing those differences and accepting those differences is that by increasing our sensitivity as learning facilitators to what those differences are, we can use them to instruct our improvement. For example, we can present or make available information in a number of different ways so that people of different inclinations can use them.

Interviewer: Yes. And learn from each other even.

Dr. Graber: And learn from each other.

Interviewer: Yes. Because the small group setting really allows students to discuss and describe and share their perspectives about what they know and students can really enrich each others’ experiences by observing it and evaluating it and either integrating it into their own background or figuring out what they want to do with it.

Dr. Graber: Which underscores that knowledge is not just personal but social. And there is a wonderful story, you may have heard, an old Indian story about the five blind men and the elephant. One of the blind men comes and feels the elephant and grasps the elephant’s tail and determines that an elephant is very much like a rope. And another blind man comes to the elephant’s side and feels that long, broad surface and determines the elephant is very much like a wall. And another grabs the elephant’s leg and determines that it is very much like a tree, and so on for the whole five. I think that is a real reflection of how we all are. We see certain some things. We do not see other things. But in our differences, and using our differences in our interaction, we get much closer to the total truth.

Interviewer: And in that little story too, it really is interesting that how important the students attitude, or the Indian’s attitude is in discussing their shared perspectives on what an elephant is because they could argue and say, “no, no, I know that I’m right,” and not be willing to listen to what the other’s perspective is. And so it’s really interesting in that illustration to really be open, even if you think that you have the truth, to be open to what others have to say.

Dr. Graber: I agree. It is part of the story of how we become better learners, by recognizing, amongst other things, that all knowledge is social. Each of us contributes only a small but important part of the answer.

Interviewer: The other interesting thing about Gestalt, I was wondering if, the concept of insight learning that it is, and I’m not even sure I understand what Gestalt means by that exactly, but it is not really the “eureka” effect, it is more that you now have integrated the whole picture in a way that allows you to see the truth in a new way. I’m not sure. Do you have any comment about that?

Dr. Graber: Gestalt is like a figure or referring to the whole, and the whole is more than just the sum of its parts but each time you change a part, you change the whole. To me it has tremendous implications for learning. As we learn how to be doctors, what changes is not just the facts we have in our head, but the way we use our bodies in detail. We could get more specific about that, and Gestalt does. How we use the muscles in our face, or our shoulders, or our arms or our backs, how rapidly we breathe. How, when we tense, when we do not tense. What makes us anxious and how we use our anxiety. What makes us happy or joyful or motivates us. And how we incorporate all of that into the practice of what we do. Every one of those things changes as we learn more. And I can only say personally that all of those things changed for me on a continuing basis in my career as a physician. I am delighted and amazed that the changes I have noted in myself.

One of the techniques of Gestalt is to become aware of those changes and to notice them and to be instructed by them. There are times when our body seems to understand things before our brain does. And so whereas we can tell ourselves, in a cerebral way, things to do, in fact, our fists or our jaws or our breathing or our temperature can tell us things, can instruct our minds as well. It’s a wonderful union.

Interviewer: When one is open to it and does not close it off and think it is only my mind that has something of value to tell me. Fascinating.

Dr. Graber: One of the things, of course, that Gestalt focuses on is how we inhibit ourselves from doing those things we choose to do. So by learning the process of inhibition, not just in a cerebral way, but by recognizing how we manifest it physically, and what it is that we do with our bodies and choice of language, we have many clues. If we develop an ongoing awareness of how we inhibit ourselves, we open up the choice to disinhibit ourselves, completely or partially. We will always inhibit ourselves some; we may, at times, choose to inhibit ourselves less. We can choose at a particular moment to do something different than that inhibition.

Interviewer: It’s really so important. It’s so elemental and it’s so important. So, just as an aside, I’d like you, to invite you to consider in our opening symposium of the Center for the Advancement of Medical Learning, would you consider all the possibilities and connections you have at the Gestalt Institute. Is there someone you would like to come and speak to address the group at that inaugural event? I would love to pursue that possibility and invite whomever you think might be worthwhile to participate.

Dr. Graber: I’ll need to explore who’s there now.

Interviewer: Okay.

Dr. Graber: ‘Cause I’m not currently affiliated with the institute but they may have some really good folks there.

Interviewer: This is a valuable perspective that we don’t much talk about in medical education and I think it would be really wonderful and enrich the opportunities of the opening ceremony if we could have someone to represent this perspective.

Dr. Graber: Yeah, I think that would be fun. Actually, exploring things from the Gestalt perspective can be not only great learning, but a great deal of fun. One of the things that excited me about Gestalt was that it approached learning in a much more flexible way than the formal institutions with which I was involved. One approach I found particularly helpful, and fun, was the approach I learned in my Gestalt study of the learning experiment. This involved real, physical actions—behaviors that we tried, and since we were actually doing them, we could consider them in a way that went far beyond the intellectual. The learning was also emotional and kinesthetic. The learning experiment can also be done in large groups with the expectation that there will be substantial learning from it. People learn different things. But people learn things that are important to them and that allow them to take their own personal next steps. I’ll look for somebody at the Institute who might give a presentation.

Interviewer: Thank you. I look forward to following up on that. So concepts that interrelate in cognition and learning, let me just give you some lists and have you free associate perception. Maybe we covered that here in our Gestalt discussion.

Dr. Graber: Well, perception is more than what we do with our five senses. Perception is both personal and social. It is based not just upon what we sense but in what filters we use when we are sensing it. The importance of those filters is immense. In order to structure knowledge, we have to use certain assumptions and build upon those assumptions. But as I have said before, we are limited by the assumptions that we make as well in that they cause us to perceive in certain, necessarily limited ways. There are some wonderful pictures found in Gestalt psychology texts and various articles on perception demonstrating how we mentally complete missing elements in our environment with things that we expect to see. If, objectively, a picture is missing an element we expect, in our mind’s eye we put in that “missing” element. So actually, in our mind’s eye, we see, touch, feel, taste and smell things which others who do not have the same pre-disposition do not see, touch, taste or smell.

“Seeing is believing” but seeing does not necessarily mean that it is objectively visible. Recognizing how we generate our own perception by our biases is incredibly valuable in keeping us from being too tied to our conclusions. Of course, if we are not tied to our conclusions, our opportunities for learning are immensely magnified.

Interviewer: What is the role of thinking?

Dr. Graber: You know, in the past several years, I have changed my thoughts about thinking and maybe it is a matter of definition, but there certainly is an argument to believe that thinking is not just something that occurs within the brain. Learning is also not just something that occurs within the brain. In fact, there is evidence that learning can occur in any cell in our body, whether it be a neuron or a gastrointestinal cell, or a skin cell. In fact, various parts of our bodies do seem to learn different ways in which to behave and our cells interact with our other cells in a, one might say, social way. So we think with all of our being and as part of the social whole. How we perceive a situation depends in part upon how others around us also perceive that situation. So there is communal thinking that is going on. I think that is a valuable perspective because, again, it allows us to try to separate what we consider in the privacy of our own home, from what we consider when we are with a group of people who come with a set of assumptions.

Interviewer: That really does redefine the act, doesn’t it? Normally, we think it’s what goes on in the brain and you’ve now challenged that assumption at the cellular level and at the molecular level, community level as well. That’s very fascinating. And community of scholars, community thinking is really so much richer and better. There is a wealth of research to show that than the individual thinking by his or her own self.

Dr. Graber: There is immense energy in the community that goes beyond the individual elements of just the people who are there. I watched my daughter two nights ago light up as she was in front of the computer. She almost seemed to glow. And at that point I knew she must be communicating online with a friend.

We immensely energize each other. Community is a tremendous source that takes us beyond just the individual energy of each person by themselves.

Interviewer: Attention.

Dr. Graber: I think that attention is perhaps one of the most critical frontiers that we need to address in attempting to facilitate learning.

In the lecture situation, it seems to me that there are basically three categories of attention.

  1. There is the intake of the facts. That is, when we are taking the notes and listening and could be from a book reading or from a slide reading;
  2. There is the digestion, which is more of a background phenomenon where we are relating what is said to things that we know. We are trying to make connections and we need those connections to be able to tie in and to remember;

Then there is what I might call distraction. Distraction could involve us thinking about other specific things like whether or not we remembered to empty the garbage before we came to school or it could involve that state of generalized awareness with no specific concrete thoughts which is it’s own instructor, in my opinion, of many things but it does not have us listening to what the lecturer is saying or to what anyone else is saying.

I believe all people move back and forth through those three stages of attention. It’s exciting to me to consider that if we can understand how we do move between the attention states of intake, digestion and distraction, and how we time those moves, that we can use these natural processes as allies in the facilitation of learning in a much better way than we ever have. Teachers have traditionally viewed digestion and distraction in the classroom as undesirable inattention and sought to limit that apparent inattention. Instead of labeling human behavior has desirable or undesirable, I believe that we benefit much more by simply noticing what those behaviors are and using the knowledge we gain from that noticing to design learning systems that fit human reality.

Interviewer: Very interesting perspective to really capitalize on the strengths and the weaknesses that we bring to the situation. Capitalize on the distractions and welcome them rather than try to deny or suppress them.

Dr. Graber: I would like us to do that. I think we will be much stronger and we’ll be in less denial. Students often learn great ways of appearing like they are paying attention while they are, in fact, distracted. In my opinion that is because we all must spend some time in distraction. But if, in fact, we can do so formally and in unison or with a similar rhythm and in similar times, then what is important to provide for intake can be done during intake times. Perhaps people will be much more effective at taking in information in a way that actually leads to learning if they are supported with time to digest and, in fact, supported with time to be distracted. I think we have exciting frontiers here where we can dramatically improve our ability to learn and our ability for the learning facilitator to interact or really to choreograph in a wonderful way their interaction with the learner. Not only will the learning process be more effective, but I think it will be more self-sustaining.

Interviewer: Ultimately the message is that you cannot really learn unless you have authenticity. If you’ve got posturing or denial or something else going on, it is not a true learning in a sense. At some underlying level what you are saying that the authentic learning is what you strive to uncover and recognize and acknowledge and then move forward to a new level of learning.

Dr. Graber: I agree. It’s how we allow ourselves to be all that we can be, all that we really are in the learning situation.

Interviewer: Motivation and drive.

Dr. Graber: I read an article in The Plain Dealer today that reminded me of a study that I had actually read long ago, it was done in the 60’s by a gentleman named Michael Mischel. Dr. Mischel gave a group of very young children marshmallows and told them that they could eat the marshmallow then if they chose but if they would wait until he came back, those that waited would receive two marshmallows. Some of the children ate the marshmallows right away and some of the children waited for the two marshmallows later on. The children that waited had various techniques of resisting this immense temptation. Mischel followed all of the children longitudinally, looking at their accomplishments in school and work. He found that there was a very, very substantial difference between the successes of the two groups. The group that chose to wait for the two marshmallows in fact did much, much better than the group that chose to eat the first marshmallow immediately.

To me, this has tremendous implications for learning. We have motivation that comes from our passions, what we consider important. We have our basic drives which are always there and important in the process of learning. And then we have the whole process of deferred gratification that provides a bridge from our motivations to accomplishment. And all of these things are tremendously important and there is evidence that certainly deferred gratification is, to some degree, teachable.

I do not believe that I have seen that taught at the higher educational levels. It is taught in a limited fashion at the lower levels in kindergarten. But really, I think that this is something that is not just for little boys and girls. This is for professionals as well. We need to, on an ongoing basis since we are always changing, learn how to keep the mission in mind and take our actions based upon the overall mission as opposed to just our immediate drives at the moment. This provides another opportunity for learning to improve people’s ability to learn more in the long run. I disagree with those who might say that if you have not learned how to defer gratification by the time you get to medical school, you are not going to learn it now. It’s one of those things that we need to learn again and again at different levels. And it is absolutely teachable.

Another focus that I think is extremely important is the power of our passions. We will learn more about those things for which we have passion. First, of course, we need to learn what, in fact, our passions are. And that is an awareness process similar to the process that we go through in Gestalt therapy, learning what excites us. What do we notice? In what part or parts of our bodies do we notice that we’re happy? Where do we notice that all of a sudden we don’t have to struggle to pay attention but that we can’t really get enough? When do we not want to close the book or stop listening or walk away? We will get some lessons from asking ourselves those questions about what, in fact, our passions are. The more closely we can link our passions with what we do, the more energy and love we bring to our work and the better at learning we are.

Our specific learning styles are also much influenced by our passions. When are we most effective as learners? We’re continuously getting clues about our own learning effectiveness. The circumstances under which we best learn are not the same for all of us. But are we encouraged as learners to pay attention to our passions and to follow them and to act upon them? If, in fact, we are encouraged to do that, not only will we become better learners ourselves but by linking our passion with our learning process, we inspire others to use who they are naturally to become better learners. It is very exciting and it is self amplifying. The more we improve as learners, the more we improve as learners.

Interviewer: And it is amazing to me the depth of wisdom in that! You are really talking about things that are not found in the literature on learning in medical education. I mean, this is an incredible conversation to me. You have spent a lifetime thinking about your own learning, observing others, and there is a lot to be learned about the experience of it. I’m really glad to have this conversation with you.

So the next concept I’d like to throw out there in terms of how it relates to learning, is intelligence.

Dr. Graber: There has been such exciting work on intelligence in the past 10–15 years. There is a growing appreciation for what Howard Gardner referred to as multiple intelligences. Gardner has done some great work in organizing one way to think about certain categories of intelligence. He is not the only one who has done that and I anticipate that over time we will come up with even more useful categorizations of intelligence.

The actual numbers of different kinds of intelligence I think far exceed what we know and can know, but I’m always tickled by my experiences with things that I think are extraordinarily easy that someone else is struggling with, or things that I think are extraordinarily difficult that others do without giving it a second thought. One of the great opportunities that we have is to better appreciate the, as yet, only barely tapped power of the group.

I talked about learning being social. Intelligence, I believe, is not just individual, but also social. We, I believe, can go way beyond where we have gone if we better tap the abilities of the group. One mechanism, by which we do that and are increasingly doing that in the learning situation, is a process that we called “networking.” I think that networking has graduated in the value system of the educational community from what we used to call “shooting the breeze.” We used to consider this “shooting the breeze” to be a waste of time and a distraction from learning. In fact, more and more people, and certainly I believe that networking is one of the most powerful learning opportunities that we have.

Networking is so powerful, in part for the reasons which we stated, the blind men and the elephant concept, the recognition that, in fact, even the most extraordinarily smart and capable person has but a limited view. But that person, networking with other smart and capable people has a much greater view. When, in fact, we teach the power of diversity and become aware of the power of diversity, then instead of us saying “other people who are like us must be smart,” we recognize that other people whom we cannot understand—and who may, in fact, to us seem not so smart—are often also extraordinarily smart in a way that we are just not well-equipped to grasp. We can include people who we have never before included in the process and gain from it. To me this is very exciting. By openness to each other, we have the power to dramatically improve our collective intelligence.

Being open to taking advantage of the very, very different intelligence tool boxes that each of us has is powerfully contributory at work and it’s equally contributory in education. So the concept of multiple intelligence I think is important and the concept of diversity and teaching the acceptance of diversity and, more so than the acceptance, the immense opportunity of benefiting from diversity. We surely have a wonderful and promising frontier here.

This is not just a concept, by the way. There are specific techniques to benefit from those who think differently than do we, and this can be taught. And we have not traditionally done this in professional school but those techniques are there and some of them have proven themselves for many years.

Likewise, to step back to the concept of passion, how to define and act upon our passions is also something that is concretely teachable and is, in fact, being taught in a number of situations. At Case Western Reserve University in the Weatherhead School of Management, there they call it coaching. And that’s what that’s all about. Appreciative inquiry is another product of Case Western Reserve University which is a wonderful technique for encouraging people to bring their strengths to play in the interactions that are so important. In this we benefit as well.

This is again another example of how having a learning community dedicated to the advancement of learning brings us power that is immensely greater than that of individual, very dedicated faculty who are passionately interested in learning but who are not learning and communicating much with each other.

Interviewer: So, the value of the Center for the Advancement of Medical Learning is to draw those people together.

Dr. Graber: It magnifies our abilities many fold and it provides more energy than the sum of the energies of everyone in it.

Interviewer: So you talk about passion and the driving force behind the learning. What about the other emotions?

Dr. Graber: Attention, intake, digestion and distraction are, in large degree, reflections of our emotional state. The energy we give and get from networking is, in large degree, a reflection of our emotional state. Our process of cultural decision making, such as we must do in the university to identify learning goals, is a reflection of our individual and collective emotional states. So understanding our emotions is important. Our emotions are part of what the emotional intelligence literature refers to as the open limbic system and what they mean by that is that we have a profound influence on one another at a very basic level. Their theory is that that is an adaptive feature so that we can come to each other’s emotional rescue and, without a doubt, we do come often to each other’s emotional rescue. But our emotions set the stage in the teacher/learner environment.

How much do we want to listen, to attend to someone else, to take it to the next step, to consider it and engage in that process, not just of intake but of digestion? Do we want to relate the new information we are receiving to the other things that we know? How much can we absorb from the passion of the learning facilitator? Some of our best professors, (I think most of us would say) are those that present their topics with contagious passion whether in front of a classroom or in personal discussions. We walk out “sharing the glow” that they brought in. Emotion is an incredibly important part of the learning environment and those emotions do not all need to be what we refer to as happy emotions. Sadness, anger, frustration, are all part of the drive systems that can incent us to learn more. Our emotions are profoundly important to our learning process, and we must strive to understand that relationship in great detail. That understanding, I’m convinced, will have important lessons for us as learning facilitators. We have long seen emotions as supporting distraction—which we have labeled as bad. Accepting the learning opportunities in the interplay of emotions in the learning process is another way of recognizing who we are and using that understanding and appreciation to go forward more effectively. Getting back to Gestalt principles, growth is based upon awareness.

Interviewer: What about personality characteristics?

Dr. Graber: Well there has been some great work done on personality characteristics and I think it is still a very, very early field, one that I have had experience with in terms of talking about types of people. One system is the Meyers-Briggs system which actually has been around for a long time. Another is the DISC system which was developed about 50 years ago to help salespeople be more effective.

One of the things that fascinates me about the DISC system is what they call the “platinum rule.” We are all aware of the golden rule of treating others as we would wish to be treated. The platinum rule is a rule to treat others as they would wish to be treated. The link between the golden rule and the platinum rule is the knowledge that we can have of how others wish to be treated.

We need to accept that not everybody wants to be approached the same way, wants to think the same way. By understanding different personality types, different inclinations, different ways of perceiving, different ways of thinking, different areas of interest and different kinds of reacting; by understanding that we, in fact, can serve up learning in a meal that is maximally digestible by that individual. We can also see how different personality types can be social learning allies of us, each in their own way.

The existence of differences in personalities and the appreciation of those differences give us immensely improved opportunities to become better learning facilitators as well as better learners. When we understand and accept that we are who we are and that we can use who we are to our advantage in certain ways, then we go ahead and do it. So often in the learning situation we walk in and we say, “Who is it that they want me to be?”

Interviewer: And then you try to be that person. Let go of yourself in many very significant ways in order to fit.

Dr. Graber: We do that. We put a great deal of energy into that. Again, I think there is a balance. We have our basic inclinations and then we do adapt ourselves to certain things and that adaptation is not totally good or totally bad. In learning, we learn how to make adaptations that we could not make before and that is wonderful. So I do believe in stretching ourselves but I believe that we need to honor who we are also and recognize the strength and importance in that and we need to stay close enough to who we are to maintain our passion. Passion is an incredibly important driver in learning.

Interviewer: So let me change the focus a little bit to you as a successful practicing physician. How do you learn, keep up with developments in your profession, what are your, what are methods of learning that work for you?

Dr. Graber: Well my whole concept of my profession has changed over the years. When I entered as a medical student I felt that I was entering someone else’s house and needed to learn what manners and behaviors I should have. There were reward systems set up that I did not myself create and for me to get those important rewards, I needed to act in certain ways. And I think that many medical students are in that position and it is understandable. I think as learners, over time we learn how to determine what it is that we personally need in order to proceed in terms of our own goals, and that is a process of maturation.

Right now, for me to learn clinical facts, the most effective way is to read what I call daily headlines which are online headlines about things going on in medicine that allow me to click and go into greater depth on things that I am interested in. Again, that is very self-directed learning. It is a way of dealing with a fact that just was not as true when I was first learning medicine. That fact is that we have immense amounts of information coming at us online all the time and we need to learn how to manage it in a way that we continue to learn and do not get too distracted by the volume. It’s too easy to become overwhelmed by the volume of information and lose our focus. Learning how to manage what sometimes feels like an information onslaught is an ongoing process. I have been learning how to do that well over time. But I think that is a new world that learners need to learn about that I did not when I first started.

I am also an administrator of emergency medicine. I am an emergency department director and I also have been involved in the development of an emergency department director leadership training program. In performing my administrative and learning program development activities, I learn a lot by trying different approaches and paying attention to how people respond to those approaches and to the feedback that I get over time. I am often, in my professional work, constructing my own learning experiments.

I would like to have a more effective way of getting together in my teaching activities with a variety of people and developing learning goals and measuring whether or not we are achieving those goals. And I look forward to being a part of the community working doing that at Case Western Reserve.

Too often we have really failed to develop learning goals which are accepted by the learning community and, in fact, testable. I think that is one of our goals as part of the community and it is something to which the CAML would contribute.

I think that certainly my Gestalt experiences and some other experiences with respect to learning DISC and Meyers-Briggs and meditation, have all changed the way in which I learn and improved the way in which I am able to pay attention to all that I notice.

Interviewer: So, it sounds to me like you have a very integrated view of learning, that it is not something you remove yourself from the world privately. You do have opportunities and times when you do that, but that you consider learning to be like part of your awake time. Is it something that you are doing continuously?

Dr. Graber: Learning is something that I’m continuously doing from the moment I watch my daughter light up in front of the computer, to the movies that I see, to the TV shows that I watch, to the books that I read, to the—in some ways—disconnected events I see occurring on the sidewalk around me as I drive to work….

I am thrilled to be continuously learning.

Interviewer: How have you come upon this system? Has it evolved, if you will?

Dr. Graber: I feel like I am continuously evolving in this process and there have been a lot of different elements to it. I think that one of the things that interests me, and has been helpful to me, is appreciating more how valuable it is for me to accept my ignorance. That has been an incredible strength that I did not have earlier on when I felt that I needed to demonstrate my competence and, in fact, fear my ignorance. The whole process of professional education was frightening to me in recognizing the immense responsibility that I would have as a physician. I needed to know what to do when called upon to do it. I needed to be right. People’s welfare depended upon that. That frightening responsibility, in my view, did not allow for ignorance, and I think I have changed very considerably in thinking since then. I appreciate that ignorance and the understanding that we are all very limited in what it is that we can know and do. I strive to always learn more, and view ignorance as learning opportunity.

It is a stance of receptiveness, a stance of willingness, to see a different way than what I have seen before. It is reflected by my increased willingness to ask a question that others may view as reflecting poorly on my knowledge, intelligence or attention. My peaceful acceptance of my ignorance leads me to accept my vulnerability. In accepting my vulnerability, I have come to appreciate, in a much greater sense, the strength I get from my union with others. My appreciation of the blessing and opportunity that lies in my ignorance and vulnerability has been powerful in my evolution as a learner.

Interviewer: It sounds to me, just listening to you speak, it is the evolution of moving from intelligence to wisdom, in fact. It’s remarkable to hear you talk about it and express it in quite that way, it is the evolution that occurs when students starting out seek so desperately to project competence and real understanding of the discipline and then at some point let go and become at ease with their competence and recognize that asking questions and allowing your uncertainties to be revealed is really part of growing, wisdom and intelligence and greater understanding of the profession.

Dr. Graber: I think we can help students along that route. It is, again, another one of our opportunities as part of the CAML. One of the things that I see the CAML doing is approaching learning in ways that we have not traditionally done in the past. I see CAML considering aspects of learning that we could not or just did not consider before. To be truly open to learning; to getting the most out of what it is that we have to learn how to love our ignorance; to appreciate that we have much wonderful to learn.

Interviewer: So, let me then ask if there are any aspects of this interview that you would like to talk more about during our next interview.

Dr. Graber: I’d like to talk more about learning. There are three categories that occurred to me for which there is much to think about separately. These are:The nature of the learner.

  1. The nature of the learner.
  2. The nature of the learning facilitator.
  3. The structure of the learning institution.

I think it would be fun to talk about those three elements and how they interact.

Interviewer: Very good. We have a lot of explore here. Thank you so much.

Dr. Graber: This was fun.

Interviewer: It is. [laughing] This is so much fun!

Dr. Graber: Yeah, it is such a treat to get to talk about this stuff and I appreciate your insights and your passion in this as well. You know, we live in a world of limited resources but we have an opening here to do some really neat stuff and I am very excited about it and I am so grateful that you are part of it.

Interviewer: Thank you very much. It’s really such a joy to be here in the beginning and to have the opportunity to think about CAML’s direction. The mission is given and to really think and explore the possibilities in terms of how we might accomplish that mission. That is a gratifying, rewarding, and challenging task for me at this point.

Extra Material: On Opportunities During Medical School to Teach an Elective

Dr. Graber: It was wonderful. Now I can’t remember exactly how that happened but somebody let me do that, you know, and I was a student teaching a formal elective. It was, at that time, in fact, as I understand it, the most popular elective, although we could only take a certain number we had many [sign up] whom we couldn’t take. The ability to put on that course really spoke wonders for the school’s openness and it allowed me to do something that I suspect the people who approved it did not really understand and yet they were ready to go with it. I realize that it could turn out well or turn out poorly, but we have to be willing to fail–sometimes to risk something to learn from people who think differently than we do. That was good.

Interviewer: That was good. I hope that when we change the curriculum as we renew it and change things about it, the fundamental philosophy that that demonstrates is maintained in each innovation of change that we go through.

Dr. Graber: I hope so and my feeling about it is good. You know, at least what I’ve seen, the pieces of it that I’ve seen.

Interviewer: Uh-huh.

Dr. Graber: You know, in the Scholars Collaboration in Teaching and Learning experience there was a fair amount of experimental stuff being tried. I was delighted to see that and there was built in an opportunity for different people to say things, to express their opinions, that I thought was supported more than in many learning experiences that I have seen.

Interviewer: Yes, I was very thrilled to see that you were able to participate in that.

Dr. Graber: Yeah, I was delighted to do that.

Extra Material: On Role Modeling in Medicine

Interviewer: Medical students come to the inpatient wards in internal medicine with attitudes that they bring with them from their prior experiences. Their attitude changes when they see physicians who care about the patients that they are dealing with, they get a role-modeling lesson, that is, somehow able to allow them to re-examine their biases and their attitudes about what they are doing and why they are in medicine. So, just bringing them here and having, giving them the opportunity to interact with people such as yourself is incredibly important.

Dr. Graber: I think here they encounter both. They will encounter people who are, who are imbued with a positive mission and they will encounter people who feel burdened and, in some ways resentful of their jobs. And I think actually both are valuable. Just as this institution has an ongoing dialog between those who allow themselves to be energized by providing care and caring, and those who feel burdened by this same process, students will have a similar internal dialog.

It’s hard to empathize with people who are suffering and people who have less than do we for a whole variety of reasons. And I think one reason we often try to explain the differences between us and our patients in ways that separate ourselves from those people is to avoid the pain and the discomfort and, to some degree, guilt that people feel that they are privileged and others are less privileged. One of the discoveries—if we are open—that we make clinically here and can be made clinically in any hospital is that even when we provide care to people who are very different from us in so many ways, there’s a human spark that goes on that’s a brotherhood or sisterhood or almost a family-like situation. We can listen to others the way we would wish to be listened to and find that the connection is there most of the time. And even when we see people who cannot communicate, most of us have relatives or friends or loved ones that we are related to who also may be impaired in their communication and I think it is helpful to imagine ourselves in that situation and how we might wish to be treated. And in that realization, the differences we note become not a burden, but an opportunity. The energy we get from our patients comes in part from that wonderful energy that is exchanged between any two people who are glad they are enjoying the company of the other. I think that is extremely relevant to clinical medicine. It is not just “touchy-feely.” It relates very much to whether or not our patients choose to listen to us. When we listen to them, they are more likely to choose to listen to us; to value what it is that we say; and to follow up appropriately on advice given. They are more likely to feel that when they are impaired from following up as we had suggested, that they can enlist our extra help because they consider that we might really want to alter things to make them doable when they were not before. One of the problems in serving people who have limited resources, when we have so many resources personally, is that we don’t realize how difficult it is from them to do some of the things that we do easily. So we need to learn from our patients about their obstacles, skills and advantages. And that makes us much more effective in what it is that we do.

Interviewer: It is a very important lesson and it is hard for medical students to learn that going through their rotations unless they are opened and attuned to listening to their patients and observing physicians at that level. It is almost an awareness of oneself that must be opened to the possibilities in order to be able to absorb what is in that environment.

Dr. Graber: I agree. Our patients and their significant others give us an extraordinary amount of valuable information, and we actually ignore a great portion of it unless we are oriented to its usefulness. We need to sharpen our awareness of what we accept and what we ignore.

We frequently make the assumption that families are critical in the care of pediatric patients. But families and significant others are equally critical in the care of patients who normally would be able to care for themselves. Even patients who are unusually intelligent and medically sophisticated are impaired in certain ways. When we medical caregivers are patients, we’re anxious, we are in pain and we are uncomfortable. It is hard for us to have perspective. So, significant others are extraordinarily important. The ability to employ our relationships and our communication with the significant others is part of what makes our therapies good. It is actually a very exciting part of medicine and something that perhaps we do not teach as much as we should. The person who receives the pills is not the only important person with whom we relate.

Interviewer: The person, persons, in that environment are really important too.

Dr. Graber: They are very important. To me one of the most exciting things about conceiving ourselves as lifelong learners is the recognition of the opportunities to learn in every situation that we have. And in dealing with people who come from different cultures and different social situations, there is immense opportunity to learn and to understand and to improve in our ability to basically facilitate health. We talked about facilitating learning. In fact, we do not create health, we facilitate health. Each individual has a responsibility for their own health and their own group’s health. Each social unit has a responsibility for their own health. I believe, most of the time that people will tend to favor activities that favor health. They’ll want to feel better, be stronger, be smarter, be more rested, and be more physically fit. We are there to help achieve the health that they, themselves choose. We are there to facilitate the energy they provide and direct toward their own good.