On Learning Communities

Conversation with Dr. Tom Graber...on Learning Communities

  • Interview Number: 3 
  • Date: June 20, 2006
  • Interviewer: Dr. Klara Papp

Interviewer: I would like to begin this interview with the theme or suggestion that you made at our last interview that we talk about the learner, the preceptor, and the institution that enables that learning to take place: the learning community. In reading over the text of our previous two interviews, I did just have a comment that I would like to start with. A quote from Confucius: “It’s truly a common man marvels at uncommon things and a wise man marvels at the commonplace.” Interesting how some of these everyday observations become so special when one realizes and appreciates them. That is the gift that I have received from these conversations with you. In talking about learning issues and the learning experience, I have had the opportunity to “marvel at the commonplace.”

So, Dr. Graber, if I may, I would begin by asking you where the origins of your enthusiasm and energy for your day-to-day observations of learning stem from. What is the origin of this appreciation and perspective that you have? May I ask you to reflect on that a little bit?

Dr. Graber: Well, I really enjoyed the Confucius quote of a common man marveling at uncommon things and a wise man marveling at commonplace. I have been struck again and again and again that most great answers are simple. At least that has been my experience. I often hear from people in my daily administrative duties about how accomplishing certain things would be impossible and I often find that barrier to be created by one trying to seek a complex solution to a complex problem. In fact, most problems are simple and most solutions are extraordinarily simple. We had a meeting this morning, which with I was delighted, where we talked about nursing morale in the emergency department. We all finally concluded that whereas we could, theoretically, address all the various frustrations that nurses might complain about, addressing all of those things, as important as that might be, might not result in improved morale. The most important thing that nurses needed to do to be happy was to choose to be happy. They needed to choose to look at the positive and build upon it, and it is really as simple as that. There are, in fact, recognized and proven ways leaders can influence a group culture to favor a positive outlook. And we discussed patient satisfaction and how the most important thing that we need to do to satisfy the patient is for each of us to determine to satisfy the patient. We need to use the immense amount of verbal but mostly non-verbal feedback we are getting from each patient during our interaction with them as a guide to what we need to do to satisfy them. We simply need to intend to use that information to satisfy them, to use that information to stop dissatisfying them, and to pay attention. We are going to have a patient satisfaction program with the physicians and nurses tonight that is based upon those simple concepts. Keeping it simple and avoiding getting way too bogged down in solving problems that do not address our mission really also applies to learning. For me, discovering an important missing puzzle piece that helps me do something that I have never done before is such a great delight and it seems to me that others share that as well. I can not imagine not wanting to be involved in that learning process. I am referring both to my personal learning process, and the privilege of helping others make those simple discoveries that make life so much easier.

Interviewer: Are you saying that truly being alive involves making new discoveries and learning and trying new things? And that otherwise, one stays in some kind of a limbo in life?

Dr. Graber: I agree that life insists that we make new discoveries. Although we cannot actually avoid experiencing new things, we have ways to inhibit what we learn from them, or at least, the awareness of what we have learned from them. This results in us being much less stimulated and interested in life, and less able to respond in a sensitive, appropriate fashion to the challenges we face.

I find it useful to think of the apparently simple concept of “noticing and responding.” It helps me to think about all the decisions we make in the simple process of noticing and responding. There is immense power in that whole concept of noticing and responding. We may talk more about that later, but it actually can be, and has been for me, a great guide in thinking about learning and in thinking about how I change what I do when I work to be a learning facilitator. What am I noticing? How am I responding? And then, what am I noticing from that response? For example, I might have some preconceived notion, some hypothesis, and attempt to act upon it, only to notice that some things are working well and some are not working so well. My response, hopefully, will be to adjust my thinking appropriately mid-route to take advantage of what is going well, and to fix the things that are working poorly. To me that is extremely key to a good educational program. The best educational programs are, to some degree, ways in which both the learner and learning facilitator can meet his or her needs.

Interviewer: That implies that it is not really something one can prepare for and execute ahead of time. It is something that one needs to perceive and respond to, to some extent, in the moment, depending upon the kind of feedback one gets from the learner.

Dr. Graber: Yeah, I think both are true. I think it is important to prepare ahead of time, but in the presentation and in the interaction, there is a critical element for which we cannot prepare. We can certainly prepare the material, we can organize the subject matter, we can devise mechanisms which we have reason to expect would be useful tools to the learner. But, during our presentation, we need to notice if what we prepared is or isn’t working. We are guided, then, by the learner about how to best proceed. That is where the rubber meets the road, the learning facilitator meets the learner, at that point we really need to be prepared on an ongoing basis to notice and respond.

Interviewer: What would you say was the nature of the learner that sets him or her apart from someone whom you would consider a non-learner? Is the answer to be found in what you just said earlier about the ability to respond, i.e., think, respond, process and adapt to the learning situation?

Dr. Graber: I think so. I would like to talk a little bit about the concept of a “non-learner.” I think that we are all learners. We are all continuously learning. And yet we do, in fact, have a concept of a non-learner. But that concept of a non-learner, I believe, is for the most part an inference made by a learning facilitator—a name that we give when we are disappointed or surprised in an unpleasant way in a learner’s behavior. We, as learning facilitators can have, at best, a partial appreciation of what the learner is learning. It depends upon our measure, our perceptiveness, our receptiveness and the expressiveness of the learning, and we have to appreciate our limitations in knowing, in fact, what the learner is picking up. When the learner and the learning facilitator do not share common goals, that is a set-up for the learning facilitator to label the learner as a non-learner when, in fact, it may simply represent a mismatch of what the learning goals are of the learner and learning facilitator. So I think that when we have a non-learner, we need to look at our perceptions, our biases, our prejudices and our measuring tools. How are we determining that a student is a non-learner?

Interviewer: Are you saying that the non-learner is learning, but just not what, in our (the teacher’s) judgment, he or she should be learning?

Dr. Graber: May not be learning what we think they should be learning or may, in fact, be learning that but learning it in a way that we do not understand at that point, and that can be an immense opportunity for the learning facilitator to learn to see more. The learning facilitator has the chance to learn to become more perceptive and to learn that other people may take a different route to get to the same learning end. So, again, there is much that the learning facilitator can get out of catching him/herself labeling somebody as a non-learner. It is an opportunity for the learner, learning facilitator or the learning institution to examine its ability to appreciate things that may be very important.

I think that the amount of learning that a person gets varies as his or her eagerness to notice and respond in encounter with the pertinent subject material. That passion is really key. The learner’s eagerness to notice and appropriately respond is something that we can influence and I think we do not often talk about our ability to influence learning passion in learning circles. There is some great stuff recently that I read about incentives by an economist named Steven Leavitt at the University of Chicago who wrote a book called Freakonomics. Fascinating book on, among other things, incentives and how we get people to do what it is that we want them to do. How do we incentivize learners? What incents learners to choose to do what they choose to do? I think there is great pertinence in that whole line of thinking to the promotion of learning.

Interviewer: Since you mentioned that at our last interview, I picked up the book. It was wonderful. I really appreciated your bringing that book to my attention. It brings together the whole notion of the connection of things that you would not ordinarily consider, of thinking outside the box. It is just a wonderful book. It illustrates this quality that you are just reflecting on, the ability to notice things in ways that seem obvious once explained, but one would not ordinarily make those connections. It is fascinating.

Dr. Graber: I think people that contribute most to their field often tend to be people that are willing to experiment with letting go of conventional ideas—they are willing to challenge their own basic assumptions. We strive as we learn to develop concepts and to structure concepts. It seems to me that only our very best educators tend to teach people how to let go of all of those concepts we work so hard to teach. To let go of these concepts, at least for a while, in the service of being open and noticing things and seeing them in new ways. Certainly, that can be taught. To release ourselves from our habitual mental structures is a process, not just mental but physical.

And should we not try this approach when we are listening to a patient and what we hear and see does not make sense? Should we consider this approach, perhaps, before we give the patient a poor prognosis? Will stepping back and, at least briefly, releasing ourselves from our assumptions sometimes allow us to see new opportunities for our patients? I personally find this process useful, and think it can be learned. I see the physical and mental activity of deliberately releasing ourselves from our assumptions as an important part of the process that we teach in helping people become lifelong learners. One of the most important things that all educational institutions, in my opinion, teach learners is how to become better learners.

Interviewer: So, I sense in your response to this question a profound respect for everyone and you are not willing to accept the fact that there is such an entity as a non-learner, that in fact, through your response, you are affirming the value and the ability of every human being to be able to perceive and learn from their environment. The job of the facilitator, in that environment, is to pick up and see the different ways that the person whom we are calling the “non-learner” is seeing. Maybe we ought to be changing our attitude and figuring out what it is this other person is doing or perceiving in that environment that we could learn from.

Dr. Graber: Yeah, absolutely. I’m familiar with some great programs out there that teach us more about diversity. These programs teach us to look at discrete, easily recognized, specific behaviors in a descriptive rather than evaluative way. When we are able to do this, we can appreciate without being threatened that other people think very differently than do we. With some effort we can, in fact, appreciate how others do what they do. We can’t think like some others do, but we can understand how they come to their conclusions without feeling threatened. When others annoy or threaten us, we become less open. We shut down our ability to get information when we define that information as unpleasant. Then we become less effective in that whole process of noticing and responding.

Interviewer: Very interesting. So let us turn the attention then to the facilitator. What can a facilitator do or be to cultivate or catalyze learning?

Dr. Graber: Well, I think that one of the things that we need to focus on, as facilitators, is how to promote and support the learner’s eagerness to notice and respond in a manner pertinent to the learning goals. So, part of our success in incentivizing our patient requires that we learn how to achieve shared learning goals with the learner. And, I think this relates to our conversation about how we may define somebody as a non-learner just because we have never taken that step of developing shared learning goals. Simply telling students what the learning goals are does not mean that they buy in or understand or accept the appropriateness of those goals, or that those are meaningful goals to them. So there is a process of developing shared learning goals. This is not just something that happens, but requires interventions that I believe we learning facilitators can learn. We can improve in the process of developing shared learning goals.

We need to learn from the learner how he or she can best use us to help them. And again, for the learning facilitator to derive what he or she needs to know from the learner is a discrete action item. How do we pay attention to the learner? It is perhaps much more easy to conceive of that in a one-on-one situation where we can pay attention to an individual, but are there specific, different teachable ways in which we can learn the best approach for us to take with our students from a class of 200 or 500? I am convinced that there are. And we can talk about what some of those are, but certainly any great professor who stands up in front of a class of 200 or 500, even if none of the students speak, is getting an immense amount of non-verbal feedback about the efficacy of his or her presentation. To develop the awareness of that feedback and a determination to use it, and perhaps I would say a joy in getting this wonderful education from that class of 500, that allows you to be all you can be. The ability to notice, make sense of and use what that group of students is saying allows you to be a catalyst for those students having that joyful experience of a new thought, something that helps, a new simple answer to make the world easier. I find this experience immensely reinforcing. And, again, I think this on-the-fly information receipt, analysis and use is possible to teach. Some come by this process naturally, but some need to be and can be taught.

The whole issue whether or not the learner is in fact learning I think is a fascinating one and it gets into, not just how it is that we notice and whether or not we experiment with different ways to notice how the learner is learning, but also into the more formal issue of whether there formal measures that, in fact, we could and ultimately should be using to measure the efficacy of our learning facilitation.

Interviewer: Interesting. I’m not going to pick up on this comment of measurement just yet. If you wish, we could come back to that because I really am very interested in exploring that with you. But what about the nature of the learning institution or learning communities that engender, cultivate, make a positive environment for learning?

Dr. Graber: I think we are still struggling to some degree with a learning institution seeing itself as the storage warehouse and distributor of knowledge goodies. The job for the student is, in this model, either to come and get those goodies, or like the baby bird, receive the worm of knowledge as it is stuffed down their throats while they passively look upward and open their beaks. Although part of what learning institutions do is to warehouse and distribute, I see that as a very limiting view for an educational institution to take. We talk about our great tradition, we look at the old ivy-covered buildings and talk about the greats, and that’s all good, and I think we should and appreciate those greats that have gone before us. But our power as an institution, just as our power as individual learning facilitators, derives largely from our ability to notice and respond in the present.

I think we need to take care not to overrate the knowledge we think we have—the presumed facts we teach to our students. Each of us can really appreciate only a tiny fraction of the information around us. We are profoundly limited in our vision by the tiny segment of energy our eyes are equipped to see or our ears are equipped to hear, as well as the biased way we collect, organize and make use of the relatively little information we do actually manage to get. The appreciation of our limitations, I think, should help us stay humble about the knowledge we claim to have and support our openness to learn more.

What an institution must be good at on an ongoing basis continuously is learning from its students. An institution must be good at learning from its students on an ongoing basis. That requirement changes the whole warehouse/distributor model. No longer is the institution just the repository of knowledge that the student is fortunate to dip into and hopefully get some. The institution is, to some degree that, but the institution more must be into noticing and responding on a continuous basis. Students change, they are different each from the other and different then they were the day before, and there is always more to learn.

The opportunities provided by the learning community excite me a great deal and I think I have mentioned before the story of the blind man—blind men—and the elephant. But that story to me is a really helpful way of thinking about how different people with different perspectives join together to approximate the truth, and still we only approximate it. In that story, five blind men surrounded an elephant, one grabbed its tail, one felt its side, one felt its trunk, one felt its leg, and certainly the one who felt its tail thought it was like a rope, and the one that felt its trunk thought it was like a mighty tree, and the one that felt its side thought an elephant was really like a wall, maybe like a coarse, hairy wall. And each of the blind men had a different concept and they argued about it but, in fact, the truth included all of their realities and, in fact, more.

I think it is a great story. The fact that each of us only perceives things partially underscores the wonderful opportunity provided by the learning community. We each have very limited ability to perceive, but each of us has a little different ability to perceive. We notice different things and we notice things differently. We respond to different things, and we respond to things differently. And the combination of all of those in the noticing and responding makes a wonderful symphony which is closer to the truth than any one of us alone could do. It is very exciting.

Speaking of the excitement, one of the incentives that makes us more eager to learn and respond, in my experience, is clearly the very opportunity to be with others. We are energized by each other and that’s one reason why we seek society. This energy is a very important part of the learning community. There is a great energy in the community that there would not be in any single person or even a few persons.

Another aspect of the learning community which I think is important is the process by which we agree upon learning goals. Learning goals are not determined by the content of the material presented so much as by the culture that chooses that content. And we could choose many different learning goals legitimately, but the ones that we do choose reflect the culture that we’re in. We need to get a larger group of people together to have the learning goals we choose, in fact reflect our culture. It really is a group process to establish learning goals. I think the Center for the Advancement of Medical Learning (CAML) will be a great community for doing all of these things: establishing learning goals, and sharing ideas and having people who are excited on specific topics find others who are equally excited but who bring to that topic a different perspective.

Interviewer: So, I so value your perspective on this and, to me, it really says that one cannot, as wonderful and as truly wealthy a resource as the Internet is, one cannot sit in the isolation of one’s room, bedroom, library, and learn effectively by one’s self using all the resources available. You really need other people and a community in which to truly be able to bring the richness of that concept, other people’s perspective of that same concept, together incorporated into your own. To learn is not at all a solitary, solo exercise.

Dr. Graber: One of the most powerful things in our emergency department medical director training course is the process of networking. An immensely powerful learning tool. It’s powerful not only because others have different perspectives. It’s powerful because we crave the social interaction and that makes us eager to hear other people’s perspectives. And networking is positive because it opens up a new world for us each time we meet another person who wants to learn from us and from whom we wish to learn.

Interviewer: So this was a web-based tutorial program that you developed for emergency room resident, for emergency room program directors?

Dr. Graber: No, we actually meet for three-day courses in different parts of the country and we have different levels that people go through.

Interviewer: I see. And it operates under your, this notion that you bring people together and they discuss and talk and learn from each other in their own experiences.

Dr. Graber: Right. We, we challenge and, sometimes, even disturb them with some of the material in our presentations and the directors take that energy in small groups where they communicate with each other about their real problems that they share. The directors are from all over the country and I think one of the joys that they have is in appreciating—despite their physical distance from one another—what immense resource they have in each other.

Interviewer: So it strikes me that there has been some research by Carole Bland and others to show that the number one predictor of success in academic medicine is the ability to network with other people and work together, draw people in and appreciate others’ contributions.

Dr. Graber: I have not read her work but that makes sense to me. I think it helps us to facilitate small groups if we are able to appreciate the independent value to the whole process of learning, of just people enjoying each other and talking to each other. It is easy to see somebody’s socializing in those groups, or getting carried away with topics as distraction from the educational mission of the small group. Depending on the quality of the interaction, it may, in fact, be a distraction. But still, networking needs to be one of the mechanisms of our education. We need to learn how to network, use each the experience we have with one another. In fact, the enjoyment we get from this is also very important to learning. It is part of our expression of loving what we do...of that eagerness to notice and respond, the openness that we have to listen to others. This is all part of what makes us good doctors.

Interviewer: So, the new curriculum is reframing the requirements so that students have large and intermediate group lectures, or interactions rather, and, in addition, they have small group case-inquiry groups that occur two hours a day, three times a week. That is viewed as now as such a key part of the student’s education. That they must partner in small groups with others and set learning goals about the cases that are being discussed during the week and do the work outside of the small group and come back and discuss it and learn from each other. So, this is definitely moving ahead in terms of your vision for learning communities. These small groups are going to be assigned. Each society will have random assignment of students within these small groups. So they will come to know each other in a very intimate way, if you will, in terms of learning, and what each brings and the diligence and the effort that they exhibit in bringing about their learning goals and in helping the group achieve its learning goals.

Dr. Graber: I think that is very exciting. It will be very powerful and that there are some things concretely that we can do to make it more powerful.

Interviewer: So, Alan Neville is the person who will have an appointment in CAML who is in charge of helping faculty recognize the role that they have within the small group and helping them to be able to facilitate the group’s learning. And he is now offering a series of workshops for faculty and will participate in observing these small groups, and give feedback to faculty in the way they are conducting these learning groups. So we are definitely a period of transition and growth in making these learning communities happen.

Dr. Graber: Is there any contemplation of videotaping some of these groups?

Interviewer: That is a great suggestion. And I think once we get the system going, it would be wonderful to [videotape]. If not videotape, then maybe audiotape.

Dr. Graber: At least audiotape, sure.

Interviewer: At least audiotape so that people can replay and think about and analyze the interactions and formulate ways of affirming the activities, the perceptions, the observations that took place in these small groups.

Dr. Graber: Video and audio tapes are a wonderful way, I think, for the learning facilitator to be aware of his or her style and how they come across. And there are some neat little things that they could do, even by looking at the percentage of time they are talking versus the percentage of time someone else is talking, just some solid numbers. Having a look at that and contemplating that. For those who are able to use them, tapes help the learning facilitator get continuously better. That whole process that we as learning facilitators want to do, noticing how well we are doing at our goals, and making adjustments based upon that is very much enhanced by having audiotape and, even more so, videotape.

Interviewer: Yes. So we’ll, I think it will be CAML’s role to figure out how we observe faculty in these small groups, and not just faculty, students as well, and how we help both the learners and the facilitators be better at what they are doing. I think that will definitely be our mission, especially as, in the beginning when these small groups are launched, and as they unfold too, CAML faculty will be there definitely and help the architecture of that.

Dr. Graber: You know one of the psychologists that I have immense respect for is Carl Rogers and, as you know, Carl Rogers developed a process he called “reflection.” Reflection, in the psychotherapeutic environment, is really basically just reflecting back to the client the essence of what it is that the therapist is hearing the client to say. Of course, what the client is saying includes both the verbal and the non-verbal, so the therapist is really doing more than just hearing. But the therapist is not advising, but really just reflecting the client. Audio- and videotaping have some of that same power we seen in rogerian reflection, whether or not there are any CAML faculty to comment on it, just for the learning facilitator to hear themselves or see themselves gives them a tremendous education that really requires no comment from anyone else. There may in fact be comments, and the comments may be helpful but it is not necessary and it is one way to provide a great benefit at a relatively low cost.

Interviewer: That is a great suggestion. I recently participated in a Harvard Macy program and I had the opportunity to observe myself teaching. I was videotaped and was allowed us to view my videotape and then the group gave me feedback. That was such a powerful experience just to see myself [laughing] and I think the tape alone speaks volumes much more than anyone. People in the room giving me feedback were kind. I was looking at that videotape and I could have replayed it numerous times and learned different things each time I observed it, so I wholeheartedly agree and it was a striking experience to see oneself.

Dr. Graber: Yes, and it may be a painful experience, but it is, it is one, for me, it is actually often painful but I also believe that I benefited once it was over. It tells me things that no one else could tell me. Like all learning modalities, there are those who will find this extremely useful, and some who will not.

Interviewer: So in terms of measuring or gauging how well we are achieving these things, really is this an area you would like to go into at this time or we have a little bit of time left, I was wondering if you had any comments about this, whether you want to explore this.

Dr. Graber: I have a couple of thoughts and maybe we could go into it at another time in more detail. Before we measure, we need to agree upon learning goals. Only then can we know whether or not we are achieving those goals. We have to have those goals in the first place. One of the wonderful things that the CAML can do, perhaps like no other organization could do, is to facilitate a joint appreciation of our learning mission and the specific goals that then logically fit under that definition of our mission.

I think mission statements can help form the basis for measurements. I see a mission statement as something that is alive. It is not something we make and keep for 20 years necessarily. If, in fact, if we do keep it for 20 years, every single year it means something different. We are changing it because we are rethinking it. We have to involve ourselves in actualizing our stated mission or it is just a waste of paper. The CAML can be involved in the continuous nurture of our learning mission.

Learning goals I see as hypotheses about how we achieve our learning mission. Basically that’s what they are. They are hypotheses about how we achieve our mission and, like any hypotheses, they may prove to be appropriately or inappropriately stated. But we can not measure without making a hypothesis that we are going to measure and I do not think we can fear too much making the wrong hypothesis. Instead, I think we can count on making the wrong hypothesis and have some faith in our ability to notice and respond. How is that hypothesis working? With the establishment of learning goals, we are then set in a whole variety of ways to set up measures.

Interviewer: I wanted to thank you for this interview. As we are launching CAML, you know, I am worried that we are going to set the wrong hypothesis [laughing], and as we speak, I am thinking, you are so right, we should embrace and welcome the mistakes that we make along with all of the successes, and we should not think that we are not going to be making mistakes [laughing] and this interview truly affirms that we should be grateful and move ahead and allow ourselves to be making those mistakes as we move ahead, trusting that we will get the affirming, positive, corrective action from the community of learners as we go. And it is not about me, it is not about the CAML staff, it is about the learning community and we are embarking on this together.

Dr. Graber: I agree and I think that in doing and in stepping forward to boldly go where we have no business going.

Interviewer: [laughing] Exactly.

Dr. Graber: To blunder into what we may blunder into from time to time and to experience the amazement and joy of turning out to be right on something [laughing], we, our medium is, in fact, our message. We are not only facilitating learning by what we do directly to facilitate learning, but what we do in our conduct as members of the CAML, to go and to try things, to make hypotheses, to be open enough that we can be wrong, acknowledge it, and go back to the drawing board. That is the whole process that we are trying to promote and we need to have the courage to demonstrate that ourselves.

Interviewer: Thank you very much. This has been incredibly affirming and wonderful interview. I am very grateful for your perspective and your position. So, we have a lot of work to do.

Dr. Graber: Yes we do. And a lot of fun.

Interviewer: [laughing] Yes.

Dr. Graber: We have to be willing to listen to respond and to make ourselves open and ready to accept ideas.

Interviewer: [laughing] Yes. Absolutely.

Dr. Graber: And if we commit ourselves to that, what an excitement we will have—you know, in the product. This really offers all CAML members an opportunity for growth, both personally and as educational scholars. I find it useful, in promoting my own growth, to consciously expect to leave each experience a changed person. I also find it useful to challenge my students to strive for and expect to leave the educational experience as different people than when they came in.

Interviewer: I find that these interviews are transforming for me. They give me an entirely new perspective. I feel that I am transformed in these conversations with you in thinking differently about issues than when I started. Thank you.