Korean Med Educ Rev > Volume 26(Suppl1); 2024 > Article
Kim: Social Cognitive Theory and Medical Education: How Social Interactions Give Rise to Learning

Abstract

The structures and processes of medical education have changed little since the publication of Flexner’s report, which stressed the scientific orientation of medical education and the curricular structure of two years of formal knowledge education and two years of clinical experience. However, the previous perspectives on medical education are facing challenges, and these call for new pedagogy and theories on which to base medical education practice. Considering that social dimensions of learning have been emphasized in educational practice, perspectives that integrate these aspects are needed. Among the various learning theories, social cognitive theory refers to the theoretical framework that contends that learning occurs within interactions with others and environments. From a social cognitive standpoint, learning through observation is critical to human functioning. Indeed, observational learning has particular significance in medical education in that it provides the context for which the importance and meaning of role models can be understood. In addition, as theoretical constructs such as self-efficacy and outcome expectancies allow us to establish an effective learning environment, exploring the concepts of the theory could be beneficial to medical education practice. In this context, the present review article aims to provide a glimpse of the fundamental assumptions and theoretical concepts of social cognitive theory and discusses the implications the theory has on teaching and learning. Further, a review of previous studies could help explain how the theory has informed medical education practice. Finally, the author will conclude with the implications and limitations of applying social cognitive theory in medical education.

Introduction

Learning, defined as a durable behavioral change resulting from experience [1], is explicated by learning theories that systematically explain how learning occurs, the factors that influence it, and the transfer of acquired knowledge [2]. Each learning theory is built on distinct ontological and epistemological foundations [1], providing unique definitions of the roles of teachers, learners, and the learning process.
In medical education, teaching and learning approaches have often been based on tradition and convention, rather than on theoretical frameworks [3]. Abraham Flexner's landmark 1910 report [4] suggested groundbreaking changes to medical education for its time, advocating for a 2+2 curricular structure and the teaching of medicine as a scientific discipline. In particular, it encouraged physician-scientists to participate in both laboratory and clinical education. Coinciding with the rise of experimental research in the late 19th century, medicine as an academic field increasingly adopted a positivist approach, aiming for objective investigation into the causal relationships of phenomena and the generation of value-neutral knowledge [5]. More than a century later, the structure and scientific focus of medical education have largely remained the same [6]. Instructors continue to deliver content, which individual learners then cognitively assimilate, mirroring the traditional paternalistic doctor-patient relationships. However, the current landscape is being challenged by a paradigm shift towards patient-centered practices, which repositions patients not just as recipients of care but as active partners in the process [7]. With these changes in clinical practice, it is necessary to discuss the values that medical education should promote and to consider the theoretical underpinnings that should guide its practices.
Social cognitive theory stands out among various learning theories by emphasizing the importance of the social environment and context in the learning process [8]. This theory advocates for learning through interaction, moving beyond one-way instruction to support a more learner-driven approach. A central element of this theory is observational learning, which underscores the importance of role models in facilitating learning. In medical education, role modeling continues to be a powerful strategy, effectively transmitting attitudes, values, and skills for interacting with patients and colleagues [9,10]. Additionally, the theory’s core concepts, such as self-efficacy, goals, and outcome expectancies, provide valuable guidance on structuring learning environments to promote individual learner development. A thorough grasp of social cognitive theory can therefore enhance existing educational methods and inspire innovative approaches to teaching and learning.
In this narrative review, I examine the historical background of social cognitive theory, introduce its key theoretical concepts, and analyze their implications for teaching and learning. Additionally, I review how social cognitive theory can be applied in the context of medical education, as well as the significance and limitations of the theory.

Social cognitive theory and key theoretical concepts

1. Historical background

Behaviorism, which emerged in the late 19th and early 20th centuries, focuses on observable behavior and defines learning as adaptive responses to external stimuli [11]. Although it established the critical concepts of classical and operant conditioning, behaviorism’s limitation lies in its disregard for the cognitive elements of learning. In contrast, cognitivism, which rose to prominence in the late 1950s, emphasizes mental activities such as thinking, memory, cognition, interpretation, and inference in the learning process. It introduced the concept of schema and posited that learning involves integrating new information into the learner’s cognitive framework through processes of assimilation and accommodation [12]. Social learning theory, which evolved from the broader behaviorist tradition, underscores the importance of social observation in the acquisition and learning of new behaviors [13]. Bandura [14], who examined human behavior and learning from a social learning theory perspective, expanded upon these discussions by underscoring the cognitive factors that influence the interplay between the environment and behavior. In 1986, he coined the term “social cognitive theory” to describe this expanded theoretical framework [8]. While behaviorism concentrates on external stimuli and observable behavior [15], and cognitivism on internal information processing and mental activities [12], social cognitive theory emphasizes both aspects. It highlights the impact of the environment on behavior and cognitive processes in learning [16].

2. Overview

Social cognitive theory posits that learning is fundamentally social, emphasizing that individuals learn through interactions with others and their environment [8]. From a social cognitive perspective, human functioning is determined dynamically by the interplay of three factors: personal characteristics, behavior, and the environment [8]. This contrasts with behaviorism’s unidirectional relationship, where learning is seen as a response to environmental stimuli. Social cognitive theory emphasizes a bidirectional relationship between human behavior and the environment, incorporating cognitive functions and other personal characteristics that influence behavior and the environment, thereby shaping learning. Bandura [8] described this interaction as “a model of triadic reciprocality” (Figure 1), also known as reciprocal determinism. Personal factors include an individual’s cognitive processes, emotions, and biological attributes, while behavioral factors represent the responses or consequences individuals experience as a result of specific actions. Environmental factors consist of all aspects that can trigger or inhibit a particular behavior [16]. In the realm of education, personal factors encompass learning objectives, self-efficacy, and attributions for success or failure. Behavioral factors include the activities undertaken for learning, as well as effort, persistence, and progress toward goals [17]. Environmental factors cover influences such as role models, instructional methods, and feedback [17]. Table 1 outlines the factors pertinent to learning. Bandura [18] notes that the influence of each factor may not be constant and can vary with the context. In medical education, for instance, heavy workloads might cause students to rush through tasks. Conversely, when situational stress is lower, students may pursue self-directed learning that aligns with their interests or goals [16]. Another key tenet of social cognitive theory is the idea that learning can occur not only through direct experience but also by observing the behaviors of others, a process known as observational or vicarious learning [8]. This challenges the behaviorist view that learning happens solely through reinforcement of performed actions, positing instead that new behaviors can be learned through observation. This has profound implications for teaching and learning strategies.

3. Key theoretical concepts

In this section, fundamental theoretical concepts of social cognitive theory are outlined.

1) Basic human abilities

Bandura defines humans as inherently possessing fundamental abilities that form the basis of learning and functioning [8,16].

(1) Symbolizing capability

The concept of symbolizing capability refers to the process of internalizing experiences by means of mental imagery or linguistic symbols. When faced with a novel problem, individuals can apply potential alternatives symbolically, rather than having to physically attempt each solution.

(2) Forethought capability

Forethought capability enables individuals to predict outcomes and increase the chances of attaining their goals through strategic planning of behavioral patterns. This capability motivates present actions based on expected future consequences.

(3) Vicarious capability

Vicarious capability refers to the ability to acquire new knowledge or skills by observing others’ actions and their consequences. If learning were limited to direct actions and experiences, it would be slow and inefficient. The ability to learn vicariously through observation accelerates the learning process, reduces trial and error, and helps prevent serious mistakes.

(4) Self-regulatory capability

Self-regulatory capability involves regulating and motivating behavior through self-evaluation based on internal standards. When a discrepancy arises between these internal standards and actual performance, individuals guide their actions to reduce the discrepancy. Self-regulatory capability is reinforced by creating supportive environments, aligning expectations with current actions, and rewarding effort.

(5) Self-reflective capability

Self-reflective capability refers to analyzing experiences and engaging in metacognitive thinking. Self-reflection allows individuals to gain a deeper understanding of themselves and the world.

2) Observational Learning

Observational learning involves acquiring new behaviors by watching others and seeing the consequences of their actions, rather than through direct personal experience. According to Bandura [8], observational learning involves four processes: attentional, retention, production, and motivational.

(1) Attentional process

The attentional process involves selectively focusing on specific behaviors and accurately perceiving relevant characteristics. The factors influencing attention include the importance of modeled events, affective valence, complexity, the observer’s cognitive abilities, arousal levels, preferences, and prior knowledge.

(2) Retention process

The retention process transforms observed behaviors and outcomes into symbolic representations, facilitating recall even when the actual modeled events are absent. Symbolic transformation simplifies essential features into memorable symbols, and reinforcement through repetition improves retention.

(3) Production process

The production process involves translating symbolic representations into actual actions and reproducing observed behaviors in a manner suitable for the given context. This process includes organizing behavioral patterns cognitively, attempting to execute them, observing actual performance, and correcting cognitive representations and performance through feedback.

(4) Motivational process

In social cognitive theory, learning and action are considered distinct concepts because acquiring and memorizing new behavioral patterns does not necessarily lead to their execution. The gap between learning and action is particularly pronounced when the value of the learned behavior is low or when the consequences of the behavior result in punishment. The impact of behavioral outcomes or rewards influences the translation of learned behavior into action. Rewards are not only given directly to oneself but also include observing the rewards received by others.
Table 2 outlines specific behaviors and activities related to each observational learning process.

3) Self-efficacy

Self-efficacy is the belief in one's ability to organize and execute the actions required to achieve success [19,20]. It affects decision-making, behavior patterns, goal-setting, commitment to achieving goals, effort, persistence when confronted with challenges, resilience during adversity, and the extent of success [19]. Within an educational setting, students’ self-efficacy is pivotal in acquiring competencies and dictates their levels of achievement [21,22]. Bandura [8,20] identified four factors that influence the development of self-efficacy.

(1) Enactive attainments

The most influential factor in shaping self-efficacy is the experience of achieving goals and successes in specific situations. Learners interpret the outcomes of their actions, which in turn informs their perceptions of own abilities to perform future tasks [23]. Generally, experiencing success bolsters self-efficacy, whereas encountering failure tends to weaken it. Overcoming challenges and persistently striving for success, especially in difficult situations, significantly contribute to the development of a strong sense of self-efficacy [20].

(2) Vicarious experience

Observing peers successfully complete tasks can strengthen one’s belief in their own ability to perform similar tasks. Although not as influential as direct, performance-based experiences, the development of self-efficacy through vicarious experiences is particularly important when direct personal achievements are scarce or when confidence in one’s own abilities is lacking [20].

(3) Social persuasion

Hearing from others that one can perform a task is another source of self-efficacy. Social persuasion becomes more effective when the feedback provided is realistic, as this can lead to greater effort. This effect is amplified when individuals regard the evaluator as both knowledgeable and trustworthy [24].

(4) Physiological state

An individual’s physiological and emotional states can partially influence their self-perceptions of abilities [19]. In tense situations, individuals might interpret physiological arousal as a sign of inadequacy or vulnerability. Conversely, a comfortable and stable state often leads to expectations of success.

Implications of social cognitive theory in teaching and learning

The dynamic interplay of individual, behavioral, and environmental factors, coupled with key concepts from social cognitive theory, including basic human capabilities and self-efficacy, offers insights into effective teaching and learning strategies and the creation of supportive learning environments.

1. Role of teachers and learners

Social cognitive theory emphasizes the interplay among environment, behavior, and personal characteristics, expanding beyond the confines of behaviorism to include cognitive processes in learning [16]. It is essential to define the roles of teachers and learners within this framework. According to this theory, the environment is a critical component, with the teacher acting as an integral part of the learning milieu [17]. However, in contrast to behaviorist approaches, teachers are not simply conduits of knowledge; they are dynamic facilitators who manage stimuli, responses, and reinforcement. They select behaviors that are conducive to observational learning, model these behaviors, direct learner attention, and provide feedback and motivation. Learners, too, assume a proactive and engaged stance in their education. They focus on observed behaviors and their consequences, practice and replicate desired behaviors, and diminish or eliminate unwanted ones. Through interactions with their peers and the environment, learners actively participate in the learning process. In the context of social cognitive theory, teachers not only encourage and inspire learning by serving as role models but also by fostering an environment where learners can actively shape their educational experiences through cognitive engagement, active involvement, and social interactions.

2. Setting goals and outcome expectancy

Clear goals and outcome expectancies are crucial components of social cognitive theory, exerting a significant influence on motivation and learning. The process of establishing goals entails defining specific criteria that direct behavior, and the conscious recognition of these goals can amplify the effort put forth to achieve them [16]. Clear goals act as reference points during the execution of a task, enabling individuals to monitor their progress, bolster their self-efficacy, and preserve their motivation [25]. Outcome expectancies pertain to the predicted consequences of one’s actions. When individuals are confident that their behavior will yield favorable results, they are more inclined to persist with those actions over time [25]. This principle is consistent with the approach of outcome-based medical education, wherein explicit goals and defined outcome expectations empower learners to refine their performance in accordance with these standards [26].

3. Modeling and models

In social cognitive theory, modeling encompasses matching behavior in a broad sense [8,27]. In a narrower sense, modeling involves observing one or more models, which can lead to changes in behavior, cognition, and emotion [25]. While historically used synonymously with imitation, modeling represents a more encompassing concept. Bandura [8] identified several distinct effects of modeling, including observational learning. This process allows for the acquisition of new behavioral patterns, criteria for judgment, cognitive skills, or rules for the formation of behavior. From an educational standpoint, modeling the expected patterns of thinking and behavior can enhance observational learning. Demonstrations enable learners to create mental representations of the skills or behaviors they aim to master. These representations then act as standards against which they can measure their own performance [16]. The effectiveness of modeling is influenced by the characteristics of the model being observed. Factors such as the model’s success and their level of recognition and influence can impact the learner’s attention [25]. In the context of self-efficacy, the influence of a peer model is particularly noteworthy. When learners observe a peer model who closely resembles them successfully performing a task, it can bolster their self-efficacy and lead to better actual performance [28].

Application of social cognitive theory to medical education

As Lewin [29] observed, “There is nothing as practical as a good theory.” Theory-based practice enables the systematic organization of content, the verification of influential factors, and the provision of a relevant framework for interpreting results. The subsequent section examines the application of theoretical concepts from social cognitive theory in various domains of medical education. It illustrates the impact of theory on actual performance and its potential as an evidence-based justification for the improvement of current practices.

1. Curriculum design

Kay and Kibble [30] illustrated how the fundamental principles of social cognitive theory can inform the design of a physiology curriculum in undergraduate medical education.

1) Background

The human physiology course was a three-credit course over one semester, conducted through face-to-face lectures, with assessments consisting of two multiple-choice midterm exams and a final exam with essay questions. The curriculum committee aimed to expand this course to a six-credit course spanning two semesters by adopting a new instructional design, including laboratory sessions.

2) New curriculum design

Students received detailed plans for a sequence of weekly experiments, with the instructor demonstrating the required techniques prior to each session. They were also given a course handbook that included the final report template and examples of both excellent and subpar reports well in advance. Laboratory work was conducted in pairs, and students were tasked with self-evaluating their performance and confidence levels before submitting weekly self-assessments. A graduate student assistant monitored each pair’s performance, assessing the precision of their experimental procedures and their progress on a weekly basis. This assistant also facilitated a comparison between the students’ actual performance and their self-assessments during the debriefing sessions following each experiment. The instructor wrapped up each experiment with a concise lecture that highlighted the principal results and the underlying physiological mechanisms. For assessment purposes, graded quizzes were administered periodically. Additionally, students were required to submit reports for five of the fifteen experiments, choosing which ones at their discretion. These reports could be submitted at any time before the end of the semester.

3) Application of theoretical concepts

This case study integrated elements of modeling, including the instructor demonstrating fundamental techniques and supplying report templates and examples. Additionally, it encompassed all four processes of observational learning. The attention processes were facilitated through lectures and demonstrations, while periodic quizzes aided in retention. The production process was represented by students conducting experiments and submitting reports. Finally, the motivational processes were supported by quizzes, reports, and the assistant’s observations and grading. Students independently carried out experiments, chose which reports to submit, and collaboratively authored reports, thereby strengthening their self-regulation skills.

2. Teaching and learning methods

1) Role modeling

The significance of observational learning in medical education is closely linked to the concept of role modeling. To discuss role modeling, it is necessary to first understand the meanings of “role” and “model.” Generally, a model is an entity that “makes clear certain aspects of complex reality” [10]. Defining a role, particularly in the context of a physician’s role, is more complex. For professionals, a role is not simply the performance of specific actions or attitudes but the internalization and embodiment of that role [10]. In medical education, teachers not only impart knowledge, skills, and attitudes through explicit explanations but also serve as models for the roles of physicians, experts, and colleagues. Role models contribute to the formation of professional identity by demonstrating not only knowledge, skills, and problem-solving approaches but also by conveying the values, attitudes, and communication styles that are inherent in the medical profession [16,31]. Acquiring the values, attitudes, and duties expected of physicians is essential for professional competence. Given the differences, conflicts, and complexities among the various roles undertaken by physicians, it is crucial to demonstrate how role models fulfill the demands of these diverse roles. From the perspective of social cognitive theory, students observe how role models behave and make decisions in specific contexts. Through direct interaction with role models, students learn how professionals function in different situations [10]. Observing the outcomes of role models’ actions enables students to predict their own behavioral outcomes in similar environments, which allows them to adjust their behavior and strive to achieve their goals [32]. Therefore, learning through role models in a dynamic medical environment extends beyond the teaching of formal knowledge and lays the groundwork for educating professional identity, which enables the internalization of duties associated with various roles.

2) Peer teaching

Peer teaching, peer-assisted learning, and peer support learning—where students or trainees take on the role of teachers—are common practices in higher education. In medical education, peer teaching serves as an effective instructional method, with students teaching their peers or participating in evaluations [33,34]. Within postgraduate medical education, there is a focus on the ‘residents as teachers’ concept, with active research into programs designed to develop teaching competencies for instructing students or junior residents [35]. The effectiveness of peer teaching can be analyzed through the lens of social cognitive theory, especially in terms of modeling and model characteristics. As described earlier, when peer teachers are perceived by students as being similar to themselves, it can lead to more effective learning by enhancing self-efficacy and motivation [25,28].

Significance and limitations of social cognitive theory in the context of medical education

In behaviorist theory, learners are often viewed as passive responders, reacting to external stimuli [15]. Cognitive theory, in contrast, views learners as active participants who engage in the cognitive processing of information [12]. Despite its emphasis on the active and mental activities of learners, cognitive theory still adopts a teacher-centered perspective. This means that the essence of learning is dependent on the teacher’s ability to effectively organize and present information in a structured manner, which allows learners to integrate new information into their existing knowledge base and construct meaning. Social cognitive theory offers a different perspective and theoretical framework that moves beyond the teacher-centered approach. According to this theory, learning is the result of ongoing and dynamic interactions among individual, behavioral, and environmental factors. Teachers, teaching methods, and feedback are considered part of these environmental factors [8,16]. As a result, learners are not just passive recipients but actively engage in and influence the learning process through their personal characteristics and actions. A significant development within social cognitive theory is the recognition of peer learners as part of the learning environment. Unlike traditional models that focus solely on the dyadic relationship between teacher and learner, social cognitive theory acknowledges the role of peer interactions in the learning process. This understanding highlights the ways in which meaningful learning can occur and how effective learning environments can be created [36]. From the standpoint of social cognitive theory, learners gain knowledge and skills through their own characteristics, experiences, and actions, as they interact dynamically with everyone in the learning environment, including faculty, patients, and peers [36]. Knowledge and skills are acquired through direct experiences and observation, which contribute to the development of self-efficacy.
In this sense, social cognitive theory assigns learners an active and meaningful role, emphasizing that learning can occur through interactions with others. However, it is crucial to expand this view to recognize that within social cognitive theory, the “individualistic” learning process is embedded within social relationships and contexts. Lave and Wenger [37] posited that learning is inherently linked to the social context, relationships, and practices it occurs within, as described by the theory of situated learning and the concept of a community of practice. A community of practice is defined as a group of individuals who share a profession or field, along with the activities pertinent to it [38]. Newcomers to the community learn by observing and participating in tasks through “legitimate peripheral participation” [37], gradually gaining proficiency and moving toward the community’s core through active engagement, relationship building, and taking on more responsibilities. As learners evolve within the community through their participation, the community itself is transformed. Situated learning and communities of practice suggest that learning can be “collective” in nature within a social setting. This is particularly relevant in medical education, which emphasizes workplace and team learning; here, collective learning within communities of practice is of great significance [36,38]. Moreover, the acquisition of knowledge, skills, and attitudes in specific contexts is intimately connected to the development of professional identity and qualities [32].
The theories of situated learning and communities of practice establish a theoretical foundation that emphasizes the social aspects of learning, extending beyond the scope of individual learning. However, it is important to recognize that both individual and group learning processes are complementary and necessary. Consequently, social cognitive theory, situated learning, and communities of practice can mutually reinforce one another, thereby strengthening the theoretical underpinnings of medical education and improving its application in real-world settings. Given the complex and layered nature of medical education, future endeavors should concentrate on the integrated application of diverse learning theories. This approach should include conducting medical education research grounded in these theoretical frameworks and striving for theoretical coherence through their practical implementation.

Conclusion

There is often a perceived gap between theory and practice, with theories considered ivory tower constructs. However, as Lewin [29] noted, a good theory is not only practical but also provides specific guidelines that can shape actions in reality. Moreover, the actual implementation of theories can make them more tangible, refined, and meaningful. Since the publication of the Flexner Report [4], medical education has traditionally been led by physician-scientists who are adept at both scientific research and clinical practice, emphasizing the teaching of medicine as a science. Nonetheless, evolving developments in medicine, technology, and society necessitate a transformation in medical education. This calls for a renewed discourse on the theoretical foundations of medical education practices to effectively address these changes.
This paper explored the role of social interactions and observational learning within the framework of social cognitive theory. The concept of reciprocal determinism, as proposed by the theory, highlights the dynamic interaction among individual, behavioral, and environmental factors in the learning process. This approach shifts the role of learners from passive recipients to active agents, with observational learning providing a theoretical underpinning for the commonly employed role-modeling techniques in education. Despite the focus of social cognitive theory on the social context and learning through relationships, it still tends to prioritize individual learning processes. To achieve a more integrated approach, individual learning should be linked with cooperative group learning. A thorough understanding of the theoretical foundations of collective learning, such as situated learning and communities of practice, is crucial for this integration. For medical education, a deep comprehension and implementation of diverse learning theories can lead to meaningful learning experiences. This is achieved through the synergistic enhancement of both individual and collective learning [39].

NOTES

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Authors’ contribution

Hae Won Kim: collected data, wrote the manuscript, wrote the references, and conducted the overall writing of the paper.

Figure 1.
Triadic reciprocal interaction among personal, behavioral, and environmental factors.
kmer-24-001f1.jpg
Table 1.
Triadic reciprocal determinants of learning
Reciprocal determinants of behavior Factors related to learning
Personal factors Goals
Self-efficacy
Outcome expectancy
Attributions
Self-regulatory processes
Behavioral factors Effort and persistence
Progress towards goal
Motivation
Learning
Environmental factors Models
Instructional strategies
Feedback
Table 2.
Observational learning processes and related learning activities
Observational learning process Learning activities
Attentional process Directing learners’ attention by accentuating the functional value of modeled activities
Using competent, reliable models
Retention process Enactive or cognitive rehearsal of modeled activities
Relating new information to previous knowledge and experience
Production process Practice of newly learned behavior
Providing corrective feedback
Motivational process Demonstration of consequences of modeled behavior

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